Surgical left ventricular reconstruction

Outcomes of continuous flow left ventricular assist device after surgical left ventricular restoration

OBJECTIVES

This study aimed to report the clinical outcomes of continuous flow left ventricular assist device implantation in end-stage chronic heart failure patients with a history of surgical left ventricular restoration.

METHODS

We retrospectively identified 190 patients undergoing continuous flow left ventricular assist device implantation at our center from November 2007 to April 2020. In total, six patients underwent continuous flow left ventricular assist device implantation after various types of surgical left ventricular restoration procedures, including endoventricular circular patch plasty (n = 3), posterior restoration procedure (n = 2), and septal anterior ventricular exclusion (n = 1).

RESULTS

Continuous flow left ventricular assist device (Jarvik 2000, n = 2; EVAHEART, n = 1; HeartMate II, n = 1; DuraHeart, n = 1; HVAD, n = 1) was successfully implanted in all patients. During a median follow-up of 48 months (interquartile range, 39-60 months; censoring heart transplantation), no death was documented, which means that overall survival after left ventricular assist device implantation was 100% at any time point. Finally, three patients received heart transplantation (waiting time: 39, 56, and 61 months, respectively) and the other three patients are still awaiting heart transplantation (waiting time: 12, 41, and 76 months, respectively).

CONCLUSIONS

In our series, continuous flow left ventricular assist device implantation after surgical left ventricular restoration was safe and feasible, even if an endoventricular patch was used, and effective for bridge to transplant strategy.

Preoperative transaortic forward flow: Prediction of surgical outcomes in patients with DCM and mitral regurgitation

BACKGROUND

In patients with dilated cardiomyopathy and mitral regurgitation, preoperative prognostic factors are very important.

METHODS

We hypothesized that preoperative transaortic forward flow might be related to postoperative survival, despite mitral regurgitant volume. We retrospectively evaluated surgical outcomes and echocardiographic parameters, including forward flow through the aortic valve.

RESULTS

Seventy-nine patients (54 males, 25 females; mean age 59 ± 12 years) with dilated cardiomyopathy and mitral regurgitation were divided into two groups according to postoperative outcome: 19 patients in group A suffered cardiac death, 60 in group B survived or died of another cause. In group A, death occurred after 227 ± 116 days, group B patients survived (except one who died of infection) for 505 ± 446 days; p < 0.01. Preoperatively, there was no significant difference in ejection fraction, end-diastolic and end-systolic volume index, mitral regurgitant volume, effective regurgitant orifice area, or right ventricular systolic pressure. Preoperative transaortic forward flow was significantly lower in group A vs. group B (1.57 ± 0.33 vs. 1.81 ± 0.46 L m(-2); p 0.04). In group B, transaortic forward flow was increased significantly before discharge (1.81 ± 0.51 vs. 2.43 ± 0.62 L m(-2); p < 0.01). Ejection fraction was significantly alleviated before discharge (28% ± 9% vs. 23% ± 8%; p < 0.01) and recovered to the preoperative value without repeat dilation of the left ventricle in late follow-up.

CONCLUSIONS

Preoperative transaortic forward flow may be a predictor of survival in patients with dilated cardiomyopathy and mitral regurgitation, irrespective of mitral regurgitant volume.

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis

PURPOSE

Ischemic heart disease (IHD) may result in lethal conditions such as ischemic cardiomyopathy (ICM) and mitral regurgitation (MR).

METHODS

We hypothesized preoperative LV volume would be highly associated with long-term survival in such patients. We retrospectively evaluated effects of LV end-systolic volume index (LVESVI) on survival.

RESULTS

Patients were divided into two groups according to LVESVI; Group S (n = 19, <100 ml/m(2)), and L (n = 55, >100 ml/m(2)). There were 74 patients (male 61, female 13; 61 ± 10 y.o.). There was no statistical significance in preoperative parameters, including ejection fraction (EF), severity of MR, severity of tricuspid regurgitation (TR), and right ventricular systolic pressure (RVSP). After operation, LVESVI and severity of MR were statistically reduced in both groups. However, EF, severity of TR and RVSP were not statistically alleviated in both groups. In Group S, 5- and 10-year survival rates were 93% and 48%. In Group L, 5- and 10-year survival rates were 50% and 29%. There was a statistical difference in long-term survival between two groups.

CONCLUSIONS

Preoperative LV volume would be one of the risk factors for long-term survival in patients with congestive heart failure secondary to IHD. Careful follow-up and optimal treatment should be recommended before LV dimension becomes too large.

Sublocalization of Cardiac Involvement in Sarcoidosis and Surgical Exclusion in Patients With Congestive Heart Failure

BACKGROUND

In sarcoidosis, cardiac involvement can cause fatal conditions such as left ventricular (LV) dysfunction and rhythm disturbance. We surgically treated critical patients with congestive heart failure due to cardiac sarcoidosis.

METHODS

During 14 years, 384 patients with nonischemic dilated cardiomyopathy were operated. Among them, 14 patients (3.6%) with New York Heart Association (NYHA) class IV (male/female, 3/11; 57 ± 11 years) caused by sarcoidosis underwent surgery (elective/emergent, 12/2). The akinetic lesion, as identified by speckle-tracking echocardiography, was excluded.

RESULTS

Localization of akinetic lesions was achieved in 13 patients (93%). In the short axis, lesional distribution was higher in the anterior (62%) and septal segments (54%) when compared with the posterior (31%) and lateral segments (23%). Along the long axis, regional distribution was higher in the mid (85%) and apical segments (69%) when compared with the basal segment (31%). The main lesions were excluded by septal anterior ventricular exclusion (n = 5), posterior restoration procedure (n = 3), endoventricular circular patch plasty (n = 3), and linear resection (n = 2). Mitral valve surgery included mitral valve plasty (n = 7) and replacement (n = 7). In patients undergoing elective surgery, early results showed that 10 patients survived (83%) and NYHA class improved (6 patients in class II and 4 in class III). Patients who underwent emergent surgery did not survive. The observation period was 55 ± 59 months in survivors. During follow-up, 4 patients died after 42 ± 48 months. The other 5 patients have survived for 71 ± 61 months. The 3- and 5-year survival rates were 65% and 52%, respectively.

CONCLUSIONS

Sarcoidosis can result in sublocalized LV involvement, which can be surgically excluded.

Posterior restoration of left ventricle and mitral valve repair in patients with muscular dystrophy

BACKGROUND

Congestive heart failure (CHF) is major risk factor for survival among patients with muscular dystrophy (MD). The degenerative postero-lateral wall of the left ventricle (LV), which results in systolic dysfunction and functional mitral regurgitation (MR) at the time of CHF, is not well described in MD.

METHODS

We restored the LV and repaired the mitral valves of 6 patients (mean age, 43 ± 9 years) during emergency and elective procedures. Two and 4 patients were in New York Heart Association (NYHA) functional classes III and IV, respectively. One patient required emergency preoperative intraaortic balloon pump support. Before operation, speckle-tracking echocardiography was applied to detect the myocardial lesion. The postero-lateral LV wall that is critically affected in MD was excluded during posterior restoration. Functional MR was repaired using a combination of ring annuloplasty, papillary muscle approximation, and chordal cutting. The LV myocardium between the end of the LV incision line and the mitral annulus was cryoablated to prevent late ventricular arrhythmia.

RESULTS

All patients survived (100%) for a mean follow-up of 59±39 (range; 5 to 101) months. The NYHA functional classes improved to I and II (n=3 each). Left ventricular end-diastolic diameter significantly decreased from 77±13 to 59±4 mm (p=0.0088), whereas ejection fraction did not significantly improve (0.24±0.1 vs 0.29±0.11, p=0.2451), although MR severity was significantly eliminated (3.5±0.5 vs 0.5±0.6, p=0.0003). No cardiac events were associated with CHF or arrhythmia during follow-up.

CONCLUSIONS

Posterior restoration of the LV and mitral repair are useful for treating CHF in patients with MD, and improve survival.