doi:10.1510/mmcts.2004.

000760

Left ventricular volume reduction

Raimondo Ascione*, Peter Wilde, Gianni D. Angelini

Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, UK

The ‘left volume ventricular reduction’ operation was originally proposed by Dr Batista to
reduce the diameter of the dilated left ventricle by excising a sizable amount of the ventric-
ular free wall. Batista explains that the mechanism of cardiac improvement totally depends
on La Place’s law, therefore left ventricular wall tension is decreased by reducing the diam-
eter leading to an increase in ejection fraction. Questions, however, still remain on diastolic
function, preoperative judgement of left ventricular wall characteristics and late re-dilatation
of the left ventricle. The operation was originally performed using normothermic cardiopul-
monary bypass on the beating heart. Additional techniques with cardioplegic arrest, con-
comitant mitral valve repair, and closure of the left ventricle for improvement of hemostasis
are shown.

Keywords: Left ventricular volume reduction; End-stage heart failure

Introduction to gradually declining function w4x. Due to these find-

History
Left volume ventricular reduction (LVVR) was first per-
formed by Randas Batista in 1983 and reported in
1996 w1x. He ventured to reduce the size of the left
ventricle, and hence to remodel its shape w1, 2x
assuming that its size-related mural stress is the cru-
cial determinant of the heart’s ultimate fate. The oper-
ation gained popularity worldwide in the mid 1990s,
because of the shortage of the available donor supply
limiting cardiac transplantation, and the large popu-
lation with end-stage heart failure, not fulfilling the
inclusion criteria for transplantation. Furthermore, pre-
liminary data reported survival rates at 6-month fol-
low-up similar to those associated with heart
transplantation w3x. However, later results were less
promising, with only 25% of patients improved follow-
ing surgery, while 33% deteriorated rapidly, and the
remaining percentage experiencing a temporary
improvement in cardiac function followed by a return
* Corresponding author: Tel.: q44-117-9283145; fax: q44-117-
9299737.
E-mail: r.ascione@bristol.ac.uk
ings, many units abandoned this surgical procedure.
However, the fact that part of the more than 1000
patients who have undergone surgery are either still
alive, or have lived for months or years with an
improved quality of life w5x, questions what would
have been the impact of this procedure if a more crit-
ical and scientific approach had been used.
Rationale
The theoretical foundation of LV volume reduction
procedure was based upon observation by Dr Batista
in the heart of animals of different size who all appear
to have a constant muscle mass ratio that maintain
normal cardiac function (Ms4.18=R3 where M is the
muscle mass and R the heart radius). The hypothesis
is that by removing a slice of the wall of a dilated LV
(Schematic 1), the mass/volume ratio of the diseased
myocardium may be re-established. Of course, the
benefit from such undertaking may be, however, jeop-
ardized by discontinuities in the radius of curvature,
in thickness of the left ventricular wall, and presence
of fibrosis, which are obvious, and vary characteristi-
cally with different diseases, and may be so discrete

䉷 2005 European Association for Cardio-thoracic Surgery 1

 R. Ascione et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000760
Schematic 1. Rationale of LV reduction procedure.
Video 1. Cardiac MRI of a case done at the Bristol Heart Institute.
Two-chamber view showing a dilated LV and LA.
Video 2. Preoperative trans-thoracic echocardiogram in a patient
with dilated cardiomyopathy.
Video 3. An incision is then made at the apex of the dilated left
ventricle followed by anterior and posterior ventriculectomy inci-
sions (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
2
to escape observation by clinical routine ventricular
imaging.
Preoperative diagnostic assessment
Most patients who are referred for ventricular remod-
elling surgery are insufficiently defined in terms of their
primary disease, the function of the prospectively
remaining myocardium, and their global physical
reserve. This has led to a somehow uncritical use of
this surgical procedure in different scenarios including
ischaemic, idiopathic, infective, etc, dilated end-stage
cardiomyopathy with controversial results.
The most important diagnostic tool is to assess the
reserve for wall thickness pump activity under hypo-
volaemic conditions. The manoeuvre simulates the
working conditions of the shrunken heart after the
intervention w5x. Hibernating wall segments can be
differentiated from scars by positive inotropic
medication. Furthermore, the pattern of coronary
vascularization needs to be assessed in case of
ischaemic end-stage cardiomyopathy. Pulmonary
hypertension is a particular point of concern in the
post-operative management. The search for the pri-
mary disease, and its state of healing at the time of
the intervention, also require greater diagnostic
endeavour w5x. To this end, the recent development of
cardiac MRI has been of great value because of the
possibility of providing reliable information on global
and segmental wall motion, LV volumes, dimensions
and geometry, discontinuities in the radius of curva-
ture, thickness and viability of the left ventricular wall
(Video 1). Concomitantly, trans-thoracic or trans-oes-
ophageal echocardiogram is of paramount impor-
tance in providing valuable information on the
presence of significant valve disease needing correc-
tion (Video 2).
Surgical technique
The procedure is performed through a median ster-
notomy, standard cannulation of the ascending aorta
and selective bi-caval cannulation.
Originally, the operation was carried out at normoth-
ermia on the beating heart (Video 3). An incision is
then made at the apex of the dilated left ventricle fol-
lowed by anterior and posterior ventriculectomy inci-
sions extended toward the atrioventricular groove and
brought together 1–2 cm prior to reaching it (Video 4,
Schematic 2).
The posterior ventriculectomy may be extended
behind the posterior medial papillary muscle, in case
 R. Ascione et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000760
Video 4. The ventriculectomy incisions are extended toward the
atrioventricular groove and brought together 1–2 cm prior reaching
it (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
Schematic 2. Schematic illustration of the surgical approach to the
dilated LV.
Video 5. The mitral valve is excised from the ventricular side (Cour-
tesy of Drs Randas J.V. Batista and Gianni D. Angelini).
a larger reduction is planned with associated mitral
valve replacement (Videos 4, 5, 6).
The ventriculectomy is then closed using a continuous
2-0 monofilament full-thickness suture, followed by
3-0 monofilament hemostatic suture (Video 7).
This will determine a reshaping of the LV with reduc-
tion of left ventricular volume and size (Video 8).
Video 6. Mitral valve replacement is performed from the ventricular
side (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
Video 7. Closure of ventriculectomy (Courtesy of Drs Randas J.V.
Batista and Gianni D. Angelini).
Video 8. Post-operative trans-thoracic echocardiogram showing
reduction of LV volume and size (Video 2 is preoperative echocar-
diogram in the same patient). (Courtesy of Drs Randas J.V. Batista
and Gianni D. Angelini).
Technical variations
Several variations of the technique have been devel-
oped depending on the need of appropriate myocar-
dial protection during surgery, of reinforcing the suture
line to prevent catastrophic bleeding, and on the pres-
ence of associated cardiac pathologies like mitral
and/or tricuspid valve regurgitation.
Although the original proposal from Dr Batista was to
perform surgery with normothermic cardiopulmonary
bypass on the beating heart, others, including our
institution, have preferred to induce cardioplegic
arrest:
● to optimise myocardial protection, particularly in
presence of coronary disease;
3
 R. Ascione et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000760

● to enhance manual handling, assessment of the

area to be resected, and facilitate valve repair;
● to facilitate the achievement of a more haemostatic
suture line.
Reinforcing of the suture line to prevent catastrophic
bleeding may further be obtained with buttressing of
the suture line with pericardium or Teflon felts, and by
using biological glue.
In case of associated significant mitral regurgitation,
often this has been dealt with by edge-to-edge repair
performed directly from the ventricular side (Video 9).
In case of associated significant tricuspid valve regur-
gitation this can be dealt with standard repair
techniques.
Photo 1. (Reproduced from Ref. 6 with permission from Elsevier).
Photomicrograph confirming the extensive fibrosis in the THI spec-
Discussion imen (top left) and a minimal amount or absence of fibrosis in the
DCI specimen (bottom left). (Masson trichrome, magnification=4).
Longitudinal section of myocardium in THI (top right) and DCI (bot-
Some obvious mechanisms causing failure of par- tom right) specimens, showing an obvious difference in hypertrophy
tial ventriculectomy as confirmed by morphometric analysis (magnification=20).

Correction of left ventricular compliance: the site,

shape and size of the resected segments are very var-
iable, since often they only depend on surgeon’s
judgement. This may lead to either overcorrection of
compliance and subsequent LV diastolic failure or
undercorrection. The latter is often associated with
the beginning of the surgical experience when sur-
geons may tend to focus on the dilated apex leaving
untouched the midportion and the base w5x.
Asymmetrical resection: this may result in different
length of the two wound-free margins. On suturing,
therefore, some areas are stretched more than others
leading to unpredictably shaped and extended block Graph 1. (Reproduced from Ref. 3 with permission from Elsevier).
of scar tissue, which may also affect coronary arterial Individual data are shown for a symptom-limited exercise study per-
perfusion w5x. formed preoperatively, at 3 months postoperatively, and 12 months
postoperatively for the peak oxygen consumption (ml/kg/min). Peak
Persistence of the primary disease: persistence of viral oxygen consumption and exercise duration increased post-
infections or immunological diseases following LV operatively.

Video 9. Post-operative trans-thoracic echocardiogram in a patient

undergoing LV reduction and concomitant mitral valve repair with Graph 2. (Reproduced from Ref. 7 with permission from Elsevier).
the edge-to-edge technique. Short axis view showing the typical NYHA functional class before and after PLV according to the etiol-
double orifices. ogy of cardiomyopathy. *P-0.05 compared to preoperative values.

4
 R. Ascione et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000760
Photo 2. (Reproduced from Ref. 14 with permission from Elsevier).
End-diastolic and end-systolic mid-ventricular tagged images from
a single patient demonstrating the effects of PLV on LV septum
mechanics. At baseline the septum stretches during systole; how-
ever, at PLV3 contraction of the septum is evident. (LVsleft ventricle;
PLVspartial left ventriculectomy; PLV3spartial left ventri-
culectomy after 3 months.).
Graph 3. (Reproduced from Ref. 4 with permission from Elsevier).
Mid-term deterioration in end-diastolic diameter across time.
reduction surgery may affect the results as the pri-
mary disease continues to degrade the remaining
myocardium.
Wall thickness pump failure: patients survived, and
had marked improvement in left ventricular function
when the left ventricular wall was able to increase in
thickness following radius reduction. Inability after
ventricular radius reduction to develop the necessary
increase in wall thickness, may predict poor results
w5x. This could also be due to presence of significant
Graph 4. (Reproduced from Ref. 8 with permission from Blackwell).
Cumulative plots on late survival.
Video 10. Cardiac MRI at 8 years follow-up in a patient undergoing
LV reduction at the Bristol Heart Institute.
fibrosis within the non-resected myocardium
(Photo 1).
Results
● Despite the early enthusiasm, in-hospital mortality
reported by various teams has seriously varied w1–
14x.
● Obvious early clinical w3x and functional w3, 4x ben-
efits have been shown in a significant percentage
of patients undergoing LV reduction surgery
(Graphs 1, 2 and Photo 2) w3, 7, 12x.
● However, there seems to be evidence of mid-term
re-deterioration (Graph 3) w4x.
● Long-term results have been reported by several
authors (Graph 4, Video 10) and are controversial
w8–14x.
5
 R. Ascione et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000760
Graph 5. (Reproduced from Ref. 8 with permission from Blackwell).
Actuarial cumulative and split survival plot of the Bristol Heart Insti-
tute series.
● There might be a relation between baseline primary
disease and late results (Graph 5) w8x.
In those who are most successful, the mortality at
1 year is comparable to the standards expected for
cardiac transplantation. In other groups, survival,
deterioration, or death, is very unpredictable.
The fact that part of the more than 1000 patients who
have undergone surgery are either still alive, or have
lived for months or years with an improved quality of
life w5x is, however, remarkable (Video 10). One won-
ders whether the development and application of this
surgical procedure (rarely used nowadays) could have
been different if it had been introduced and evaluated
in a more scientific fashion.
References
w1x Batista RJ, Santos JL, Takeshita N, Bocchino L,
Lima PN, Cunha MA. Partial left ventriculectomy
to improve left ventricular function in end-stage
heart disease. J Card Surg 1996;11:96–97.
w2x Batista RJ, Verde J, Nery P, Bocchino L, Takeshita
N, Bhayana JN, Bergsland J, Graham S, Houck
JP, Salerno TA. Partial left ventriculectomy to treat
end-stage heart disease. Ann Thorac Surg
1997;64:634–638.
w3x Starling RC, McCarthy PM, Buda T, Wong J,
Goormastic M, Smedira NG, Thomas JD,
Blackstone EH, Young JB. Results of partial left
ventriculectomy for dilated cardiomyopath:
hemodynamic, clinical and echocardiographic
observations. J Am Coll Cardiol 2000;36:
2098–2103.
w4x Franco-Cereceda A, McCarthy PM, Blackstone
EH, Hoercher KJ, White JA, Young JB, Starling
RC. Partial left ventriculectomy for dilated
cardiomyopathy: is this an alternative to
transplantation? J Thorac Cardiovasc Surg
2001;121:879–893.
w5x Lunkenheimer PP, Redmann K, Cryer CW,
Wubbeling F, Konertz W, Batista RJ, Ho SY,
Anderson RH. The relationship between structure
and function: why does reshaping of the left
ventricle surgically not always result in functional
improvement? Comput Biol Med 2003;33:
185–196.
w6x Frazier OH, Gradinac S, Segura AM, Przybylowski
P, Popovic Z, Vasiljevic J, Hernandez A, McAllister
HA Jr, Bojic M, Radovancevic B. Partial left
ventriculectomy: which patients can be expected
to benefit? Ann Thorac Surg 2000;69:1836–1841.
w7x Claus M, Beling M, Grohmann A, Borges AC,
Baumann G. Long-term results after partial left
ventriculectomy. Int J Cardiol 2003;89:223–230.
w8x Ascione R, Lim KH, Chamberlain M, Al-Ruzzeh S,
Angelini GD. Early and late results of partial left
ventriculectomy: single center experience and
review of the literature. J Card Surg 2003;18:
190–196.
w9x Gradinac S, Miric M, Popovic Z, Popovic AD,
Neskovic AN, Jovovic L, Vuk L, Bojic M. Partial
left ventriculectomy for idiopathic dilated
cardiomyopathy: early results and six-month
follow-up. Ann Thorac Surg 1998;66:1963–1968.
w10x Moreira LF, Stolf NA, de Lourdes Higuchi M, Bacal
F, Bocchi EA, Oliveira SA. Current perspectives of
partial left ventriculectomy in the treatment of
dilated cardiomyopathy. Eur J Cardiothorac Surg
2001;19:54–60.
w11x Konertz W, Khoynezhad A, Sidiropoulos A, Borak
V, Baumann G. Early and intermediate results of
left ventricular reduction surgery. Eur J. Cardio-
thorac Surg 1999;15:S26–S30.
w12x Vural KM, Tasdemir O. Mid-term results of partial
left ventriculectomy in end-stage heart disease.
Eur J Cardiothorac Surg 2000;18:550–556.
w13x Lucchese FA, Frota Filho JD, Blacher C, Pereira
W, Lucio E, Beck L, Leonetti LA, Leaes PE. Partial
left ventriculectomy: overall and late results in 44
class IV patients with 4-year follow-up. J Card
Surg 2000;15:179–185.
w14x Setser RM, White RD, Sturm B, McCarthy PM,
Starling RC, Young JB, Kasper J, Buda T,
Obuchowski N, Lieber ML. Noninvasive assess-
ment of cardiac mechanics and clinical outcome
after partial left ventriculectomy. Ann Thorac Surg
2003;76:1576–1586.