Accepted Manuscript
The Frozen Apex: A Useful Addition to the Surgeons
Armamentarium?
James K. Kirklin MD Professor of Surgery
PII: S1043-0679(18)30205-3
DOI: [Link]
Reference: YSTCS 1136
To appear in: Seminars in Thoracic and Cardiovascular Surgery
Received date: 24 August 2018
Accepted date: 24 August 2018
Please cite this article as: James K. Kirklin MD Professor of Surgery , The Frozen Apex: A Useful
Addition to the Surgeons Armamentarium?, Seminars in Thoracic and Cardiovascular Surgery (2018),
doi: [Link]
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ACCEPTED MANUSCRIPT
Editorial Commentary: Manuscript number #STCVS_2018_5
“Frozen Apex” Repair of a Dilated Cardiomyopathy
Manuscript Author: Masashi Komeda
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Commentary: James K. Kirklin
Commentary Title: The Frozen Apex: A Useful Addition to the Surgeons
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Armamentarium?
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James K. Kirklin, MD
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Contact Information
James K. Kirklin, MD
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Professor of Surgery
Division of Cardiothoracic Surgery
Kirklin Chair of Cardiothoracic Surgery
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Director, Kirklin Institute for Research in
Surgical Outcomes (KIRSO)
Department of Surgery
University of Alabama at Birmingham
PH: 205-934-3991
FAX: 205-934-3310
EMAIL: jkirklin@[Link], mgsmith@[Link]
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The Frozen Apex: A Useful Addition to the Surgeons Armamentarium?
Komeda and colleagues present an interesting twist to the surgical techniques
currently recommended for left ventricular volume reduction and restoration.1 Through
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elegant illustrations, the authors provide technical details on their procedure, which
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requires “less than 15 minutes” to perform.
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The ravages of ischemic heart disease became apparent to the cardiac surgeon
early in the history of cardiopulmonary bypass. Cooley reported the first repair of a left
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ventricular aneurysm just 4 years after cardiac surgery using a pump oxygenator
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became a clinical reality. The evolution of our understanding of the pathophysiologic
impact of large areas of infarcted myocardium (and the surgical procedures aimed at
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functional restoration) has variously included the damaging hemodynamics effects of a
large dyskinetic segment (left ventricular aneurysm resection),2 the detrimental impact
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of large akinetic areas on ventricular and mitral valve function (surgical ventricular
restoration), the late remodeling effects in the border zone between infarcted and intact
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myocardium (modifications of Dor’s procedure),3 and apical dyskinesis-induced
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disruption of left ventricular twist and recoil 4 (frozen apex repair).
The novel technique reported by Komeda builds on the principles of performing a
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procedure that excises infarcted endocardium/myocardium, reduces the area of
akinesis with concentric purse string sutures, may utilize a small endocardial patch to
reduce tissue stress and preserve geometry, and covers the repair with overlaying scar
for optimal hemostasis. The ease and apparent efficacy of the frozen apex repair create
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a useful tool in the heart failure surgeon’s armamentarium when the apex is involved
with aneurysm or dyskinesis.
Although the reported results are encouraging, a word of caution is in order. In
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follow up at approximately 1 year, ejection fraction on average was improved and
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systolic volume reduced. However, 4 of the 8 patients had either no change or an
increase in diastolic volume. So, yes, this is a useful addition to the surgeon’s toolbox,
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but further evaluation of efficacy is in order.
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References
1. Komeda, M., Uchiyama, H., Fujiwara, S. and Ujiie, T., 2018, August. “Frozen Apex”
Repair of a Dilated Cardiomyopathy. In Seminars in thoracic and cardiovascular
surgery. WB Saunders.
2. Cooley, D.A. and Hallman, G.L., 1968. Surgical treatment of left ventricular
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aneurysm: experience with excision of postinfarction lesions in 80 patients. Progress in
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cardiovascular diseases, 11(3), pp.222-228.
3. Dor, V., Di Donato, M., Sabatier, M., Montiglio, F., Civaia, F. and Restore Group,
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2001, October. Left ventricular reconstruction by endoventricular circular patch plasty
repair: a 17-year experience. In Seminars in thoracic and cardiovascular surgery (Vol.
13, No. 4, pp. 435-447). WB Saunders.
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4. Buckberg, G.D., 2002. Basic science review: the helix and the heart. The Journal of
Thoracic and Cardiovascular Surgery, 124(5), pp.863-883.
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