SURGICAL RESTORATION OF VENTRICULAR FUNCTION

DR. REZWANUL HOQUE BULBUL

MBBS, MS, FCPS, FRCS(GLASGOW), FRCS(EDINBURGH)

ASSOCIATE PROFESSOR, CARDIAC SURGERY

BSMMU, DHAKA, BANGLADESH

DILATED CARDIOMYOPATHYPATHOPHYSIOLOGY
Dilated cardiomyopathy is characterized by ventricular chamber enlargement and systolic dysfunction with greater LV cavity size with little or no wall hypertrophy. Hypertrophy is judged as the ratio of LV mass to cavity size; this ratio is decreased in persons with dilated cardiomyopathies. Dilated cardiomyopathies are associated with both systolic and diastolic dysfunction. The decrease in systolic function is by far the primary abnormality. This leads to an increase in the end-diastolic and end-systolic volumes. Associated with activation of RAAS, increased arginine-vasopressin, ANP,BNP and CNP, increased catecholamine with down regulation of receptors, volume overload and increased workload of the heart. Elevation of TNF-alpha, IL-1b, IL-2R, IL-6 may mediate myocardial cell injury.
http://emedicine.medscape.com/article/152696-overview#a0104

DCM- INCIDENCE, PREVALENCE & ETIOLOGY

The reported incidence is 400,000-550,000 cases per year, with a prevalence of 4-5 million people. Causes of dilated cardiomyopathy include the following- ( Ischemic, non-ischemic, valvular) Genetics Secondary to other cardiovascular disease: ischemia, hypertension, valvular disease, tachycardia induced Infectious: viral, rickettsial, bacterial, fungal, metazoal, protozoal Probable infectious: Whipple disease, Lyme disease Metabolic: endocrine diseases (e.g., hyperthyroidism, hypothyroidism, acromegaly, myxoedema, hypoparathyroidism, hyperparathyroidism), diabetes mellitus, electrolyte imbalance (e.g., potassium, phosphate, magnesium) Nutritional: thiamine deficiency (beriberi), protein deficiency, starvation, carnitine deficiency Toxic: drugs, poisons, foods, anaesthetic gases, heavy metals, ethanol Collagen vascular disease Infiltrative: hemochromatosis, amyloidosis, glycogen storage disease, Granulomatous (sarcoidosis) Physical agents: extreme temperatures, ionizing radiation, electric shock, nonpenetrating thoracic injury Neuromuscular disorders: muscular dystrophy (limb-girdle [Erb dystrophy], Duchenne dystrophy, fascioscapulohumeral [Landouzy-Dejerine dystrophy]), Friedreich disease, myotonic dystrophy Primary cardiac tumour (myxoma), Senile, Peripartum Immunologic: postvaccination, serum sickness, transplant rejection

http://emedicine.medscape.com/article/152696-overview#a0104

DEFINITION OF SURGICAL VENTRICULAR RESTORATION

Surgical ventricular restoration (SVR) is a procedure designed to restore or remodel the left ventricle to its normal, spherical shape and size in patients with akinetic segments of the heart, secondary to either dilated cardiomyopathy or post infarction left ventricular aneurysm. The SVR procedure is usually performed after coronary artery bypass grafting (CABG) and may proceed or be followed by mitral valve repair or replacement and other procedures such as endocardectomy and cryoablation for treatment of ventricular tachycardia. A key difference between surgical ventricular restoration and ventriculectomy (i.e., for aneurysm removal) is that in SVR the ventricle is reconstructed using patches of autologous or artificial material that are placed to close the defect while maintaining the desired ventricular volume and contour.

Additionally, SVR is distinct from partial left ventriculectomy (i.e., the Batista procedure) which does not attempt to specifically resect akinetic segments and restore ventricular contour.

BlueCross BlueShield Association Medical Policy Reference Manual "Surgical Ventricular Restoration." Policy No. 7.01.103

RELATIONSHIP BETWEEN STRUCTURE & FUNCTION

The central theme of cardiac surgery is that alteration of structure improves function, and this concept is fundamental during surgical restoration of dilated hearts in cardiac failure. The conical pattern of normal cardiac size and shape is well known and the underlying spatial arrangements are closely linked to the helical ventricular myocardial band and comprised of a surrounding wrap of the basal loop with transverse fibres and an apical loop of reciprocal oblique fibres forming a spiral vortex at the apex. The spherical configuration of the enlarged global ventricle widens the apical loop by making the oblique apical loop fibres develop a transverse orientation that more closely resembles the horizontal fibre orientation of the basal loop.
Configuration of muscle fibers at the apex: figure of 8, produce 60% E.F. with only 15% muscle fiber shortening .Transverse fiber direction: - E.F.= 30% increases to 60% with oblique direction

The bioengineering infrastructure for this mechanical change in size and shape reduces ejection fraction, which is 60% with oblique fibre direction and lowered to 30% when fibre orientation is transverse.
Buckberg GD: Form versus disease: optimizing geometry during ventricular restoration. Eur J Cardiothorac Surg 2006;29 Suppl 1:S238S244

LAPLACE LAW
T=(P*R)/M Where T is the tension in the walls, P is the pressure difference across the wall, R is the radius of the cylinder, and M is the thickness of the wall. An example of Laplace Law is Dilated cardiomyopathy. In this condition heart becomes greatly distended and the radius (R) of ventricle increases. Therefore to create the same pressure (P) during ejection of the blood much larger wall tension (T) has be developed by the cardiac muscle. Thus dilated heart requires more energy to pump the same amount of blood as compared to the heart of normal size. The new surgical procedure, called ventricular remodelling, uses Laplace principle to improve the function of dilated, failing hearts.

A- OBLIQUE APICAL LOOP FIBRE IN NORMAL HEART B- TRANSVERSE APICAL LOOP FIBRE IN DILATED HEART

Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

ISCHEMIC DCM
White emphasized on ESVI rather than E.F. as the prognostic barometer LV Volume: a sensitive prognostic parameter for both late and early events after a MI Prior to early reperfusion: transmural infarction classic thinned, dyskinetic (paradoxical wall motion) LV aneurysm With early reperfusion epi- and mid-myocardium spared with endocardial necrosis segmental akinesis (lack of contractility) Endocardium and mid-myocardium damage >50% of the LV wall incapable of functional recovery Progressive heart dilatation follows asynergy of >50% (30%) LV circumference after anterior MI GUSTO (1997): ESVI >40 ml/m2 a high incidence of CHF & poor long-term survival HF developed by progressive decrease of compensatory contraction of remote muscle.
Overview: Ventricular restoration a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004

RATIONALE FOR SVR

Because of the shortage of donors for heart transplantation, surgical ventricular reconstruction (SVR) has been under development to treat end-stage heart failure due to a dilated left ventricle. The operative procedures have been developed and modified based on the clinical results and preoperative findings of several examinations.

SVR is performed to reduce the size and volume of the ventricle as well as to reshape it.
The procedures, which differ based on the particular left ventricular lesion, are endoventricular patch plasty or septal anterior ventricular restoration for anteroseptal exclusion and partial left ventriculectomy or a posterior restoration procedure for posterolateral exclusion. In the indicated patients, SVR has been emerging as an alternative to heart transplantation.
The New England Journal of Medicine (2009) Volume: 361, Issue: 5, Pages: 529;

INDICATION FOR SVR

Indication Anteroseptal MI with dilated LV: LVESVI >60ml/m2, LVEDVI >100ml/m2 Left ventricular asynergy( akinesia or dyskinesia) > 35% of LV anterior wall

Relative contraindication
Diffusely diseased RCA or LCX not amenable to CABG with inferior wall asynergy or aneurysm Absolute contraindication

Idiopathic pulmonary HTN with PASP>60 mm Hg

Severe RV dysfunction
Surgical Ventricular Restoration, ntuh.sicu.org.tw/upload/.../Surgical%20Ventricular%20Restoration.p...

CONCEPT OF SURGICAL CORRECTION

Based upon Laplace's law Reduces the size of the ventricle Restores the elliptical shape of the heart Return the left ventricular volume/mass ratio toward normal Significantly improves the pumping action of the heart

Improves clinical status

Usually done with CABG, often done with valve repair

COOLEY 1959, THE FIRST SURGICAL TREATMENT OF LARGE DYSKINETIC, LV ANEURYSM ON CPB , LINEAR CLOSURE, DOES NOT ADDRESS SEPTAL ANEURYSM, DISTORTION OF LV GEOMETRY AND PERSISTENCE OF THIS DAMAGED AREA LEADS TO RECURRENT HF MANY YEARS LATER.

V Rao et al. Asian Cardiovasc Thorac Ann 2008;16:401-406

SEPTAL PLASTY OPERATION OF STONEY, 1978

Ventricular aneurysmectomy

Emphasis on anteroseptal repair by using a flap of scarred tissue

JATENE, 1984
Imbricated the scar and reformed the elliptical scar

Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

SCHEMA OF SURGICAL PROCEDURES

Schemata of the Dor procedure, Batista procedure, and Overlapping-type left ventriculoplasty (OLVP). a: Dor procedure: LV volume reduction is accomplished by an endoventricular patch in the anterior and septal portions. The basic concept is the same as Cooleys method and the septal anterior ventricular exclusion (SAVE) procedure. b: Batista procedure: LV lateral wall is broadly resected and closed with direct suture. c: OLVP: This procedure performs ventriculotomy of the anterior wall without ventriculectomy, and doubles in part the LV anterior wall by overlapping the incised wall around the apex. Papillary muscles approximation (PMA) is also performed as an adjunct to OLVP, depending on the situation of the case.

Yoshiro Matsui Shigeyuki Sasaki. Ann Thorac Cardiovasc Surg Vol. 14, No. 2 (2008)

PROCEDURES OF CHOICE

CIRCULAR PATCH REPAIR

Circular patch repair. The aneurysm wall is incised. An inferior aneurysm is shown. Circular patch repair. The aneurysmal wall is excised, leaving a 2-cm rim of fibrous aneurysmal wall attached to healthy muscle.

Circular patch repair. The aneurysmal defect is closed with a Dacron patch using interrupted 2-0 monofilament horizontal mattress sutures with reinforcing pledgets.

Glower D Di , Lowe J Ei . Left Ventricular Aneurysm. Cohn Lh, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2008:803-822

ENDOVENTRICULAR PATCH REPAIR

Endocardial patch. Without excising the aneurysm wall, the ventricular defect is closed with a Teflon felt patch using 3-0 polypropylene suture secured at three or four points along the suture line. Additional 3-0 pledgeted horizontal mattress sutures may be used to achieve haemostasis. Endocardial patch. The aneurysm wall is closed over a Teflon patch after resecting excess aneurysm tissue. A double row of running vertical 2-0 polypropylene sutures is used.

Glower D Di , Lowe J Ei . Left Ventricular Aneurysm. Cohn Lh, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2008:803-822

ENDOVENTRICULAR CIRCULAR PATCH PLASTY

Both akinetic and dyskinetic scarred portion of the ventricle is excluded Avoids pericardial adhesion as it does not contain external prosthetic material Relieve ischemia by complete coronary revascularization: grafting the LAD providing upper septal perfusion

Ventricular sizing: 60 mL/m2 (EDV<150 mL/m2) and 70 mL/m2 (EDV>150 mL/m2) Diminish ventricular volume diminish wall stress, reduce myocardial oxygen consumption
Ventricular geometry is better maintained resulting in diminished wall stress, improved wall compliance, reduced filling pressure, enhanced diastolic coronary flow, decreased myocardial O2 consumption, improved systolic contraction.

STEPS TO DOR PROCEDURE

Fontan, 1989 Placed a circumferential suture around the border of ischemic and normal tissue to create an oval neck for patch placement after securing this suture .Patch: oval with a long diameter of 2 2.5 cm in situ made 2.5 3 cm to compensate space taken up by suture line.

Cooley, 1992
Excluding septal aneurysm wall by placing an endoventricular patch placed between the scarred and viable areas

DOR PROCEDURE- STEPS

a. Open left ventricle during restoration showing palpation

to define the contracting and noncontracting muscle.

b. Shows Fontan suture in place and interrupted sutures through neck and into suture holders, quite similar to valve procedures.

Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

STEPS-CONTINUED
a. Sizing the oval from Fontan suture,

b. shows placement of prericardial patch with inner ring on surgical neck

c.shows oblique pericardial patch in final intraventricular position.

Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

STEPS- CONTINUED

Finding the left ventricular apex, either from the outside where it is adjacent to right ventricular apex, or from the inside with use of a conical intraventricular balloon.

STEPS- CONTINUED

a. b.

Wrap around anterior infarction and scar, shows open left ventricle with inferior scar. Imbrication of the inferior wall from mattress sutures either the outside in

c or the inside in d.

STEPS

Creation of LV apex by securing the imbricating inferior sutures and using the tip b as the apex in a. Placement of oblique patch to rebuild a conical shape in b.

STEPS

a. Demonstration of the normal width between papillary muscles in b, Widening from distance between papillary muscle bases is shown in c.

STEPS
Narrowing of the widened dimension between bases of papillary muscles is shown in a.

Placement of mattress sutures

between the bases of the papillary muscles and the ventricular muscle between the bases in shown in b,

and securing these sutures to restore the normal dimension between the papillary
muscle bases in c.

STEPS

The normal annular dimensions are compared to the widened annulus with central functional mitral regurgitation ,and downsizing the annulus with a posteriorly placed mitral ring shown below.

TRIANGULAR PATCH VENTRICULOPLASTY

Scar involving the base, septum and lateral wall following inferior infarction in a.

Site of inferior wall incision parallel to posterior descending coronary

artery in b and exposure of intraventricular cavity following incision in c.

Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

CONTINUED
Triangular patch that conforms to the base of the infarct region shown in upper left. Insertion of double arm imbricating sutures in base, septum and lateral wall in upper right. Securing the imbricating suture to make a smaller triangle (retriangulation) in lower left. Patch placement with sewing the patch rim for haemostasis (centre) and ventricular closure

on lower right.

SAVER
Surgical anterior ventricular endocardial restoration Utilize Dors principle with some technical modification

SAVER in the dilated remodeled ventricle after anterior myocardial infarction, Journal of the American College of Cardiology 37(5) 2001 1199-1209

SAVER

Pacopexy or SAVER procedure with open left ventricle and interrupted mattress sutures in septum and LV free wall A,

insertion of oblique patch from apex to high septum, using Teflon strip in (B),
and closure to rebuild a conical chamber in (c).

SAVER/SAVE PROCEDURE

Left ventricular restoration in dilated cardiomyopathy in ischemic disease without discrete scar.

The SAVER or Pacopexy procedure is used to make the spherical chamber become elliptical. A patch is placed between the apex and septum to reconstruct a conical chamber.

Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

UNIFIED CONCEPTS
Unified concept with the dilated spherical left ventricular shape in either ischemic, nonischemic or valvular cardiomyopathy Geometrically changing shape to create a conical of elliptical chamber in either ischemic, non-ischemic or valvular disease to alter structure toward normal as shown here.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007

VENTRICULAR REMODELLING OPERATION (BATISTA PROCEDURE): 1994

The ventricular remodelling operation (also known as the Batista procedure, partial left ventriculectomy, heart reduction surgery, and wedge resection of the heart) has been proposed as a surgical procedure to replace or postpone heart transplantation in patients with dilated non-ischemic cardiomyopathy. It involves removing a viable portion of the enlarged left ventricle and repair of the resultant mitral regurgitation with a valve ring. It attempts to augment systemic blood flow through improvement in the mechanical function of the left ventricle by restoring its chamber to optimal size. In most cases, partial left ventriculectomy is accompanied by mitral valve repair. Although initial reports on the Batista procedure lacked significant information on its safety and effectiveness, overall clinical impression was that the operation may serve as a bridge to heart transplantation especially in patients with idiopathic dilated cardiomyopathy. In a prospective evaluation of the Batista procedure, Weston et al (2000) reported that at 3, 6, and 12 months post-surgery the ejection fractions of patients who had undergone the operation were not significantly better than prior to surgery. Moreover, there was no survival benefit with 60% of the patients expiring within 6 months after the Batista procedure.

http://www.aetna.com/cpb/medical/data/100_199/0182.html

LIMITATION & OUTCOME OF BATISTA PROCEDURE

Remove LV lateral wall irrespective of regional dysfunction used less for ischemic etiologies Reduce systolic wall stress and improve E.F. A deleterious effect on diastolic compliance: reduce recruitable stroke work (Starling law), magnitude of shape change or pumping capacity SVR: resection of non-functional myocardium resection of akinetic portion with normal thickness in dilated, poorly functioning heart

Long-term effectiveness for primarily IDCM: despite impressive improvement in acute LVEF (1631%), disappointingly low event-free survival rates at 1 year (49%) and 3 years (26%)
ACC/AHA: class III procedure

ACORN CORCAP CARDIAC SUPPORT DEVICE

The CorCap Cardiac Support Device, manufactured by Acorn Cardiovascular, Inc., resembles a net that is placed around and attached to the heart to support the damaged heart muscle and limit further enlargement. It provides passive support that reduces the stress on the ventricular wall.

http://www.columbiasurgery.org/pat/cardiac/acorn.htm

MYOSPLINT, 2002
Reshape the spherical LV into two elliptical LV

Surgical left ventricular remodeling in heart failure, The European Journal of Heart Failure 7 (2005) 704-709

OTHER BRIDGE TO TRANSPLANTATION PROCEDURE

May be used as bridge or destination therapy Cardiac resynchronization/ biventricular pacing AICD VAD TAH Heart transplantation is the procedure by which the failing heart is replaced with another heart from a suitable donor.[1] It is generally reserved for patients with end-stage congestive heart failure(CHF) who are estimated to have less than 1 year to live without the transplant and who are not candidates for or have not been helped by conventional medical therapy.

E-mail: drrhbulbul@yahoo.com

Cell no- +8801711560305