MMCTS
(June 28, 2005). doi:10.1510/mmcts.2004.000760
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Left ventricular volume reduction
Raimondo Ascione*,
Peter Wilde and
Gianni D. Angelini
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, UK
* Corresponding author: * Tel.: +44-117-9283145; fax: +44-117-9299737. E-mail: r.ascione{at}bristol.ac.uk
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Summary
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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 ventricular 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 diameter 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 cardiopulmonary bypass on the beating heart. Additional techniques with cardioplegic arrest, concomitant mitral valve repair, and closure of the left ventricle for improvement of hemostasis are shown.
Key Words: Left ventricular volume reduction • End-stage heart failure
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Introduction
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History
Left volume ventricular reduction (LVVR) was first performed by Randas Batista in 1983 and reported in 1996 [1]. He ventured to reduce the size of the left ventricle, and hence to remodel its shape [1, 2] assuming that its size-related mural stress is the crucial determinant of the heart's ultimate fate. The operation gained popularity worldwide in the mid 1990s, because of the shortage of the available donor supply limiting cardiac transplantation, and the large population with end-stage heart failure, not fulfilling the inclusion criteria for transplantation. Furthermore, preliminary data reported survival rates at 6-month follow-up similar to those associated with heart transplantation [3]. However, later results were less promising, with only 25% of patients improved following surgery, while 33% deteriorated rapidly, and the remaining percentage experiencing a temporary improvement in cardiac function followed by a return to gradually declining function [4]. Due to these findings, 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 [5], questions what would have been the impact of this procedure if a more critical and scientific approach had been used.
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Rationale
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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 (M=4.18xR3 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, jeopardized by discontinuities in the radius of curvature, in thickness of the left ventricular wall, and presence of fibrosis, which are obvious, and vary characteristically with different diseases, and may be so discrete to escape observation by clinical routine ventricular imaging.
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Preoperative diagnostic assessment
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Most patients who are referred for ventricular remodelling 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 hypovolaemic conditions. The manoeuvre simulates the working conditions of the shrunken heart after the intervention [5]. 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 primary disease, and its state of healing at the time of the intervention, also require greater diagnostic endeavour [5]. 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 curvature, thickness and viability of the left ventricular wall (Video 1). Concomitantly, trans-thoracic or trans-oesophageal echocardiogram is of paramount importance in providing valuable information on the presence of significant valve disease needing correction (Video 2).
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Video 1 Cardiac MRI of a case done at the Bristol Heart Institute. Two-chamber view showing a dilated LV and LA.
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Video 2 Preoperative trans-thoracic echocardiogram in a patient with dilated cardiomyopathy.
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Surgical technique
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The procedure is performed through a median sternotomy, standard cannulation of the ascending aorta and selective bi-caval cannulation.
Originally, the operation was carried out at normothermia on the beating heart (Video 3). An incision is then made at the apex of the dilated left ventricle followed by anterior and posterior ventriculectomy incisions extended toward the atrioventricular groove and brought together 1–2 cm prior to reaching it (Video 4, Schematic 2).
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Video 3 An incision is then made at the apex of the dilated left ventricle followed by anterior and posterior ventriculectomy incisions (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
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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).
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The posterior ventriculectomy may be extended behind the posterior medial papillary muscle, in case a larger reduction is planned with associated mitral valve replacement (Videos 4, 5, 6).
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Video 5 The mitral valve is excised from the ventricular side (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
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Video 6 Mitral valve replacement is performed from the ventricular side (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
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The ventriculectomy is then closed using a continuous 2-0 monofilament full-thickness suture, followed by 3-0 monofilament hemostatic suture (Video 7).
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Video 7 Closure of ventriculectomy (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
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This will determine a reshaping of the LV with reduction of left ventricular volume and size (Video 8).
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Video 8 Post-operative trans-thoracic echocardiogram showing reduction of LV volume and size (Video 2 is preoperative echocardiogram in the same patient). (Courtesy of Drs Randas J.V. Batista and Gianni D. Angelini).
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Technical variations
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Several variations of the technique have been developed depending on the need of appropriate myocardial protection during surgery, of reinforcing the suture line to prevent catastrophic bleeding, and on the presence 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;
- 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
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Video 9 Post-operative trans-thoracic echocardiogram in a patient undergoing LV reduction and concomitant mitral valve repair with the edge-to-edge technique. Short axis view showing the typical double orifices.
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In case of associated significant tricuspid valve regurgitation this can be dealt with standard repair techniques.
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Discussion
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Some obvious mechanisms causing failure of partial ventriculectomy
Correction of left ventricular compliance: the site, shape and size of the resected segments are very variable, 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 surgeons may tend to focus on the dilated apex leaving untouched the midportion and the base [5].
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 of scar tissue, which may also affect coronary arterial perfusion [5].
Persistence of the primary disease: persistence of viral infections or immunological diseases following LV reduction surgery may affect the results as the primary 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 [5]. This could also be due to presence of significant fibrosis within the non-resected myocardium (Photo 1).
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Photo 1 (Reproduced from Ref. 6 with permission from Elsevier).
Photomicrograph confirming the extensive fibrosis in the THI specimen (top left) and a minimal amount or absence of fibrosis in the DCI specimen (bottom left). (Masson trichrome, magnificationx4). Longitudinal section of myocardium in THI (top right) and DCI (bottom right) specimens, showing an obvious difference in hypertrophy as confirmed by morphometric analysis (magnificationx20).
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Results
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- Despite the early enthusiasm, in-hospital mortality reported by various teams has seriously varied [1,2,3,4,5,6,7,8,9,10,11,12,13,14].
- Obvious early clinical [3] and functional [3, 4] benefits have been shown in a significant percentage of patients undergoing LV reduction surgery (Graphs 1, 2 and Photo 2) [3, 7, 12].
- However, there seems to be evidence of mid-term re-deterioration (Graph 3) [4].
- Long-term results have been reported by several authors (Graph 4, Video 10
) and are controversial [8,9,10,11,12,13,14].
- There might be a relation between baseline primary disease and late results (Graph 5) [8].
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Graph 1 (Reproduced from Ref. 3 with permission from Elsevier).
Individual data are shown for a symptom-limited exercise study performed preoperatively, at 3 months postoperatively, and 12 months postoperatively for the peak oxygen consumption (ml/kg/min). Peak oxygen consumption and exercise duration increased post-operatively.
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Graph 2 (Reproduced from Ref. 7 with permission from Elsevier).
NYHA functional class before and after PLV according to the etiology of cardiomyopathy. *P<0.05 compared to preoperative values.
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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; however, at PLV3 contraction of the septum is evident. (LV=left ventricle; PLV=partial left ventriculectomy; PLV3=partial left ventri-culectomy after 3 months.).
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Graph 3 (Reproduced from Ref. 4 with permission from Elsevier).
Mid-term deterioration in end-diastolic diameter across time.
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Video 10 Cardiac MRI at 8 years follow-up in a patient undergoing LV reduction at the Bristol Heart Institute.
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Graph 5 (Reproduced from Ref. 8 with permission from Blackwell).
Actuarial cumulative and split survival plot of the Bristol Heart Institute series.
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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 [5] is, however, remarkable (Video 10). One wonders 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.
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References
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- 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.[Medline]
- 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.[Abstract/Free Full Text]
- 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.[Abstract/Free Full Text]
- 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.[Abstract/Free Full Text]
- 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.[CrossRef][Medline]
- 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.[Abstract/Free Full Text]
- Claus M, Beling M, Grohmann A, Borges AC, Baumann G. Long-term results after partial left ventriculectomy. Int J Cardiol 2003;89:223–230.[Medline]
- 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.[Medline]
- 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.[Abstract/Free Full Text]
- 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.[Abstract/Free Full Text]
- Konertz W, Khoynezhad A, Sidiropoulos A, Borak V, Baumann G. Early and intermediate results of left ventricular reduction surgery. Eur J. Cardiothorac Surg 1999;15:S26–S30.
- Vural KM, Tasdemir O. Mid-term results of partial left ventriculectomy in end-stage heart disease. Eur J Cardiothorac Surg 2000;18:550–556.[Abstract/Free Full Text]
- 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.[Medline]
- Setser RM, White RD, Sturm B, McCarthy PM, Starling RC, Young JB, Kasper J, Buda T, Obuchowski N, Lieber ML. Noninvasive assessment of cardiac mechanics and clinical outcome after partial left ventriculectomy. Ann Thorac Surg 2003;76:1576–1586.[Abstract/Free Full Text]
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Summary
Introduction
