Jacob Bergsland

Myocardial Revascularization of the Beating Heart in High‐Risk Patients

Objective: Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique in patients at high risk for conventional coronary artery bypass grafting (CABG). The purpose of this article is to evaluate the potential benefit of such an approach. Methods: We retrospectively evaluated the perioperative results of off‐pump CABG (OPCAB) performed from January 1995 to December 1999. Patients were divided into three groups on the basis of their preoperative risk factors: age greater then 80 years, reoperative CABG, and left ventricular ejection fraction percentage (LVEF%) less than 40%. The three subgroups were compared with patients operated on‐CPB (ONCAB) during the same period of time. A total of 172 octogenarians had ONCAB versus 97 OPCAB, 307 reoperations were ONCAB versus 274 OPCAB, and 514 patients with LVEF% less than 40% were operated ONCAB versus 220 OPCAB. Results: Preoperative comorbidities were homogeneously distributed in the OPCAB and ONCAB groups. More extensive coronary artery disease was found in the ONCAB groups. A trend for a lower number of perioperative complications was reported in the OPCAB groups. Freedom from overall complications was significantly higher (p < 0.005) in the OPCAB group. Actual mortality rates in the OPCAB and ONCAB groups were comparable (p = NS). Conclusions: CABG can be performed safely without CPB in patients with a high preoperative risk profile. Freedom from perioperative complications is markedly higher when the OPCAB approach is utilized.

Partial Left Ventriculectomy: The 2nd International Registry Report 2000

Background: Partial left ventriculectomy (PLV) has been performed without standardized inclusion or exclusion criteria. Methods: An international registry of PLV was expanded, updated, and refined to include 287 nonischemic cases voluntarily reported from 48 hospitals in 11 countries. Results: Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation, presence or absence of mitral regurgitation, and transplant indication had no effects on event‐free survival, which was defined as absence of death or ventricular failure that required a ventricular assist device or listing for transplantation. Preoperative patient conditions, such as duration of symptoms (> 9 vs < 3 years; p = 0.001), New York Heart Association (NYHA) class (Class IV vs < Class IV; p = 0.002), depressed contractility (fractional shortening [FS] < 5% vs > 12%; p = 0.001), and refractory decompensation that required emergency procedure (p < 0.001) were associated with reduced event‐free survival. Five or more cases in each hospital led to significantly better outcomes then the initial four cases. Rescue procedures for 14 patients nonsignificantly improved patient survival (2‐year survival 52%) over event‐free survival (2‐year survival 48%; p = 0.49), with improved NYHA class among survivors (3.6 to 1.8; p < 0.001). Outcome was better in 1999 then in all series before 1999 (p = 0.02) most likely due to patient selection, which was refined to avoid known risk factors such as reduced proportion of patients in NYHA Class IV, FS < 5%, and hospitals with experience in 10 or less cases. A combination of these risk factors could have stratified 17 high‐risk patients with 0% 1‐year survival and 26 low‐risk patients with 75% 2‐year event‐free survival. Conclusion: Avoidance of risk factors appears to improve survival and might help stratify high‐ or low‐risk patients. Although less symptomatic patients with preserved contractility had better results after PLV, change of indication requires prospective randomized comparison with medical therapies or other approaches.

Partial Left Ventriculectomy in Patients with Dilated Failing Ventricle

Abstract Background: While partial left ventriculectomy (PLV) improves left ventricular energetic efficiency, concomitant reduction in mitral regurgitation may improve ventricular function. Methods: Two hundred ninety‐five patients undergoing lateral ventricular wall excision between the papillary muscles (lateral PLV) and 101 patients with an additional excision of papillary muscles and mitral valve replacement (extended PLV) were compared with 65 patients undergoing excision of anterior wall or ventricular aneurysm (anterior PLV). Results: All patients had reduced functional capacity, New York Heart Association (NYHA) Class 111 to IV (3.62 ± 0.49). Etiologies were cardiomyopathy (37.3%), coronary artery disease (32.3%), valvular disease (19.7%), Chagas disease (7.8%), and others (2.8%). Patients undergoing lateral and extended PLV had cardiomyopathy as the primary cause of heart failure, while a majority of anterior PLV patients had ischemic disease. Associated procedures included mitral valvuloplasty or replacement (lateral PLV 67%, extended PLV 100%, anterior PLV 40%) and tricuspid annuloplasty (67%, 76%, 28%, respectively.) In each group after surgery, end‐systolic dimension decreased more than end‐diastolic dimension despite reduced mitral regurgitation. Although extended PLV resulted in greater volume reduction and less mitral regurgitation, these patients had delayed recovery and poor survival. Patients with valvular disease had the most advanced myocardial hypertrophy with the best survival, while those with Chagas disease had more severe myocarditis, interstitial fibrosis, and the poorest survival. Conclusion: Lateral PLV improved hemodynamics and functional capacity as much as aneurysmectomy by reducing ventricular volume and mitral regurgitation. Inclusion and exclusion criteria have to be sought to make PLV safer and more effective.

On-pump and off-pump coronary artery bypass grafting in the elderly: predictors of adverse outcome.

Objective: To establish the role that coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) may have in improving perioperative outcomes of patients 70 years of age and older. Background: Coronary revascularization in elderly patients is associated with morbidity and mortality rates higher than those observed in younger patients. The impact of CABG without CPB on perioperative outcomes has not been clearly established. Methods: This retrospective, nonrandomized study consisted of 1872 CABG patients. Of these, 1389 underwent CABG with CPB (CPB group) and 483 patients underwent CABG without CPB (off‐pump group). Preoperative variables and outcomes were compared between the two groups. Multivariate logistic regression analysis was used to identify independent predictors of mortality, stroke, and adverse outcome. Results: Demographics, Canadian Cardiovascular Society staging, operative priority, and other preoperative variables were comparable between the two groups. The prevalence of previous myocardial infarction was higher in the CPB group (62.6% vs 56.7%; p < 0.005), whereas the prevalence of calcified aorta and preoperative renal failure were higher in the off‐pump group (5.4% vs 9.5%; p = 0.04 and 1.7% vs 3.3%; p = 0.04, respectively). Although the graft/patient ratio was higher in the CPB group (3.4 vs 1.9), these patients displayed more extensive coronary artery involvement. At univariate analysis, patients in the off‐pump group had a higher rate of freedom from complications (88.2% vs 81.3%; p < 0.005) and a lower incidence of stroke (2.1% vs 4.2%; p = 0.034) than patients in the CPB group. Although there was a trend for a higher actual mortality in the off‐pump group (4.8% vs 3.7%; p = ns), the risk adjusted mortality in this group was lower (1.9% vs 2.1%). Multivariate analysis showed that while the use of CPB correlated independently with an increased risk of overall complications, it was not associated with a higher probability of death or stroke. Conclusions: This investigation suggests that elderly patients undergoing CABG may benefit from off‐pump revascularization, as the use of CPB correlated independently with an increased risk of overall complications. However, CPB did not emerge as an independent predictor of death or stroke at multivariate analysis.

Improved Left Ventricular Contraction and Energetics in a Patient with Chagas' Disease Undergoing Partial Left Ventriculectomy

A 43‐year‐old patient with heart failure, precluded from heart transplantation or dynamic cardiomyoplasty because of Chagas disease cardiomyopathy, mitral regurgitation, and ventricular mural thrombi, underwent mitral valvuloplasty and partial left ventriculectomy (PLV) between the papillary muscles. Intraoperative pressure‐volume relationship analyses suggested improvement in left ventricular contraction, energetics, isovolumic relaxation, and mitral valve competency. These improvements allowed prompt, short‐term recovery despite unchanged myocardial pathology, which suggests that a surgical approach can after anatomic‐geometric factors and achieve clinical improvement in a dilated failing ventricle.

Partial Left Ventriculectomy for Patients with Ischemic Cardiomyopathy

Background: Partial left ventriculectomy (PLV) has been performed in patients with dilated cardiomyopathy (DCM), but improved myocardial energetics may make PLV useful also for ischemic cardiomyopathy (ICM) unamenablis to conventional treatment. Methods: Of 262 patients undergoing PLV, 94 patients with ICM as the underlying pathology were analyzed and compared with 168 patients with DCM. Results: ICM patients were older (57.3 years vs 50.9 years, p = 0.0001) and heavier (69.7 kg vs 65.9 kg, p = 0.039) than those with DCM, but ventricular end‐diastolic and end‐systolic dimensions were similar with comparably depressed fractional shortening (16% vs 15%, p = 0.294) and equally severe functional limitation [New York Heart Association (NYHA) Class 3.7 vs 3.6, p = 0.734]. A majority of patients in both groups underwent lateral PLV (76% vs 74%, p = 0.883) with myocardium excised between papillary muscles and simultaneous mitral valvuloplasty (41% vs 74%, p < 0.0001). Because ICM patients required coronary artery bypass grafting (CABG) more frequently (79% vs 0.6%, p < 0.0001), operation was more extensive in terms of bypass time (74 minutes vs 47 minutes, p < 0.0001), percentage requiring cardiac arrest (43% vs 19%, p < 0.0001), and arrest duration (34 minutes vs 28 minutes, p = 0.280), but all had similar resection and postoperative ventricular dimensions. Nonetheless, ICM patients required shorter intensive care unit (ICU) time (4.4 days vs 5.9 days, p = 0.048) and similar postoperative hospital stays, resulting in similar hospital survival rates (69% vs 71%, p = 0.778) and functional capacity in long‐term follow‐up. Conclusions: Results suggest that PLV can be performed in patients with ICM with comparable risks and benefits as in DCM. Relative efficacy of CABG and mitral repair as compared to volume reduction remains to be studied.

Limited Access Left Thoracotomy for Reoperative Coronary Artery Disease: On or Off Pump

Abstractu2002 Between 1971 and 1988 left thoracotomy was performed on pump for selected reoperations. Since 1993, 92 patients were operated on with a limited approach and an increased number of cases were done off pump (70 patients). The purpose of this paper is to describe the transition of our operative techniques from on pump to off pump for reoperative coronary patients. From 1995 to 1999, 22 patients (Group 1) were operated on pump and 70 patients (Group II) off pump; 86 of 92 (93.5%) had reoperations. The demographic data were similar in these two groups regarding age, gender, ejection fraction, and total number of grafts performed. In this study 92 patients had a crude mortality of 4.3%. Limited access thoractomy provides safer reoperation than previously (1971–1988) with an improved on or off pump (4.5% vs. 4.3%) mortality, compared to the on pump mortality of 10% between 1971–1988. Off‐pump operations are performed with increasing frequency and with the same risk and less postoperative complications.

Ventricular volume reduction procedures.

Abstract Although partial left ventriculectomy (PLV) has been abandoned in many institutions, a few hospitals continue to perform it with a relatively favorable outcome. Other volume reduction procedures have become popular with renewed interest in ventricular reshaping to improve function. Although recent refined selection criteria have improved survival with PLV, earlier unpredictable results prompted less invasive procedures based on the same physiologic concept of reducing radius or wall tension by wrapping, piercing, or clasping. These new techniques are not only less invasive but also reversible and adjustable and appear safer for less symptomatic patients at risk of progressive heart failure. Nonetheless, mechanisms of action and degrees of volume reduction and/or restriction need to be delineated before widespread clinical application. (J CARD SURG 2003;18 (Suppl 2):S69‐S75)

Histopathology of Resected Myocardium and Outcome of Partial Left Ventriculectomy

Background: Since preoperative hemodynamics are not proven to be a predictor of effects of partial left ventriculectomy (PLV), myocardial histopathology may be better correlated with effects and outcome of PLV. Methods: Myocyte size (μ) in the excised myocardium was measured in 338 patients undergoing PLV. Endocardial fibrosis, interstitial fibrosis, and inflammatory cell infiltration were enumerated as none = 0, mild = 1, moderate = 2, and severe = 3. These histopethologic observations were correlated with patients postoperative survival. Results: Reduced survival was seen in patients with advanced (≥ moderate) interstitial fibrosis in all patients (n = 338, p = 0.064) and in the subgroup with nonischemic etiology (n = 229, p = 0.0039). Although correlation between endocardial and interstitial fibrosis was significant (r = 0.55, p < 0.01), endocardial fibrosis failed to correlate with postoperative survival. While Chagas disease was associated with severe inflammation and poor survival, the presence of inflammatory cell infiltration had no effect on survival in all patients combined (p = 0.943). Although most patients (n = 266, 79%) had myocyte diameter over 30 μ, those with less hypertrophy (> 30 μ, n = 70, 21%) had a tendency toward increased survival (p = 0.067) regardless of underlying etiology. Conclusion: Interstitial fibrosis may be an important factor in stratification of patients for repair (PLV) or replacement (transplantation). PLV may be more beneficial in patients with less hypertrophy, before development of interstitial fibrosis. Endomyocardial biopsy might not predict the extent or variation in degree of interstitial fibrosis, which may be better evaluated by other metabolic or perfusion studies that measure overall myocardial histopathology and viability.

Use of the “Single Suture” Technique to Expose the Anterior Surface of the Heart

Abstractu2002 The “single suture” technique, which consists of placing a suture in the oblique sinus of the posterior pericardium and connecting it to a vaginal tape, is commonly adopted in off‐pump coronary artery revascularization to obtain elevation of the heart and coronary artery exposure. This report describes the use of this technique to expose the anterior wall of the heart in the setting of ventricular aneurysm repair.