Michel Sabatier

Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars

BACKGROUND Many believe that dyskinesia is the only predictor of favorable surgical outcome after large myocardial infarction and that akinetic scars do not recover well in patients with globally depressed ventricular function. METHODS This study evaluates clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n = 51) or large dyskinetic scar (n = 49) and depressed left ventricular function (ejection fraction <30%). Groups were comparable for symptoms, indication for operation, and delay from myocardial infarction. Heart failure was a major indication for operation in both groups. Coronary grafting was performed in 98% of patients: 10 had mitral valve repair or replacement, and 47 patients with preoperative ventricular arrhythmias had cryotherapy. In-hospital mortality was 12% (five patients in the akinetic group [10%] and seven in the dyskinetic group [14%]). RESULTS Results showed an early and late improvement in New York Heart Association functional class and ejection fraction (from 23% +/- 5% to 31% +/- 11% to 40% +/- 13% in akinetic patients and from 23% +/- 6% to 41% +/- 10% to 41% +/- 12% in dyskinetic patients). Ventricular tachycardia was reduced significantly in both groups early and late after the operation. CONCLUSION We conclude that in patients with either large akinetic or dyskinetic scar and severe left ventricular dysfunction, endoventricular circular patch plasty associated with coronary grafting and cryotherapy, when indicated, provides surviving patients with significant improvement in cardiac function. This approach can be considered as an alternative to heart transplantation in patients with severe left ventricular dysfunction.

Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle

This study reports hemodynamic, electrophysiologic, and clinical results in 171 patients (157 men and 14 women, mean age 57 +/- 8 years) 1 year after endoventricular circular patch repair and coronary grafting for postinfarction left ventricular dyskinetic or akinetic aneurysm. All patients had hemodynamic and electrophysiologic study before the operation and early and 1 year after the operation. The vast majority of aneurysms were anterior (n = 166), with a mean delay from infarction of 43 +/- 50 months. Fifty-two percent of patients were in New York Heart Association class III or IV, and preoperative ejection fraction was less than 40% in the majority of them (75%). Preoperative clinical ventricular tachycardia was present in 25 patients and was inducible in 59 patients. All patients had endoventricular circular patch repair with a synthetic (n = 99) or autologous patch (n = 72); 96% had associated coronary grafting with a mean number of bypass grafts of 1.9 +/- 0.9. Results at 1 year demonstrated a significant increase in ejection fraction (from 36% +/- 13% to 46% +/- 12% (p < 0.0001) and a significant reduction in ventricular volumes (end-diastolic volume index from 116 +/- 5 to 94 +/- 29 ml/m2 and end-systolic volume index from 77 +/- 45 to 53 +/- 25 ml/m2, p < 0.0001). New York Heart Association functional classification was significantly improved (2.6 +/- 0.9 vs 1.4 +/- 0.6, p < 0.0001) and ventricular tachycardias were almost suppressed (no documented clinical ventricular tachycardias and 8% incidence of inducible ventricular tachycardias after 1 year, chi 2 < 0.001). Patients who benefit most from the operation are those with more severe preoperative left ventricular dysfunction (i.e., ejection fraction < 30%), more frequent ventricular arrhythmias, and larger ventricular volumes. At regression analysis, critical disease of the right coronary artery was the only independent predictor of unsatisfactory pump improvement (as evaluated by postoperative increase of ejection fraction < 10 absolute points). In conclusion, in our large series of patients operated on by one surgical team between 1988 and 1993, who were studied hemodynamically both before and after the operation, endoventricular circular patch repair of left ventricular aneurysm associated with coronary grafting definitely improves left ventricular pump function and clinical status 1 year after the operation.

Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair.

OBJECTIVES This retrospective study attempted to relate surgical outcome with the extent and type of preoperative wall motion asynergy in patients with postinfarction myocardial scar who underwent endoventricular circular patch plasty repair and associated coronary grafting. BACKGROUND Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic scar, and previous studies have reported that the absence of paradoxic systolic motion correlates with higher operative mortality and no improvement in pump function. METHODS Two hundred forty-five patients who underwent endoventricular circular patch plasty repair and associated coronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation. All had right and left cardiac catheterization. The centerline method was applied to preoperative right anterior oblique LV angiography to assess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening <2 SD from the normal mean value (extent of asynergy ([A%]). RESULTS The overall perioperative mortality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all the clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a higher perioperative mortality rate (12%) than patients with a small scar (2.2%). After the operation, the ejection fraction (EF) increased from 36 +/- 13% to 50 +/- 13% (mean +/- SD), and pulmonary pressures significantly decreased. End-diastolic volume decreased from 199 +/- 75 to 89 +/- 36 ml/m2. Patients with a large akinetic scar had the most severely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressive improvement in function (EF from 25 +/- 9% to 41 +/- 12%), not different from that observed with large dyskinetic scarring (EF from 26 +/- 7% to 46 +/- 11%). CONCLUSIONS Surgical outcome of endoventricular circular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence of dyskinesia. Patients with a large akinetic scar and severely depressed pump function benefit from a relatively simple surgical procedure previously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, and the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function.

Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy

Background—In ischemic cardiomyopathy, dyssynchrony of left ventricular (LV) mechanical contraction produces adverse hemodynamic consequences. This study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. Methods and Results—A prospective study of the global and regional components of dyssynchrony was conducted in 30 patients (58±8 years of age) undergoing SVR at the Cardiothoracic Center of Monaco. The protocol used simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Angiograms were done before and after SVR to study a 600-ms cycle during atrial pacing at 100 bpm. Mean QRS duration was similar, at 100±17 ms preoperatively and 114±28 ms postoperatively (NS). Preoperative LV contraction was highly asynchronous, because P/V loops showed abnormal isometric phases with a right shifting. Endocardial time motion was either early or delayed at the end-systolic phase so that P/L loops were markedly abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized to allow a better contribution of single regions to global ejection. The hemodynamic consequences of SVR were improved ejection fraction (30±13% to 45±12%; P =0.001); reduced end-diastolic and end-systolic volume index (202±76 to 122±48 and 144±69 to 69±40 mL/m2; P =0.001); more rapid peak filling rate (1.75±0.7 to 2.32±0.7 EDV/s; P =0.0001); peak ejection rate (1.7±0.7 to 2.6±0.9 Sv/s; P =0.0002), and mechanical efficiency (0.56±0.15 to 0.65±0.18; P =0.04). Conclusions—SVR produces a mechanical intraventricular resynchronization that improves LV performance.

Results of nonguided subtotal endocardiectomy associated with left ventricular reconstruction in patients with ischemic ventricular arrhythmias

We analyzed the effects of nonguided endocardiectomy in patients with ischemic ventricular arrhythmias who underwent reconstructive operations for postinfarction left ventricular aneurysm. A total of 106 patients among 287 consecutive patients had spontaneous or inducible ventricular tachycardia (49 spontaneous and 57 inducible). Cryotherapy was done in 67 patients and coronary revascularization was done in 98%. Patients underwent complete hemodynamic study including programmed ventricular stimulation before and early after operation. Thirty-seven patients underwent hemodynamic evaluation after 1 year. The hospital mortality rate was 7.5%. At early and late studies the mean ejection fraction was significantly increased. Ventricular tachycardia was no longer inducible in 92% of patients after operation; only two patients had spontaneous ventricular tachycardia early after operation. At late study 10.8% of patients had inducible ventricular tachycardia and no spontaneous ventricular tachycardia was documented. All surviving patients had clinical follow-up (mean 21.3 months, range 2 to 64 months). There were eight late deaths and no episodes of ventricular tachycardia or syncope that necessitated hospitalization. In conclusion, nonguided, extended endocardiectomy associated with left ventricular reconstruction is safe and effective in curing ischemic spontaneous and inducible ventricular tachycardia.

Outcome of left ventricular aneurysmectomy with patch repair in patients with severely depressed pump function

To determine the efficacy of left ventricular (LV) aneurysm resection and endoventricular patch repair with septal exclusion in patients with severely depressed pump function, we retrospectively selected 62 patients (mean age 59 +/- 7 years) with preoperative LV ejection fraction < or = 20%, from a series of 322 patients with postinfarction LV aneurysm who underwent this type of surgery at our center during a 5-year period. Mean ejection fraction was 17 +/- 3%; all patients were in New York Heart Association (NYHA) class III/IV, and all had hemodynamic and electrophysiologic studies before and after surgery. We analyzed both operative and long-term survival, and hemodynamic, electrophysiologic, and angiographic variables, as well as the symptomatic state after surgery. Follow-up was available in all patients (mean 23 +/- 14 months). Subtotal endocardiectomy and cryotherapy were associated in patients presenting with spontaneous or inducible ventricular arrhythmias (VA). Hospital mortality rate was 19.3%. Ejection fraction improved from 17 +/- 3% to 37 +/- 10% (p < 0.001); ventricular arrhythmias decreased significantly after surgery. Factors influencing early mortality at multivariate analysis were the presence of critical lesions on the circumflex artery and the duration of cardiopulmonary bypass. At 1-year control, a significant reduction in NYHA class was observed and no patient was in NYHA class IV. The improvement in ejection fraction was maintained (39 +/- 11%), as well as the reduction in inducible and spontaneous ventricular arrhythmias. There were 5 late deaths at follow-up, accounting for a late mortality of 10% at 5 years.

Favorable effects of left ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial

OBJECTIVE We sought to examine the hemodynamic effects at 1 month and 1 year of left ventricular reconstruction by means of endoventricular patch plasty for patients with acute or chronic, very severe post-myocardial infarction heart failure who would have been systematically excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial. METHODS From 2002 to May 2008, 274 patients underwent left ventricular reconstruction for post-myocardial infarction scarring; 117 of these patients would not have been eligible for the STICH trial. The pertinent criteria for exclusion included 12 patients with no coronary vessel suitable for coronary artery bypass grafting; 17 patients within a month of myocardial infarction, including 11 with acute heart failure (8 septal ruptures and 3 cases of ventricular tachycardia); 48 patients receiving intravenous inotropes, intra-aortic balloon pumping, or both; 15 patients with bifocal or posterior scarring; 4 patients scheduled for heart transplantation; and 21 patients meeting 5 other exclusion criteria. These patients (mean age, 64 years; age range, 34-83 years) preoperatively had a mean 49% (range, 35%-75%) scarred left ventricular circumference, as determined by means of magnetic resonance imaging assessment. In the patients with chronic heart failure, the preoperative ejection fraction was 26% ± 4% (range, 9%-34%), the end-diastolic volume index was 130 ± 43 mL/m(2) (range, 62-343 mL/m(2)), and the end-systolic volume index was 95 ± 37 mL/m(2) (range, 45-289 mL/m(2)). Mitral regurgitation was mild to severe in 56 patients and associated with annular dilatation (≥35 mm) in 51 patients. A strategy of left ventricular reconstruction by means of endoventricular circular suturing and patching excluded the scarred left ventricular wall and was balloon sized to provide a diastolic volume of 50 mL/m(2). Circular patches were used for anteroseptoapical lesions, and triangular patches were used for posterior lesions. The mitral valve was repaired in 51 patients, and coronary revascularization was performed in 105 patients (arterial grafts in 95 and mixed in 12). Seventy-eight patients had endocardectomy, and cryotherapy was used in 39 patients for ventricular tachycardia. RESULTS Four in-hospital and 2 delayed deaths occurred during the first year. In 101 patients with chronic heart failure, magnetic resonance imaging revealed that ejection fraction improved from 26% ± 4% preoperatively to 40% ± 8% at 1 month and 44% ± 11% at 1 year postoperatively. At these same time points, the end-diastolic volume index was reduced from 130 ± 43 mL/m(2) to 81 ± 27 and 82 ± 25 mL/m(2), respectively, and the end-systolic volume index was reduced from 96 ± 45 mL/m(2) to 50 ± 21 and 47 ± 20 mL/m(2), respectively. CONCLUSIONS With minimal associated mortality, left ventricular reconstruction produces durable improvement in left ventricular function in patients with a large scarred ventricular wall. Considering that this patient cohort would have been systematically excluded from the STICH trial, care should be taken not to extrapolate that studys results too widely so as to inappropriately deny selected patients an effective treatment for ischemic cardiomyopathies with an injured ventricle.

Endoventricular patch reconstruction of ischemic failing ventricle. a single center with 20 years experience. advantages of magnetic resonance imaging assessment.

The left ventricular reconstruction (LVR) with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular aneurysm or asynergy after myocardial infarction. Scarred LV wall can be dyskinetic or akinetic according to the type of infarction (transmural or not), and the progressive dilatation of LV (remodeling) depends on the size of the asynergic scar. Assessment of this extension and of LV volume and performances, is easy and reliable by magnetic resonance (CMR). The surgical technique is based on the insertion inside the ventricle on contractile myocardium, of a circular patch restoring curvature and physiological volume, and allowing exclusion of asynergic non resectable regions. The ventricular reconstruction method also has other components that include coronary revascularization (almost always), mitral repair (if needed) and endocardectomy when spontaneous or inducible ventricular tachycardia (VT) are present. The experience of the authors (> 1100 cases) and results obtained by other Centers, allows proposal of this technique as a way to treat the ischemic failing ventricle.

Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD?

Ventricular arrhythmias cause ~50% of deaths in remodeled ventricles after myocardial infarction, and the Multicenter Automatic Defibrillator Implantation Trial (MADIT II) showed that the Implantable Cardioverter Defibrillator (ICD) saved lives in high risk coronary patients with advanced left ventricular dysfunction. We studied 382 patients with remodeled hearts by preoperative Ventricular stimulation (PVS) to evaluate surgical ventricular restoration (SVR) that excludes scar and lower ventricular volume alters the early and late arrhythmia process without ICD utilization.Methods: Clinical and hemodynamic results before and after SVR in post-infarction patients, are compared to contrast spontaneous and/or inducible ventricular tachycardia to patients without arrhythmias. Study arrhythmia groups included: Spontaneous in 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia: Inducible in 105 patients without clinical ventricular arrhythmias but PVS inducible ventricular tachycardia; and No arrhythmias in 190 patients without spontaneous or PVS inducible ventricular tachycardia.Results: Preoperative LV end systolic volume index helped define preoperative arrythmia potential: Spontaneous > 120/m2, inducible > 100 ml/m2, and none < 100ml/m2. Overall operative mortality rate was 7.6% (29/382). Sudden cardiac death rate was 2.5% causing 18.7% of all deaths. Surgical management reduced inducible ventricular tachycardia, from 41% preoperatively (144/352) to 8% (26/307) at early study, and 8% (14/177) one year later. Cardiac mortality was low at 5-years and not different between groups, despite use of only one late ICD device.Conclusions: Favorable electrical success rate and low mortality always included volume reduction to interrupt functional re-entry circuits, but also added endocardiectomy, cryoablation, CABG and mitral repair when needed. Overall SVR findings show volume and shape alteration limits ventricular arrhythmias that impair prognosis, and suggests ICD devices are not needed.

Endoventricular Patch Plasties With Septal Exclusion for Repair of Ischemic Left Ventricle : Technique, Results and Indications from A Series of 781 Cases

Most cases of left ventricular aneurysms undergo operation through resection of the exteriorized dyskinetic area with longitudinal suturing of the opening and this technique has been considered by cardiologists (Froehlich et al) to bring no improvement to the morphology and performance of the left ventricle. Some technical modifications have been adopted, such as the septal plicature (Cooley) or circular suturing of the opening (Jatene). Since 1984 our team has used an endoventricular patch, sutured over the contractile area and excluding the akinetic non-resectable scars, bringing a significant and calculable improvement to the left ventricular function. This technique of left ventricular reconstruction (LVR), called endoventricular circular patch plasty (EVCPP) has been already used on more than 750 patients (May 97). Clinical and echographic data for each case are completed by right catheterisation with measurement of the cardiac output, pulmonary arterial pressures (PAP) and programmed ventricular stimulation (PVS), in order to detect eventual ventricular tachycardia (IVT). During left heart catheterisation, the morphology of the left ventricle (LV) is studied on right and left anterior oblique incidences and the LV ejection fraction (EF) is checked globally (GEF) and especially in its contractile portion (CEF). After surgery, a hemodynamic study associated with a PVS, is carried out during the first post-operative month, and again after one year. Results were clinically satisfactory in more than 90% of cases (8.9% of NYHA III-IV), and in more than 90% of cases with ventricular arrhythmia with the hemodynamic persistent EF at one year, superior to the pre-operative CEF. Thus we have to propose the following indications: Elective: This ventricular reconstruction can be recommended for ventricular aneurysms or akinesias with angina, arrhythmias or attacks of cardiac insufficiency, when GEF > 30% and CEF > 40%. The operative mortality rate varies from 1,5 to 3%, which is better than allowing natural evolution. Mandatory: In emergency, when safe immediate circulatory assistance or a cardiac transplant is unavailable, LVR can give hope for survival to more than 80% of patients, whereas natural evolution is without hope. Finally the operative indication is uncertain in two contrasting circumstances: In asymptomatic patients when hemodynamic and angiographic examinations after myocardial infarction show left ventricular dyskinesia. If GEF is below 40% and CEF below 50%, it seems wise to propose LVR in order to prevent unfavourable evolution. In end-stage ischemic cardiomyopathies, if the EF is below 20%, CEF is below 30%, cardiac output is below 1.5 l, and the mean pulmonary pressure is above 25, then a cardiac transplant should be considered. EVCPP with septal exclusion is a safe technique and easily reproduced when associated with coronary revascularization as far as practicable, then EVCPP improves the ventricular function. When associated with sub-total endocardectomy, then EVCPP allows excellent control of VA.