Milutin Mirić

Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up

BACKGROUND Recent reports show that partial left ventriculectomy improves hemodynamic and functional status in patients with dilated cardiomyopathy. This study sought to determine the effects of partial left ventriculectomy on clinical outcome and left ventricular function during 6-month follow-up. METHODS Twenty-two patients underwent partial left ventriculectomy. Mitral valve repair was performed whenever possible, otherwise the valve was replaced. Hemodynamic and functional data were obtained at baseline, as well as 2 weeks and 6 months postoperatively. RESULTS Overall, 7 of 22 patients died; there were three early and four late deaths. One-year survival was 68%+/-10%. Ejection fraction increased from 23.9%+/-6.8% before the operation to 40.7%+/-12.5% at 2 weeks and to 36.8%+/-7.7% at 6 months (p<0.001, for both). The cardiac index before the operation, at 2 weeks, and at 6 months was 2.3+/-0.8, 2.9+/-0.6, and 3.4+/-1.0 L/m2 per minute, respectively (p = 0.035, and p = 0.009, compared with baseline). The increase in ejection fraction 2 weeks postoperatively was less in patients with left circumflex artery dominance (10.9%+/-3.2% compared with 19.9%+/-10.7%, respectively, p = 0.017). At 6-month follow up, all surviving patients except one improved New York Heart Association functional class when compared with preoperative status (from 3.8+/-0.4 to 1.4+/-0.6, p = 0.0002). CONCLUSIONS Early hemodynamic improvement after partial left ventriculectomy was maintained during midterm follow-up.

Effects of partial left ventriculectomy on left ventricular performance in patients with nonischemic dilated cardiomyopathy

OBJECTIVES This study sought to assess the effects of partial left ventriculectomy (PLV) on left ventricular (LV) performance in a series of consecutive patients with nonischemic dilated cardiomyopathy. BACKGROUND Reduction of LV systolic function in patients with heart failure is associated with an increase of LV volume and alteration of its shape. Recently, PLV, a novel surgical procedure, was proposed as a treatment option to alter this process in patients with dilated cardiomyopathy. METHODS We studied 19 patients with severely symptomatic nonischemic dilated cardiomyopathy, before and 13+/-3 days after surgery, and 12 controls. Single-plane left ventriculography with simultaneous measurements of femoral artery pressure was performed during right heart pacing. RESULTS The LV end-diastolic and end-systolic volume indexes decreased after PLV (from 169 to 102 ml/m2, and from 127 to 60 ml/m2, respectively, p < 0.0001 for both). Despite a decrease in LV mass index (from 162 to 137 g/m2, p < 0.0001), there was a significant decrease in LV circumferential end-systolic and end-diastolic stresses (from 277 to 159 g/cm2, p < 0.0001 and from 79 to 39 g/cm2, p = 0.0014, respectively). Ejection fraction improved (from 24% to 41%, p < 0.0001); the stroke work index remained unchanged. CONCLUSIONS The PLV improves LV performance by a dramatic reduction of ventricular end-systolic and end-diastolic stresses. Further studies are needed to assess whether this effect is sustained during long-term follow-up and to define the role of PLV in the treatment of patients with dilated cardiomyopathy.

Functional capacity late after partial left ventriculectomy : relation to ventricular geometry and performance

OBJECTIVES While partial left ventriculectomy (PLV) may improve functional status, the duration and determinants of this improvement are poorly known. This study sought to assess the relationship between left ventricular (LV) shape and function and functional status in late survivors after PLV for non-ischemic dilated cardiomyopathy (DCM). METHODS We assessed the relations between LV shape and function and functional status in 17 consecutive patients who survived >12 months after PLV for non-ischemic DCM. Invasive diagnostic studies were performed before, early after, at mid-term after, and late after PLV. According to their functional status after >12 months of follow-up, patients were divided into responders (n=10) or non-responders (n=7). RESULTS After PLV, the LV systolic major-to-minor axis ratio was higher in responders at early, mid-, and late follow-up (P=0.003, P=0.008 and P=0.04, respectively). LV circumferential end-diastolic stress decreased early after PLV, but increased afterwards in non-responders only (P=0.049). LV ejection fraction was similar in the two groups at baseline, and at early and mid-follow-up, but was lower in non-responders at late follow-up (P=0.006). However, LV end-diastolic and end-systolic volumes, and LV end-systolic circumferential stress showed no difference between the two groups. CONCLUSIONS It appears that poor functional capacity in late post-PLV survivors is related to postoperative LV geometry.

Partial Left Ventriculectomy and Limited Heart Transplantation Availability

Background and Aim: Partial left ventriculectomy, a novel cardiac volume reduction operation, is applied in countries without a developed heart transplantation program. We sought to determine its impact in our population of patients. Methods: Partial left ventriculectomy was performed in 38 patients during the last 4 years. Basic inclusion criteria were nonischemic dilated cardiomyopathy and poor response to medical therapy for heart failure. Hemodynamic evaluation was carried out before and after operation. A modified surgical technique of mitral valve repair and ventricle suturing was applied. Results: Thirty‐day, 6‐month, and 2‐year survival rates were 82%± 7%, 65%± 8%. and 61%± 9%, respectively. Duration of heart failure symptoms was the only predictor of survival (p = 0.042). A high proportion of noncardiac causes of death was noted. Functional capacity in surviving patients improved at every successive measurement up to 1 year postoperatively. Conclusions: The introduction of partial left ventriculectomy in a country with limited heart transplantation availability had a great impact on the management of end‐stage heart failure and may represent the only surgical option for some patients. The average cost per patient was substantially lower when compared to heart transplantation.

Acute hemodynamic effects of Metoprolol ± Nitroglycerin in patients with biopsy-proven lymphocytic myocarditis

We evaluated acute hemodynamic effects of metoprolol +/- nitroglycerin in 11 patients with left ventricular dysfunction and biopsy-proven lymphocytic myocarditis. Acute administration of metoprolol improved ejection phase indexes, probably through the prolongation of diastole; the addition of a vasodilator further enhanced these effects by improving arterial elastance.

Spontaneous Ventricular Arrhythmias Following Partial Left Ventriculectomy for Nonischemic Dilated Cardiomyopathy: Relation to Hemodynamics and Survival

The study assessed the value of ambulatory electrocardiogram (AECG) monitoring for identification of patients who are at increased risk for cardiac death or arrhythmic event following partial left ventriculectomy (PLV). Furthermore, the impact of PLV and its hemodynamics on the occurrence of spontaneous ventricular arrhythmias was assessed in long‐term survivors. In 32 idiopathic dilated cardiomyopathy patients who underwent PLV, ambulatory ECG (AECG) was performed preoperatively, early postoperatively, and 6 months and 12 months after surgery. In 17 of 19 patients who survived > 12 months after the procedure, left ventricular (LV) angiography was performed at the same time points and was used to calculate LV ejection fraction, and end‐diastolic and end‐systolic wall stress. During a mean follow‐up of 478 ± 405 days, 11 cardiac events occurred. Cox univariate regression revealed frequency of premature ventricular contractions > 30/hour at baseline (p = 0.0213) and duration of heart failure symptoms (p = 0.0226) as predictors of cardiac death or arrhythmic event after PLV. In a multivariate analysis, only frequency of premature ventricular contractions > 30/hour was a significant predictor. There was no change in the frequency or severity of ventricular arrhythmias after PLV. However, frequency of premature ventricular contractions correlated with LV end‐diastolic stress (r = 0.35, p = 0.013), and ejection fraction (r =−0.34, p = 0.016). Preoperative AECG monitoring may help stratification of PLV patients. Serial AECG did not show that PLV influence the incidence or the complexity of spontaneous ventricular arrhythmias. In contrast, it appears that a hemodynamically “successful” procedure may decrease the incidence of ventricular arrhythmias.