Surgical Restoration of Ventricular Function

8/2/2019 Surgical Restoration of Ventricular Function

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SURGICAL RESTORATION OFVENTRICULAR FUNCTION

DR. REZWANUL HOQUE BULBULMBBS, MS, FCPS, FRCS(GLASGOW), FRCS(EDINBURGH)

ASSOCIATE PROFESSOR, CARDIAC SURGERY

BSMMU, DHAKA, BANGLADESH


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DILATED CARDIOMYOPATHY-

PATHOPHYSIOLOGY

Dilated cardiomyopathy is characterized by ventricular chamberenlargement and systolic dysfunction with greater LV cavity size withlittle or no wall hypertrophy. Hypertrophy is judged as the ratio of LVmass to cavity size; this ratio is decreased in persons with dilatedcardiomyopathies.

Dilated cardiomyopathies are associated with both systolic anddiastolic dysfunction. The decrease in systolic function is by far theprimary abnormality. This leads to an increase in the end-diastolicand end-systolic volumes.

Associated with activation of RAAS, increased arginine-vasopressin,

ANP,BNP and CNP, increased catecholamine with down regulation ofreceptors, volume overload and increased workload of the heart.

Elevation of TNF-alpha, IL-1b, IL-2R, IL-6 may mediate myocardialcell injury.

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


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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


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DEFINITION OF SURGICAL

VENTRICULAR RESTORATION

Surgical ventricular restoration (SVR) is a procedure designed to restore orremodel the left ventricle to its normal, spherical shape and size in patientswith akinetic segments of the heart, secondary to either dilatedcardiomyopathy 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 orreplacement and other procedures such as endocardectomy and cryoablationfor 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 usingpatches 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 Batistaprocedure) which does not attempt to specifically resect akinetic segmentsand restore ventricular contour.

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


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RELATIONSHIP BETWEEN

STRUCTURE & FUNCTION

The central theme of cardiac surgery is that alteration of structure improvesfunction, and this concept is fundamental during surgical restoration of dilatedhearts in cardiac failure.

The conical pattern of normal cardiac size and shape is well known and theunderlying spatial arrangements are closely linked to the helical ventricular

myocardial band and comprised of a surrounding wrap of the basal loop withtransverse fibres and an apical loop of reciprocal oblique fibres forming a spiralvortex at the apex.

The spherical configuration of the enlarged global ventricle widens the apical loopby making the oblique apical loop fibres develop a transverse orientation that moreclosely 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 shapereduces ejection fraction, which is 60% with oblique fibre direction and lowered to30% when fibre orientation is transverse.

Buckberg GD: Form versus disease: optimizing geometry during ventricular restoration. Eur J Cardiothorac Surg 2006;29

Suppl 1:S238S244


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LAPLACE LAWT = ( P * R ) / M Where T is the tension in the walls,

P is the pressure difference acrossthe wall, R is the radius of thecylinder, and M is the thickness ofthe wall. An example of Laplace Lawis Dilated cardiomyopathy. In thiscondition heart becomes greatlydistended and the radius (R) of

ventricle increases. Therefore tocreate the same pressure (P) duringejection of the blood much largerwall tension (T) has be developed bythe cardiac muscle. Thus dilatedheart requires more energy to pumpthe same amount of blood ascompared to the heart of normalsize. The new surgical procedure,

called ventricular remodelling, usesLaplace principle to improve thefunction of dilated, failing hearts.


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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


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ISCHEMIC DCM

White emphasized on ESVI rather than E.F. as the prognostic

barometerLV Volume: a sensitive prognostic parameter for both late and earlyevents 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 withendocardial necrosis segmental akinesis (lack of contractility)Endocardium and mid-myocardium damage >50% of the LV wallincapable of functional recovery

Progressive heart dilatation follows asynergy of >50% (30%) LVcircumference after anterior MI

GUSTO (1997): ESVI>

40 ml/m2

a high incidence of CHF & poorlong-term survival

HF developed by progressive decrease of compensatory contractionof remote muscle.

Overview: Ventricular restoration a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004


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RATIONALE FOR SVR

Because of the shortage of donors for heart transplantation, surgicalventricular reconstruction (SVR) has been under development totreat 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 severalexaminations.

SVR is performed to reduce the size and volume of the ventricle aswell as to reshape it.

The procedures, which differ based on the particular left ventricularlesion, are endoventricular patch plasty or septal anterior ventricularrestoration for anteroseptal exclusion and partial left ventriculectomyor a posterior restoration procedure for posterolateral exclusion.

In the indicated patients, SVR has been emerging as an alternativeto heart transplantation.

The New England Journal of Medicine (2009) Volume: 361, Issue: 5, Pages: 529;


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INDICATION FOR SVR

Indication

Anteroseptal MI with dilated LV: LVESVI >60ml/m2, LVEDVI>100ml/m2

Left ventricular asynergy( akinesia or dyskinesia) > 35% of LVanterior wall

Relative contraindication

Diffusely diseased RCA or LCX not amenable to CABG withinferior 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...


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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 ratiotoward normal

Significantly improves the pumping action of theheart

Improves clinical statusUsually done with CABG, often done with valverepair


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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


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SEPTAL PLASTY OPERATION OF

STONEY, 1978

Ventricularaneurysmectomy

Emphasis on

anteroseptal repair byusing a flap of scarredtissue


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JATENE, 1984

Imbricated the scar and reformed the elliptical scar

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


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SCHEMA OF SURGICAL

PROCEDURESSchemata of the Dor procedure, Batistaprocedure, and Overlapping-type leftventriculoplasty (OLVP).

a: Dor procedure: LV volume reduction isaccomplished by an endoventricular patch in theanterior 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 broadlyresected and closed with direct suture.

c: OLVP: This procedure performs ventriculotomyof the anterior wall without ventriculectomy, anddoubles in part the LV anterior wall by

overlapping the incised wall around the apex.Papillary muscles approximation (PMA) is alsoperformed as an adjunct to OLVP, depending onthe situation of the case.

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


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PROCEDURES OF CHOICE


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CIRCULAR PATCH REPAIR

Circular patch repair. The aneurysm wall is incised. Aninferior aneurysm is shown.

Circular patch repair. The aneurysmal wall is excised,leaving a 2-cm rim of fibrous aneurysmal wall attachedto healthy muscle.

Circular patch repair. The aneurysmal defect is closedwith a Dacron patch using interrupted 2-0 monofilamenthorizontal 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


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ENDOVENTRICULAR PATCH REPAIR

Endocardial patch. Without excising theaneurysm wall, the ventricular defect is closedwith a Teflon felt patch using 3-0polypropylene suture secured at three or fourpoints along the suture line. Additional 3-0pledgeted horizontal mattress sutures may beused to achieve haemostasis.

Endocardial patch. The aneurysm wall isclosed over a Teflon patch after resectingexcess aneurysm tissue. A double row ofrunning vertical 2-0 polypropylene sutures isused.

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


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ENDOVENTRICULAR CIRCULAR PATCH PLASTY

Both akinetic and dyskinetic scarred portion of the ventricle isexcluded

Avoids pericardial adhesion as it does not contain externalprosthetic material

Relieve ischemia by complete coronary revascularization:

grafting the LAD providing upper septal perfusionVentricular sizing: 60 mL/m2 (EDV150 mL/m2) Diminish ventricular volume diminish wallstress, reduce myocardial oxygen consumption

Ventricular geometry is better maintained resulting indiminished wall stress, improved wall compliance, reducedfilling pressure, enhanced diastolic coronary flow, decreasedmyocardial O2 consumption, improved systolic contraction.


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STEPS TO DOR PROCEDURE

Fontan, 1989

Placed a circumferential suture around the borderof ischemic and normal tissue to create an ovalneck for patch placement after securing thissuture .Patch: oval with a long diameter of 2 2.5cm in situmade 2.5 3 cm to compensatespace taken up by suture line.

Cooley, 1992

Excluding septal aneurysm wall by placing anendoventricular patch placed between the scarredand viable areas


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DOR PROCEDURE- STEPS

a. Open left ventricle during

restoration showing palpation

to define the contracting and non-contracting muscle.

b. Shows Fontan suture in place

and interrupted sutures through

neck and into suture holders,

quite similar to valve procedures.



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STEPS-CONTINUED

a. Sizing the oval from Fontansuture,

b. shows placement of

prericardial patch with inner ringon surgical neck

c.shows oblique pericardialpatch in final intraventricularposition.



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STEPS- CONTINUED

Finding the left ventricular apex, either from theoutside where it is adjacent to right ventricularapex, or from the inside with use of a conical

intraventricular balloon.


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STEPS- CONTINUED

a. Wrap around anteriorinfarction and scar,

b. shows open leftventricle with inferiorscar. Imbrication of theinferior wall frommattress sutures eitherthe outside in

c or the inside in d.


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STEPS

Creation of LV apex by securingthe imbricating inferior sutures

and using the tip b as the apexin a.

Placement of oblique patch torebuild a conical shape in b.


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STEPS

a. Demonstration of the normal

width between papillary muscles inb,

Widening from distance betweenpapillary muscle bases is shown inc.

c


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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 papillarymuscle bases in c.


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STEPS

The normal annulardimensions are compared to

the widened annulus withcentral functional mitralregurgitation ,and downsizingthe annulus with a posteriorlyplaced mitral ring shownbelow.


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TRIANGULAR PATCH VENTRICULOPLASTY

Scar involving the base,

septum and lateral wallfollowing inferior infarction in

a.

Site of inferior wall incisionparallel to posteriordescending coronary

artery in b and exposure of

intraventricular cavityfollowing incision in c.



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CONTINUED

Triangular patch that conforms to thebase of the infarct region shown inupper 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.


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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 Collegeof Cardiology 37(5) 2001 1199-1209


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SAVER

Pacopexy or SAVER procedurewith open left ventricle andinterrupted mattress sutures in

septum and LV free wall A,insertion of oblique patch fromapex to high septum, usingTeflon strip in (B),

and closure to

rebuild a conical chamber in (c).


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SAVER/SAVE PROCEDURE

Left ventricular restoration

in dilated cardiomyopathy in

ischemic disease without discretescar.

The SAVER or Pacopexyprocedure is used to make thespherical chamber becomeelliptical. A patch is placedbetween the apex and septum

to reconstruct a conical chamber.



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UNIFIED CONCEPTS

Unified concept with the

dilated spherical left ventricular

shape in either ischemic,nonischemic

or valvular cardiomyopathy

Geometrically changing shapeto create a conical

of elliptical chamber in either

ischemic, non-ischemic orvalvular disease to alterstructure toward normal asshown here.



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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 ofthe heart) has been proposed as a surgical procedure to replace or postponeheart transplantation in patients with dilated non-ischemic cardiomyopathy. Itinvolves removing a viable portion of the enlarged left ventricle and repair ofthe resultant mitral regurgitation with a valve ring. It attempts to augmentsystemic blood flow through improvement in the mechanical function of the

left ventricle by restoring its chamber to optimal size. In most cases, partialleft ventriculectomy is accompanied by mitral valve repair.

Although initial reports on the Batista procedure lacked significant informationon its safety and effectiveness, overall clinical impression was that theoperation may serve as a bridge to heart transplantation especially in patientswith 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 ofpatients who had undergone the operation were not significantly better thanprior to surgery. Moreover, there was no survival benefit with 60% of thepatients expiring within 6 months after the Batista procedure.

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

LIMITATION & OUTCOME OF BATISTA
http://www.aetna.com/cpb/medical/data/100_199/0182.htmlhttp://www.aetna.com/cpb/medical/data/100_199/0182.html


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LIMITATION & OUTCOME OF BATISTA

PROCEDURE

Remove LV lateral wall irrespective ofregional dysfunction used less forischemic etiologies

Reduce systolic wall stress and improveE.F.

A deleterious effect on diastoliccompliance: reduce recruitable strokework (Starling law), magnitude of shapechange or pumping capacity

SVR: resection of non-functionalmyocardium resection of akineticportion with normal thickness in dilated,poorly functioning heart

Long-term effectiveness for primarilyIDCM: despite impressive improvement

in acute LVEF (1631%), disappointinglylow event-free survival rates at 1 year(49%) and 3 years (26%)

ACC/AHA: class III procedure


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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 damagedheart muscle and limit further enlargement.

It provides passive support that reduces thestress on the ventricular wall.

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

ACORN CORCAP CARDIAC

SUPPORT DEVICE
http://www.columbiasurgery.org/pat/cardiac/acorn.htmhttp://www.columbiasurgery.org/pat/cardiac/acorn.htm


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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


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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 failingheart is replaced with another heart from a suitable donor.[1] Itis generally reserved for patients with end-stage

congestive heart failure(CHF) who are estimated to have lessthan 1 year to live without the transplant and who are notcandidates for or have not been helped by conventionalmedical therapy.


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Surgical Restoration of Ventricular Function