Lakartidningen. 2005 Oct 24-30;102(43):3134-7.
Left ventricular reconstruction in ischemic heart disease. Good surgical alternative in advanced heart failure
Sartipy U, Albage A, Lindblom D.
Thoraxkliniken, Karolinska Universitetssjukhuset Solna, Stockholm. ulrik.sartipy@karolinska.se
Left ventricular (LV) dilatation occurs after myocardial infarction and leads to heart failure. LV reconstruction or surgical ventricular restoration (SVR) by means of the Dor procedure reduces LV volume and restores normal LV shape. Mitral repair and surgery for ventricular tachycardia are performed as needed. SVR improves LV function and early and long-term results are good in terms of survival and arrhythmia control. International results as well as the experience of the procedure at Karolinska University Hospital are presented and illustrated with a case report.
Ann Thorac Surg. 2005 Aug;80(2):537-41; discussion 542.
Absent long-term benefit of patch versus linear reconstruction in left ventricular aneurysm surgery.
Lange R, Guenther T, Augustin N, Noebauer C, Wottke M, Busch R, Mayr N, Meisner H, Holper K.
Department of Cardiovascular Surgery, German Heart Center, Clinic at the Technical University, Munich, Germany. lange@dhm.mhn.de
BACKGROUND: Endoventricular patch reconstruction of the left ventricle is considered the gold standard in surgery for left ventricular aneurysms, because of improved preservation of ventricular geometry. However, the superiority over conventional linear closure has not been demonstrated, as assessed by the long-term outcome. METHODS: Two hundred patients (66%) underwent linear closure (group L) and 105 patients (34%) had endoventricular patch reconstruction (group D) using the Dor technique. Linear closure has been performed since 1974 and from 1985 on the Dor technique has been applied as an alternative procedure. Both patient groups differed regarding age, sex distribution, site of infarction, and indication for surgery. Prior to the operation, 71% of the patients were in New York Heart Association (NYHA) class III or IV and mean ejection fraction was 34% +/- 12%. Follow-up extends up to 25 years, with a cumulative total of 2,605 patient years. RESULTS: Early mortality was 6.5% in group L vs 5.7% in group D (not significant [NS]). Actuarial survival after 10 years was 56 +/- 3.2%, with no difference between groups. Freedom from reoperation after 10 years was 95.6% in group L vs 95.2% in group D (NS). Preoperative risk factors for late mortality were age, left ventricular enddiastolic volume index and concomitant mitral valve surgery. The type of procedure and the date of operation had no influence on mortality. To date, 63% of the survivors are in NYHA class I and II. CONCLUSIONS: In regard to long-term survival, rate of reoperation, and postoperative NYHA functional class, no benefit could be demonstrated when linear closure was compared with ventricular patch reconstruction for LV aneurysm repair. Hence, the technique of ventricular reconstruction may not be as important as previously thought, and at least for small aneurysms the simple and time sparing technique of linear closure may still be considered.
Eur J Heart Fail. 2005 Aug;7(5):704-9.
Surgical left ventricular remodeling in heart failure.
Tonnessen T, Knudsen CW.
Department of Cardiothoracic Surgery, Heart and Lung Center, Ulleval University Hospital, 0407 Oslo, Norway. thto@uus.no
The high mortality and morbidity of patients in terminal heart failure are a therapeutic challenge to modern medicine. Surgically, cardiac transplantation is an excellent treatment for many patients. However, lack of donors combined with an increasing number of patients has led to the search for other surgical strategies. Patients with symptomatic large left ventricular aneurysms have been treated with resection of the aneurysm and closure of the left ventricle either directly (linear closure, first reported by Cooley) or by implantation of a patch (endoventricular patch plasty or Dor procedure). Akinetic areas of the left ventricle have also been successfully treated by the latter method. According to the law of Laplace, large dilated ventricles have increased wall tension and thus increased oxygen consumption. Based on this fact, Batista and coworkers have reduced the volume of enlarged left ventricles in patients in terminal heart failure by removing a wedge of myocardium from the apex of the heart towards the base of the left ventricular free wall. Although a favorable outcome has been reported in selected patients, this method is currently not recommended for treatment of heart failure because of high surgical failure rates. The present paper reviews some of the relevant literature regarding surgical left ventricular remodeling in heart failure. Two new techniques (Myosplint and CorCap cardiac support device) are also briefly described.
Eur J Cardiothorac Surg. 2005 Jun;27(6):1005-10. Epub 2005 Feb 26.
The Dor procedure for left ventricular reconstruction. Ten-year clinical experience.
Sartipy U, Albage A, Lindblom D.
Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Karolinska Institutet, Stockholm 171 76, Sweden. ulrik.sartipy@karolinska.se
OBJECTIVE: Surgical ventricular restoration by means of the Dor procedure is a surgical option in patients with coronary artery disease, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aim of this study was to evaluate the 10-year clinical experience of this procedure in our institution. METHODS: From May 1994 to June 2004, surgical ventricular restoration was performed in 101 patients (77 males), mean age 63.8 (35-80) years. All patients presented with angina and/or heart failure and/or ventricular tachycardia. Postinfarction left ventricular aneurysm was present in 97 patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 4. The preoperative left ventricular ejection fraction was 27+/-10 (7-50) %. Multi-vessel disease was present in 80 patients. Ventricular tachycardia was diagnosed in 53 patients (spontaneous VT in 25). Mitral regurgitation more than grade 2 was found in 13 patients. The mean Euroscore was 7.1+/-2.9 (3-17). RESULTS: All patients underwent the Dor procedure, which in 53 patients included a non-guided endocardectomy and cryoablation for treatment of ventricular tachycardia. Coronary artery bypass grafting was performed in 99 patients and a mitral valve procedure was performed in 29. Intra-aortic balloon pumping was used postoperatively in 14 cases and 24 patients needed inotropic support for more than 24 h. Mean time on the ventilator was 16+/-25 (3-168) hours and mean stay in the intensive care unit was 2.1+/-2.2 (0-13) days. Postoperative stroke occurred in 7 patients. Early mortality was 8/101 (7.9%). Mean follow-up in operative survivors was 4.4+/-2.8 (0.1-10.4) years. Actuarial survival at 1, 3 and 5 years was 88, 79 and 65%. CONCLUSIONS: The Dor procedure is a reproducible surgical option for treatment of postinfarction left ventricular aneurysm. Early and long-term results are good in terms of survival.
Ann Thorac Cardiovasc Surg. 2005 Jun;11(3):159-63.
Late development of mitral regurgitation after left ventricular reconstruction surgery.
Yotsumoto G, Sakata R, Ueno T, Iguro Y, Kinjo T, Kobayashi A, Matsumoto K, Tei C, Otsuji Y, Tanaka Y.
Second Department of Surgery, Kagoshima University, Kagoshima, Japan.
PURPOSE: Late presence of mitral regurgitation (MR) after the Dor procedure (left ventricular (LV) reconstruction associated with coronary artery bypass grafting) for postinfarction patients carries a poor prognosis. The aim of this study was to review our experience with the Dor procedure and to analyze the correlation of surgical results with late MR. METHODS: The study group comprised 19 patients with previous anterior transmural myocardial infarction (MI). Ten patients were classified as New York Heart Association (NYHA) functional class III or IV at surgery. MR was moderate in 2 patients and mild in 15 patients. RESULTS: Myocardial revascularization was performed in all patients, with a mean of 3.7+/-1.2 grafts. Mitral valve was repaired in 6 patients. Four patients with mild MR underwent posterior annuloplasty, and 2 with moderate MR underwent rigid annular remodeling. Early postoperative NYHA functional class improved from 2.7+/-0.9 to 1.3+/-0.5; however, MR deteriorated to moderate in 5 patients with worsening NYHA functional class 3 months after surgery. Although the valve was not repaired during surgery in 4 patients with preoperative mild MR, 1 patient with moderate MR underwent annuloplasty with a rigid ring. All patients with late MR underwent more than 30-mL/m2 reduction of end-diastolic volume index at surgery. Cumulative 4-year survival including hospital deaths was 89.5%. CONCLUSION: To prevent the risk of late MR, a more than 30-mL/m2 reduction of end-diastolic volume index should be avoided and mitral valve repair should be performed even if preoperative functional MR is only mild.
Ann Thorac Surg. 2003 Nov;76(5):1571-4; discussion 1574-5.
The beating heart approach is not necessary for the Dor procedure.
Maxey TS, Reece TB, Ellman PI, Kern JA, Tribble CG, Kron IL.
Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
BACKGROUND: Ventricular reconstruction using the Dor technique has been demonstrated to improve outcome in patients with dilated left ventricles. It has been suggested that a beating heart approach improves ventricular function by allowing the surgeon to palpate that part of the ventricle to exclude. METHODS: We performed a retrospective analysis of patients who underwent an endoventricular circular patch plasty (Dor procedure) between 1998 and 2001. All patients who received ventricular restoration, with or without revascularization or valve repair, were included in the analysis. Discrete left ventricular aneurysms were excluded. Patients were divided into two groups: group 1 (n = 15) underwent ventricular reconstruction with the beating heart technique, whereas group 2 (n = 38) underwent restoration with the aorta cross-clamped. Clinical and hemodynamic data were collected from medical records and computerized databases and compared between the two groups. RESULTS: Fifty-three patients underwent endoventricular circular patch plasty. All patients had enlarged ventricles (echocardiogram demonstrating unidimensional end-diastolic diameter >/= 6.0 cm) and echocardiographic evidence of severe left ventricular dysfunction (mean ejection fraction: group 1 = 21.4%; group 2 = 23.4%). No operative mortalities occurred in either group and all patients were discharged home alive (mean postoperative hospital stay 8.3 days [6 to 22 days]). All patients had improvement in left ventricular function with mean postoperative left ventricular ejection fraction of 36.9% (25% to 52%) in group 1 versus 38.1% (31% to 50%) in group 2, p = 0.081. Ventricular arrhythmias occurred in 5 of 15 group 1 patients and in 9 of 38 group 2 patients. Two patients in the entire cohort (1 patient in group 1, and 1 patient in group 2) had at least one readmission within 12 months with evidence of heart failure. The group 1 patient went on to successful transplant 11 months later, whereas the group 2 patient died 10 months later. CONCLUSIONS: These results demonstrate that the Dor technique of ventricular restoration significantly improves left ventricular function and the beating heart approach provides no additional advantage over continuous aortic cross clamping.
Ann Thorac Surg. 2003 Apr;75(4):1205-8; discussion 1208-9.
Ventricular energetics in endoventricular circular patch plasty for dyskinetic anterior left ventricular aneurysm.
Tanoue Y, Ando H, Fukumura F, Umesue M, Uchida T, Taniguchi K, Tanaka J.
Department of Cardiovascular Surgery, Aso-Iizuka Hospital, Iizuka-city, Japan. tanoue@heart.med.kyushu-u.ac.jp
BACKGROUND: The endoventricular circular patch plasty (Dor procedure) applies to patients with a left ventricular dysfunction due to an ischemic dilated ventricle. In the present study, we analyzed left ventricular energetics in patients who underwent the Dor procedure. METHODS: We measured left ventricular contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) based on the cardiac catheterization data before and after the Dor procedure in 8 patients with a postinfarction dyskinetic anterior left ventricular aneurysm. Concomitant procedures included coronary artery bypass grafting in all patients, mitral valve repair in one patient, and cryoablation in one patient. End-systolic elastance (Ees) and Ea were approximated as follows: Ees = mean arterial pressure/minimal left ventricular volume, and Ea = maximal left ventricular pressure/(maximal left ventricular volume-minimal left ventricular volume), and thereafter Ea/Ees and SW/PVA were calculated. The left ventricular volume was normalized with the body surface area. RESULTS: End-systolic elastance (Ees) increased after the Dor procedure (from 1.15 +/- 0.60 to 1.86 +/- 0.84 mm Hg x m2 x mL(-1), p < 0.01), thus resulting in an improvement in Ea/Ees and SW/PVA (from 2.94 +/- 1.11 to 1.64 +/- 0.49, p < 0.01, and from 0.426 +/- 0.110 to 0.559 +/- 0.082, p < 0.01, respectively), even though Ea did not substantially change (from 2.96 +/- 0.78 to 2.74 +/- 0.55 mm Hg x m2 x mL(-1), p = 0.4). CONCLUSIONS: Left ventricular contractility and efficiency improves after the Dor procedure in patients with a dyskinetic anterior left ventricular aneurysm. However, afterload does not change. The use of appropriate afterload-reducing therapy thus plays an especially important role in the management of patients who undergo the Dor procedure.
Annu Rev Med. 2002;53:383-91.
Surgical management of heart failure: an overview.
Zeltsman D, Acker MA.
Section of Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA.
Cardiac transplantation remains the gold standard of surgical therapies for advanced and end-stage heart failure. However, this very limited option trades one disease for another and can benefit only a small minority of patients. Heart failure is currently considered secondary to a structural increase in ventricular chamber volume or remodeling. Surgical therapies formerly contraindicated for the failing heart, as well as new therapies, can successfully affect ventricular remodeling and improve cardiac function. Surgical revascularization for patients with ejection fractions <20% is becoming common. Mitral valve repair is being explored, with surprisingly low operative mortality and encouraging intermediate results. Direct surgical approaches to restoring normal geometry and size to failing hearts, such as left ventricular reduction (Batista procedure), endoventricular patch plasty (Dor procedure), cardiomyoplasty, and prosthetic external constraints are under clinical investigation. Developments in mechanical assist therapy and a new generation of implantable intracorporeal assist devices are also discussed.
Echocardiography. 2002 Oct;19(7 Pt 1):605-12.
Volume reduction surgery for end-stage ischemic heart disease.
Shiota T, McCarthy PM.
Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, 44195, USA. shiota@cluba.com
The Dor procedure, or infarction excision surgery, was first used in 1984. It is a surgical treatment option for patients with end-stage ischemic heart failure. In a recently published multicenter study that included a total of 439 patients, average ejection fraction increased from 29 +/- 10% to 39 +/- 12% after surgery. In our experience, the overall survival rate 18 months after surgery is 89%, and the preoperative mortality rate is 6.6%. These results are similar to the previous reports from Dor's group, which confirmed the certain value of the surgery. Echocardiography, including intraoperative transesophageal echocardiography, plays an important role in clarifying cardiac anatomies, absolute left ventricular (LV) volumes, ejection fraction, and mitral regurgitation in patients with ischemic heart failure undergoing this surgery. With the development of ultrasound and computer technology, three-dimensional echocardiography may be preferred when evaluating the surgical results, including determination of absolute LV volumes. Communication between experienced cardiac surgeons and echocardiographers in the operating room is essential for successful outcomes and reliable evaluation of the surgery.
J Thorac Cardiovasc Surg. 2002 Nov;124(5):886-90.
Comment on:
J Thorac Cardiovasc Surg. 2002 Nov;124(5):863-83.
The Dor procedure: what has changed after fifteen years of clinical practice?
Menicanti L, Di Donato M.
Semin Thorac Cardiovasc Surg. 2001 Oct;13(4):448-58.
Erratum in:
Semin Thorac Cardiovasc Surg 2002 Jan;14(1):119.
Surgical anterior ventricular endocardial restoration (SAVER) for dilated ischemic cardiomyopathy.
Athanasuleas CL, Stanley AW, Buckberg GD, Dor V, Di Donato M, Siler W; RESTORE Group.
Department of Cardiac Surgery, Norwood Clinic and Kemp-Carraway Heart Institute, Birmingham, AL 35234, USA.
Anterior infarction changes ventricular shape and volume. Akinesia is most commonly observed after early reperfusion. Dyskinesia develops in the absence of reperfusion. Both produce heart failure by dysfunction of the remote muscle. Traditional surgery deals with dyskinesia. This study evaluates surgical anterior ventricular endocardial restoration (SAVER), an operation that excludes the apical and septal scar in both akinesia and dyskinesia. A new international group of cardiologists and surgeons from 13 centers, the RESTORE Group) investigated SAVER in ischemic cardiomyopathy following anterior infarction. From January 1998 to July 2000, 662 patients underwent surgery. Early and 3-year outcomes were investigated. Concomitant procedures included coronary artery bypass grafting (CABG) in 92%, mitral repair in 22%, and mitral replacement in 3%. Hospital mortality was 7.7%. Mortality among 606 patients with SAVER and CABG alone was 4.9%. It was 8.1% among 147 patients who underwent concomitant mitral valve repair. Few patients required IABPs (8.4%), LVADs (0.4%), or ECMO (0.6%). Postoperatively, ejection fraction increased from 29.7% +/- 11.3% to 40.0% +/- 12.3% and left ventricular end systolic volume decreased from 96 +/- 63 to 62 +/- 39 mL/m(2) (P <. 05). At 3 years, the survival rate was 89.4% +/- 1.3%. Survival was lower among those with preoperative volume >80 mL/m(2) compared with volume < or = 80 mL/m(2) (83.5% +/- 3.3% v 94.5% +/- 2.0%). Freedom from readmission to hospital for heart failure was at 88.7% at 3 years and was not related to preoperative volume. SAVER is a safe and effective procedure for treating the remodeled dilated anterior ventricle following anterior myocardial infarction. Copyright 2001 by W.B. Saunders Company
Semin Thorac Cardiovasc Surg. 2001 Oct;13(4):468-75.
Erratum in:
Semin Thorac Cardiovasc Surg. 2004 Spring;16(1):113.
Intermediate survival and predictors of death after surgical ventricular restoration.
Di Donato M, Toso A, Maioli M, Sabatier M, Stanley AW Jr, Dor V; RESTORE Group.
Department of Critical Care Medicine, University of Florence, Florence, Italy.
This study examined the effects of Dor procedure on long-term survival in patients with previous transmural anterior myocardial infarction who were referred to a single experienced center for left ventricular reconstruction by endoventricular patch-plasty repair. Our aim was to evaluate the impact of this procedure on long-term survival and to assess the ability of preoperative, perioperative, and postoperative variables to predict late survival. Major indications for surgery were left ventricular dysfunction, angina, ventricular arrhythmias, or a combination of the three; 20 patients underwent urgent cardiac surgery. The total group was 245 patients, with 8.1% hospital mortality, and 19 patients lost to follow-up [corrected]. The study group comprised 207 patients. Many pre- and postoperative clinical, hemodynamic, and functional variables, as well as operative parameters, were studied by univariate analysis. During a mean follow-up period of 39+/-19 months, 30 end points were observed, including 27 deaths and 3 heart transplants. Event-free survival was 98%+/-1% at 1 year, 95.8%+/-1.4% at 2 years, and 82.1%+/-3.3% at 5 years. Cox regression analysis showed preoperative New York Heart Association functional class, ejection fraction, end systolic volume index, and remote asynergy as independent predictors of mortality. The procedure has a favorable impact on 5-year survival. Independent predictors of late survival are the preoperative functional status and the left ventricular systolic function. Copyright 2001 by W.B. Saunders Company
Ann Thorac Cardiovasc Surg. 2001 Oct;7(5):311-4.
Left ventricular pseudoaneurysm after sutureless repair of subacute left ventricular free wall rupture: a case report.
Iha K, Ikemura R, Higa N, Akasaki M, Kuniyoshi Y, Koja K.
Department of Cardiovascular Surgery, Chubu Tokushukai Hospital, 3-20-1 Teruya, Okinawa 904-8585, Japan.
A 65-year-old woman presenting with a left ventricular pseudoaneurysm 27 months after sutureless repair of a subacute left ventricular free wall rupture complicating acute myocardial infarction is described. An autologous pericardial patch and gelatin resorcin formaldehyde (GRF) glue were used in the repair. A small pseudoaneurysm bulged out over the true aneurysm of the left ventricle. We performed a Dor operation and concomitant bypass grafting to the right coronary artery. Although sutureless repair is an effective procedure for subacute left ventricular free wall rupture, left ventricular pseudoaneurysm in the late postoperative period may be a rare problem after this repair.
Semin Thorac Cardiovasc Surg. 2001 Oct;13(4):476-9.
The role of left ventricular reconstruction for cardiogenic shock.
Parrino PE, Kron IL; RESTORE Group.
Division of Thoracic Cardiovascular Surgery, Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, VA, USA.
Left ventricular remodeling after myocardial infarction is recognized as an early adaptive mechanism that later results in adverse physiologic changes. Surgical therapy for this condition includes exclusion of nonfunctional segments of ventricular wall and restoration of more normal ventricular geometry. The Dor procedure, or endoventricular patch plasty, is recognized as an excellent means of accomplishing this goal. Most series in regard to the Dor procedure report results in patients who electively come to surgery after developing global ventricular distension after an area of akinesia or dyskinesia. We report a small series of 6 patients who presented with acute myocardial infarction and who developed cardiogenic shock after ventricular dilation. Each patient underwent emergent revascularization and left ventricular reconstruction using the Dor technique. A seventh patient with akenesia, but without preoperative shock, required the Dor procedure to wean from cardiopulmonary bypass. There were no in-hospital deaths, and follow-up showed good outcomes. In certain select acute subsets (large anterior myocardial infarction, cardiogenic shock, and ventricular dilation), immediate revascularization and restoration of left ventricular size improves outcomes by changing left ventricular shape and thereby pre-empting remodeling and restoring blood flow to ischemic myocardium. Copyright 2001 by W.B. Saunders Company
Semin Thorac Cardiovasc Surg. 2001 Oct;13(4):480-5.
Surgical ventricular restoration in patients with postinfarction coronary artery disease: effectiveness on spontaneous and inducible ventricular tachycardia.
Di Donato M, Sabatier M, Dor V; RESTORE Group.
Centre Cardiothoracique de Monaco, Monaco.
Surgical ventricular reconstruction (SVR) involves resection of scar, septal exclusion, cavity reduction by endoventricular patch, and complete coronary grafting. At the Cardiothoracic Centre of Monaco, ventricular stimulation (PVS) is performed before SVR, unless contraindicated. In patients with spontaneous and/or inducible ventricular arrhythmias, nonguided endocardiectomy and cryosurgery are added. We report clinical and hemodynamic results after SVR in postinfarction patients, to compare management of patients with spontaneous and/or inducible ventricular tachycardia, with those without arrhythmias. The 3 subsets were: Group A, 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia (Spontaneous); Group B, 105 patients without clinical ventricular arrhythmias but with inducible ventricular tachycardia at PVS (Inducible); and Group C, 190 patients without spontaneous arrhythmias and not inducible ventricular tachycardia at PVS (No arrhythmias). Overall surgical mortality rate was 7.6% (29 of 382). Sudden death mortality was only 18.7% of all deaths. Surgical management caused marked reduction of inducible ventricular tachycardia, from 144 of 352 inducible ventricular tachycardia before surgery (41%), to 26 of 307 (8%) at early study, and 14 of 177 (8%) one year later. Cardiac mortality was low at 5 years, and not different among groups; this indicates that the surgical procedure limits the ventricular arrhythmias that normally impair prognosis in postinfarction dilated cardiomyopathy. We believe the favorable electrical success rate and low mortality are not linked to one aspect of the surgical procedure, but to an integrated approach that relieves ischemia (coronary bypass graft), and reduces left ventricular volumes (SVR) to improve pump function, and nonguided endocardiectomy plus cryoablation, to interrupt functional reentry circuits. Copyright 2001 by W.B. Saunders Company
Heart Fail Rev. 2001 Sep;6(3):187-93.
The endoventricular circular patch plasty ("Dor procedure") in ischemic akinetic dilated ventricles.
Dor V.
Centre Cardio-Thoracique, Monaco.
From 1984 to 2000, 950 Left Ventricular ischemic asynergy (dyskinetic or akinetic) were operated using the endoventricular circular patch plasty technique. This allows to exclude all asynergic areas of the left ventricular wall and reshape the remaining wall. Both morphology and hemodynamic of left ventricle, are improved. Hospital mortality was below 7%. Life expectancy at 10 years reaches 80% if pre-operative L.V.E.F. is above 30%, and end systolic volume index (E.S.V.I.) below 90[emsp4 ]ml, and 60% in L.V.E.F. is below 30% and E.S.V.I. above 90[emsp4 ]ml. L.V.R. by endoventricular plasty has to be considered in the treatment of ischemic congestive heart failure.
Kyobu Geka. 2001 Jul;54(7):539-43.
Endoventricular circular patch plasty (dor operation) for postinfarction left ventricular aneurysm and ischemic cardiomyopathy
Suzuki T, Kikuchi Y, Sakurada T, Hirano T, Kitada M, Kusajima K, Obata H, Kazui T.
Department of Cardiovascular Surgery, National Obihiro Hospital, Obihiro, Japan.
The determination of purse-string suture line is one of the most important point in endoventricular circular patch plasty (Dor operation) for postinfarction left ventricular aneurysm (LVAN), especially for ischemic cardiomyopathy (ICM). We suggest following three points to decide appropriate suture line. First, the purse-string suture on the basal side should be placed on the 1-2 cm level under diagonal branch. Secondly, lateral wall should not be over excluded to maintain left ventricular function. And the third, akinetic or dyskinetic lesion of apex and septal wall should be excluded as much as possible. Nine cases of five LVAN and four ICM were underwent Dor operation in our institute from Dec. 1999 to Jan. 2000. All patients were weaned from cardiopulmonary bypass easily except one patient, who was operated under IABP support, because of his preoperative severe heart failure. All patients recovered well without any serious complications and postoperative left ventricular graphies were satisfactory. Left ventricular ejection fraction and stroke volume index were increased from 34 +/- 17 to 55 +/- 16% and from 38 +/- 7 to 47 +/- 6 ml/m2, end-diastric and systric volume index decreased from 141 +/- 37 to 88 +/- 19 ml/m2 and from 96 +/- 41 to 41 +/- 23 ml/m2 respectively. The Dor procedure adopted our idea led to satisfactory result in hemodynamic and also in morphologic study.
Ann Thorac Cardiovasc Surg. 2001 Jun;7(3):170-4.
Aortic valve replacement combined with endoventricular circulatory patch plasty (Dor operation) in a patient with aortic valve stenosis and severe ischemic cardiomyopathy.
Horiguchi K, Ohtake S, Matsumiya G, Sawa Y, Nishimura M, Satou H, Kawai N, Matsuda H.
Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan.
A 58-year-old woman with ischemic cardiomyopathy and aortic valve stenosis, underwent aortic valve replacement and simultaneous endoventricular circulatory patch plasty (Dor operation). She underwent coronary artery bypass grafting for severe triple vessel disease 10 years ago. Recently she started to show severe congestive heart failure. Aortic valve stenosis with pressure gradient of 85-mmHg was also found. Coronary bypasses were all patent, but the left ventricle (LV) was severely dilated (LVDd/Ds=71/61 mm) and the ischemic cardiomyopathy was considered as the cause. She successfully underwent aortic valve replacement and endoventricular circulatory patch plasty. The initial postoperative course was complicated with intractable ventricular arrhythmia, but subsequent course was smooth and the patient was discharged with improved symptoms (NYHA Class II). Postoperative catheterization showed decreased left ventricular volume and improved contractility. This case implies the role of LV remodeling procedure in the ischemic cardiomyopathy combined with aortic valve lesion
J Am Coll Cardiol. 2001 Apr;37(5):1199-209.
Comment in:
J Am Coll Cardiol. 2001 Apr;37(5):1210-3.
Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV.
Athanasuleas CL, Stanley AW Jr, Buckberg GD, Dor V, DiDonato M, Blackstone EH.
Norwood Clinic and Kemp-Carraway Heart Institute, Birmingham, Alabama 35234, USA. dra@norwoodclinic.com
OBJECTIVES: The goal of this study was to evaluate the safety and efficacy of surgical anterior ventricular endocardial restoration (SAVER). The procedure excludes noncontracting segments in the dilated remodeled ventricle after anterior myocardial infarction. BACKGROUND: Anterior infarction leads to change in ventricular shape and volume. In the absence of reperfusion, dyskinesia develops. Reperfusion by thrombolysis or angioplasty leads to akinesia. Both lead to congestive heart failure by dysfunction of the remote muscle. The akinetic heart rarely undergoes surgical repair. METHODS: A new international group of cardiologists and surgeons from 11 centers (RESTORE group) investigated the role of SAVER in patients after anterior myocardial infarction. From January 1998 to July 1999, 439 patients underwent operation and were followed for 18 months. Early outcomes of the procedure and risk factors were investigated. RESULTS: Concomitant procedure included coronary artery bypass grafting in 89%, mitral valve (MV) repair in 22% and MV replacement in 4%. Hospital mortality was 6.6%, and few patients required mechanical support devices such as intraaortic balloon counterpulsation (7.7%), left ventricular assist device (0.5%) or extracorporeal membrane oxygenation (1.3%). Postoperatively, ejection fraction increased from 29 +/- 10.4 to 39 +/- 12.4%, and left ventricular end systolic volume index decreased from 109 +/- 71 to 69 +/- 42 ml/m2 (p < 0.005). At 18 months, survival was 89.2%. Time related survival at 18 months was 84% in the overall group and 88% among the 421 patients who had coronary artery bypass grafting or MV repair. Freedom from readmission to hospital for congestive heart failure at 18 months was 85%. Risk factors for death at any time after the operation included older age, MV replacement and lower postoperative ejection fraction. CONCLUSIONS: Surgical anterior ventricular endocardial restoration is a safe and effective operation in the treatment of the remodeled dilated anterior ventricle after anterior myocardial infarction.
J Card Surg. 2001 Mar-Apr;16(2):159-64.
Volume reduction surgery for end-stage heart failure: experience in Korea.
Chang BC, Lim CY, Park PW, Park KY, Lee YT, Kim YJ.
Division of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea. bcchang@yumc.yonsei.ac.kr
Partial left ventriculectomy (PLV) is regarded as one of the alternatives to heart transplantation for idiopathic dilated cardiomyopathy (d-CMP). Between June 1996 and March 2000, 20 patients underwent left ventricular volume reduction surgery at five major cardiac centers in Korea. PLV was performed in 16 patients with d-CMP and in 1 patient with ischemic CMP. The modified Dor procedure was performed in three patients; two patients with d-CMP and one patient with ischemic CMP. Median age was 35 years (range 3-64 years). There were 13 male and 7 female patients; there were 4 patients in Class III and 16 patients in Class IV. Among the 16 patients in Class IV, 5 patients were inotropic dependent, 2 patients were resuscitated from cardiac arrest or shock in hospital, and 1 patient was treated with intra-aortic balloon pumping. Operative technique for PLV was the same as described by Batista and colleagues. For the modified Dor procedures, the apical left ventricle was opened and a circumferential pursestring suture was placed at the base of both papillary muscles to reduce the diameter of the left ventricle concomitant with mitral annuloplasty. Mitral valve repair was performed in 15 patients and mitral valve replacement was performed in 1 patient. Moderate-to-severe tricuspid regurgitation was noted in 12 patients (with tricuspid annuloplasty in 11 of these patients and replacement in 1 patient). Postoperatively, there were seven operative deaths after PLV and one death after the modified Dor procedure. Cause of death after PLV was right heart failure in four of the seven cases, sepsis in one case, and ventricular tachyarrhythmia in the remaining two cases. After the modified Dor procedure, there was one operative death with left ventricular failure. Postoperatively, mean ventricular end-diastolic dimension markedly decreased from 75.3 mm to 50.9 mm. However, this dimension had increased slightly to 58.2 mm, an average observed 22 months later. Mean left ventricular ejection fraction (LVEF) improved significantly from 20.6% to 33.5% (p < 0.0001), but decreased to 28.5% on average 22 months later (p = 0.058). Eleven patients were discharged from the hospital and followed-up for a mean of 20.2 months (range 1-41 months). During the early postoperative period, most were in good condition. However, heart failure progressed with mitral regurgitation in four patients, two of whom underwent heart transplantation. In conclusion, PLV for d-CMP seems to be an effective alternative surgical procedure to heart transplantation in Korea. The modified Dor procedure may be another alternative to transplantation for left ventricular volume reduction. However, in patients showing progression of heart failure, early intervention with ventricular assist or heart transplantation will be necessary. Also, further studies will be necessary for selection criteria and for prevention of ventricular tachyarrhythmia.
Ann Cardiol Angeiol (Paris). 2001 Feb;50(1):56-64.
Surgery of heart insufficiency
Dreyfus G.
Service de chirurgie cardiaque, hopital Foch, BP 36, 40, rue Worth, 92151 Suresnes, France. g.dreyfus@hopital-foch.org
Apart from heart transplantation for heart failure, the problem arises of which surgical approach should be adopted to treat this disorder. Ischemic heart disease can be surgically managed in three ways: via bypass, the Dor procedure, or by isolated or associated mitral plasty; however, cases of enlarged heart disease can only be surgically treated in two ways: i.e., by mitral plasty, or by the Batista procedure. In cases of ischemic heart disease, the following conditions must be present for coronary bypass: the patients should have an adequate contractile myocardial reserve, that is to say the left ventricle should not be greatly enlarged (< 80 mm in telediastole) or a cardiac output reserve, and there should not be any sign of over-high pulmonary hypertension (an index of > 1.6 or a pulmonary pressure of < 45); an assessment of myocardial viability should then be carried out, mainly based on a thallium fixation at rest and on echographically determined doubtamine-associated stress. In the present study, the mortality rate in a series of 260 patients was 6.3% for subjects aged under 70 years old, with an actuarial survival rate of 82% at one year post-surgery, and of 70% at five years. The Dor procedure can be used in the treatment of dyskinesia, which is now practically non-existent, but also in cases of acute akinesia with resulting left ventricular dysfunction. The aim of this technique is to alter the form of a cavity that has become ovoid to an elliptical form via the insertion of a circular endoventricular patch. The results reported for this technique show an improvement in functional class and ejection fraction. Finally, the technique for repairing mitral failure is more complicated than the two previous methods, as it requires a dynamic assessment of mitral failure, which is best carried out by an evaluation of echographically determined stress. Any mitral failure of ischemic origin of > grade 2 can be corrected during bypass surgery by ring insertion, thereby effecting a simple annuloplasty. On the other hand, the assessment of cases of enlarged heart disease is more complicated, and it is more difficult to carry out palliative surgery. The mitral plasty procedure proposed by Bolling is the technique of choice for patients with severe mitral failure, in general when the ventricle is not too enlarged. However, surgery involving the reduction in size of the left ventricle (the Batista procedure) always includes mitral plasty, and may be performed in patients with a very enlarged ventricle (> 70 mm), in general with moderate mitral failure. These two techniques have been critically assessed both as regards results and when they should be adopted, and their limitations have also been discussed. In conclusion, there are valid surgical alternatives to heart transplantation in cases of heart failure that does not respond to medical treatment, and they should probably be seriously considered before any decision is made to perform heart transplantation. These results appear encouraging, particularly in terms of functional class and left ventricular function, but there are conflicting results for hemodynamic improvement. As regards survival, it is not yet possible to propose prospective randomized trials to compare medical treatment with these surgical techniques. However, further development of these techniques is bound to occur, and an ever-widening gap will exist between the limited number of cases requiring transplantation and the more complex surgical approaches adopted in future, such as permanent circulatory backup or xenografts.
J Thorac Cardiovasc Surg. 2001 Jan;121(1):91-6.
Comment in:
J Thorac Cardiovasc Surg. 2001 Jan;121(1):97.
Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery.
Di Donato M, Sabatier M, Dor V, Gensini GF, Toso A, Maioli M, Stanley AW, Athanasuleas C, Buckberg G.
Department of Internal Medicine and Cardiology, University of Florence, Italy.
OBJECTIVES: In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation. METHODS: Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation. RESULTS: Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. CONCLUSIONS: Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively.
J Thorac Cardiovasc Surg. 2001 Jan;121(1):91-6.
Comment in:
J Thorac Cardiovasc Surg. 2001 Jan;121(1):97.
Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery.
Di Donato M, Sabatier M, Dor V, Gensini GF, Toso A, Maioli M, Stanley AW, Athanasuleas C, Buckberg G.
Department of Internal Medicine and Cardiology, University of Florence, Italy.
OBJECTIVES: In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation. METHODS: Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation. RESULTS: Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. CONCLUSIONS: Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively.
Ann Thorac Cardiovasc Surg. 2000 Oct;6(5):289-94.
Current surgical strategy for post-infarction left ventricular aneurysm--from linear aneurysmecomy to Dor's operation.
Ohara K.
Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan.
The surgical strategy for left ventricular (LV) aneurysm after myocardial infarction has been changing recently. Conventionally, linear aneurysmectomy has been widely performed as a standard procedure for post-infarction LV aneurysm. However, this technique remains unsatisfactory because LV distortion occurs postoperatively and an akinetic or dyskinetic area persists in the ventricular septum, resulting in limited improvement of cardiac function. To overcome these problems, Dor and associates excluded all akinetic or dyskinetic myocardium from the left ventricle including the septum and placed a tight circumferential suture around the aneurysmal base to reduce the LV volume and return the LV contour to near normal (endoventricular circular patch plasty: EVCPP). As an alternative to conventional linear aneurysmectomy, EVCPP (Dor's operation) is now being performed more widely for the treatment of post-infarction LV aneurysm, and it achieves better postoperative cardiac function. Recently, EVCPP has attracted interest as a treatment for post-infarction large akinetic scars and ischemic cardiomyopathy (ICM), both of which have a poor prognosis. In this article, based on the author's clinical experience and on the literature, EVCPP is reviewed with respect to its indications for patients with post-infarction LV aneurysm or large akinetic scars, and pointers and results for this technique are discussed.
J Card Surg. 1998 Nov-Dec;13(6):418-28.
Restoration of contractile function in the enlarged left ventricle by exclusion of remodeled akinetic anterior segment: surgical strategy, myocardial protection, and angiographic results.
Athanasuleas CL, Stanley AW Jr, Buckberg GD.
Department of Cardiac Surgery, Kemp-Carraway Heart Institute, Carraway Methodist Medical Center, Birmingham, Alabama, USA.
A variant of the Dor cardioprotective approach for reducing ventricular volume was applied to 12 consecutive postinfarction patients with akinetic anterior segments. Cardioplegia was avoided for restoration, but used for revascularization and valve replacement. The continually perfused beating open heart was used for protection during surgical anterior ventricular restoration (SAVR). These ischemic cardiomyopathy patients (age 77 +/- 6 years) preoperatively had high LVEDVI (170 vs 75 mL/m2, normal) and LVESVI (132 vs 25 mL/m2, normal) and 20 +/- 8% ejection fraction (mean +/- S.D.). An oval patch with outer flange for hemostasis was used. Patients also underwent revascularization (10/12), reoperation (6/12), and valve procedures (6/12). Continuous perfusion of the beating open heart was used for cardiac protection during restoration. Blood cardioplegia was used for revascularization and valvular procedures. Transesophageal echocardiogram (TEE) estimated intraventricular contractility in all patients, and biplane ventriculograms were used in 8 patients to measure cardioreduction. Immediate hemodynamic performance was excellent in all patients, despite 178 +/- 34 minutes of bypass. Extracorporeal circulation was stopped 10 minutes after closing the ventriculotomy. No intraaortic balloon pump or LV assist devices were needed. Ejection fraction estimated by TEE increased from 20% to 45%; and biplane ventriculograms showed 28% reduction of LVEDVI, 39% reduction of LVESVI, and raised ejection fraction from 20% to 35%. The spherical ventricular shape after akinetic infarction was made into a more normal elliptical contour by this procedure. Subsequently, restoration may become as important as revascularization in treating akinetic segments after anterior infarction.
J Cardiol. 1998 Mar;31(3):165-70.
Dor operation for end-stage ischemic cardiomyopathy
Suma H, Isomura T, Horii T, Ichihara T, Sato T, Nishimi M, Fujisaki H, Ukawa T, Iwahashi K.
Department of Cardiovascular Surgery, Shonan-Kamakura General Hospital, Kanagawa.
Endoventricular circular patch plasty (Dor operation) was used to treat end-stage dilated ischemic cardiomyopathy in 13 patients from January to December, 1997. There were 10 men and three women aged from 57 to 78 years (mean 63 years). Single, double, triple and left main trunk coronary disease was present in one, two, eight and two patients, respectively. Mean ejection fraction was 22% (6-30%) and signs of congestive heart failure were clear in all patients [New York Heart Association (NYHA) class III in eight patients and class IV in five patients]. Angina pectoris was present in five patients. Six patients had associated significant mitral regurgitation. Coronary artery bypass grafting (mean 3.2 grafts) was used in 11 patients and mitral valve reconstruction was performed in 6 patients (4: replacement and 2: repair) combined with akinetic area exclusion by the Dor technique. All patients were successfully weaned from cardiopulmonary bypass without mechanical support and no perioperative death occurred. Three patients died in hospital at 1-2 postoperative months due to pneumonia, stroke and heart failure, respectively. Two patients died during the late period due to stroke and sudden death. Among the eight survivors, six patients were in NYHA class I-II and two patients in class III. Ejection fraction increased from 22% to 36%, end-diastolic and systolic volume indices decreased from 168 +/- 58 to 123 +/- 39 ml/m2 and from 131 +/- 60 to 81 +/- 33 ml/m2, respectively. Pulmonary capillary wedge pressure decreased from 19 +/- 10 to 14 +/- 5 mmHg. The Dor procedure is an effective surgical alternative for patients with end-stage ischemic cardiomyopathy who are considered to be candidates for cardiac transplantation.
J Am Coll Cardiol. 1997 Jun;29(7):1569-75.
Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair.
Di Donato M, Sabatier M, Dor V, Toso A, Maioli M, Fantini F.
Department of Cardiology, University of Florence, Italy.
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.
Semin Thorac Cardiovasc Surg. 1997 Apr;9(2):146-55.
The treatment of refractory ischemic ventricular tachycardia by endoventricular patch plasty reconstruction of the left ventricle.
Dor V.
Cardio-Thoracic Center of Monaco, Monte Carlo, Monaco.
Although the endoventricular patch plasty technique was originally developed to improve the functional status of the left ventricle following resection of an aneurysm, it became apparent early on in our experience that the technique also cured most cases of ventricular tachycardia associated with these aneurysms. As a result, we began to include as a part of our preoperative work-up an electrophysiology study in which we attempted to induce ventricular tachycardia even if it had not occurred spontaneously. Using our standard surgical approach, plus the use of cryotherapy, we have now operated on 106 patients with either spontaneous or inducible ventricular tachycardia preoperatively in association with ventricular dyskinesia or akinesia. The operative mortality in this series of patients was 7.5%. Postoperatively, ventricular tachycardia could not be induced in 92% of the survivors and only 2 patients have had episodes of spontaneous ventricular tachycardia. Because this technique does not require any intraoperative electrophysiological mapping, we believe this to be an excellent surgical approach for patients with refractory ischemic ventricular tachycardia
Semin Thorac Cardiovasc Surg. 1997 Apr;9(2):139-45.
Reconstructive left ventricular surgery for post-ischemic akinetic dilatation.
Dor V.
Cardio-Thoracic Center of Monaco, Monte Carlo, Monaco.
The term dyskinesia refers to a post-ischemic fibrous area of ventricle that moves in a paradoxical manner during ventricular systole and diastole, ie, an aneurysm. Akinesia indicates that such an area of scarred ventricle exhibits no movement during either systole or diastole. In the past, it has been considered extremely important, from a surgical standpoint, to differentiate between dyskinesia, which can be treated surgically, and akinesia, which cannot be treated by surgery. Because the only alternative form of surgical therapy in many of these patients is cardiac transplantation, we have applied the technique of reconstruction of akinetic areas by our endocardial ventricular patch plasty technique in the same manner as that used for areas of dyskinesia. The surgical results, especially in patients with large areas of akinesia in the left ventricle, confirm the validity of this direct approach to the treatment of a frequently complex problem.
Semin Thorac Cardiovasc Surg. 1997 Apr;9(2):131-8.
Surgical management of left ventricular aneurysms: a clarification of the similarities and differences between the Jatene and Dor techniques.
Cox JL.
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
In the mid 1980s, two highly innovative and entirely new approaches to the surgical treatment of left ventricular aneurysms were introduced almost simultaneously and completely independently by Dr Adib Jatene in Sao Paulo, Brazil and Dr Vincent Dor, then at the University of Nice, France and now at the Centre Cardio-Thoracique de Monaco. The similarities between these two approaches to the repair of left ventricular aneurysms and their close temporal evolution have caused confusion regarding their differences and the precise surgical technique of each approach. It is the purpose of this article to clarify the similarities and differences between these two techniques.
Semin Thorac Cardiovasc Surg. 1997 Apr;9(2):123-30.
Left ventricular aneurysms: the endoventricular circular patch plasty.
Dor V.
Cardio-Thoracic Center of Monaco, Monte Carlo, Monaco.
The endoventricular circular patch plasty (EVCPP) technique was first used by us in 1984 to re-establish a more normal morphology of the left ventricular cavity distorted by post-myocardial infarction scar tissue. This technique includes the placement of a subendocardial circumferential pursestring suture inside the left ventricle around the base of the aneurysm at the junction of scarred and normal endocardium. A patch is then placed at this level to establish a new contour for the left ventricular cavity. Because this patch is placed at the junction of scar and normal endocardium, a substantial portion of the distal ventricular septum is excluded from the left ventricular cavity. The overall hospital mortality in our series of more than 715 cases is approximately 7% and, in the survivors, the ejection fraction is increased an average of 0.10.
J Thorac Cardiovasc Surg. 1995 Nov;110(5):1291-9; discussion 1300-1. Related Articles, Links
Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle.
Dor V, Sabatier M, Di Donato M, Maioli M, Toso A, Montiglio F.
Centre Cardio-Thoracique de Monaco, Monaco.
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.
Thorac Cardiovasc Surg. 1989 Feb;37(1):11-9.
Left ventricular aneurysm: a new surgical approach.
Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F.
Centre Cardiothoracique de Monaco.
Since 1984, we have used a circular patch to reconstruct the left ventricle ("endoventricular circular plasty") in order to maintain a more physiologic cavity. This technique has three theoretical advantages over standard linear closure of the left ventricle (LV). First, it allows exclusion of the septal akinetic segment of the LV. Secondly, circular reorganization of the remaining LV muscle avoids the restraint caused by the linear suture closure and achieves a more physiologic LV cavity. Thirdly, circular plasty using the patch allows a complete resection of aneurysmal segments including resection of extensive subendocardial scar tissue, when appropriate, without critically compromising the cavity size. The technique involves the following steps: --Resection of dyskinetic or akinetic LV free wall and thrombectomy when indicated. --A dacron patch lined with pericardium is secured at the junction of the endocardial muscle and scarred tissue, thereby excluding non contractile portions of the LV and septum. --Myocardial revascularization is performed as indicated with particular attention paid to revascularizing the proximal left anterior descending segment. The group of patients forming this study includes 130 cases of LV reconstruction since 1984. The three main indications for surgery were angina (40%), cardiac failure (35%), arrhythmias (10%). There have been 8 hospital deaths, 4 late mortalities related to recurrence of cardiac failure in this group.(ABSTRACT TRUNCATED AT 250 WORDS)
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