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J Thorac Cardiovasc Surg 1995;110:1774-1775
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

On dynamic cardiomyoplasty

307-A MDR Building
Department of Surgery
Division of Plastic and Reconstructive Surgery
University of Louisville
Louisville, KY 40292

To the Editor:

At the completion of its first decade in clinical use, dynamic cardiomyoplasty is being judged on the basis of its late results. A realistic scrutiny shows limited or no value of the current technique of cardiomyoplasty, especially in terms of functional assistance to cardiac muscle rather than as a structural support. ¹ However, this conclusion is a result of the disadvantaged debut of the technique, with inadequate background experimentation, and should not suggest its abandonment.

The distal portion of the latissimus dorsi muscle, which is wrapped around the heart and the function of which is vital to the overall success of the procedure, has been experimentally and clinically shown to undergo fatty degeneration, atrophy, and fibrosis after dynamic cardiomyoplasty. ^2,3 This portion of the latissimus dorsi muscle derives its blood supply mostly from the perforating vessels, two of which are always of considerable size ⁴ and are cut during surgical elevation of the muscle. Although the importance of these perforating vessels in muscle perfusion is different from species to species, it seems that in human beings, especially under demanding conditions such as in dynamic cardiomyoplasty, perfusion through these vessels is crucial. One technique that can be applied to overcome this problem is surgical delay of the muscle flap. Surgical delay provides better perfusion from the major vascular pedicle to the distal portion of the muscle and has been shown to improve latissimus dorsi muscle function for use in cardiomyoplasty. ⁵ This technique involves ligation of all the segmental vascular pedicles to the latissimus dorsi muscle except the most distal one, which is also ligated and cut while the flap is being elevated during a separate operation.

However, need for a second surgical operation is a major concern. Also, thoracodorsal vessels are still the only vessels that are depended on for distal muscle perfusion. Risk of reduction in blood flow because of kinking of or pressure on the pedicle (which is passed from outside to the inside of the thorax), possible direct deleterious effects of the electrical current on the thoracodorsal vessels coursing between the two stimulation electrodes, possible damage to the vessels during electrode placement, and relative difficulty in handling of tissues during a second operation are the other issues that must be considered.

I want to describe the use of an another technique to improve distal latissimus dorsi muscle perfusion in dynamic cardiomyoplasty. This technique is called superchargingthe flap and was developed to improve the pedicled transverse rectus abdominis flap perfusion in breast reconstruction. Application of this technique in cardiomyoplasty consists of anastomosing an artery close to the new location of the muscle (e.g., internal thoracic artery) to one or two of the biggest distal perforating arteries of the latissimus dorsi muscle. This is done during the definitive operation. This procedure does not require a second surgical operation, provides perfusion of the distal muscle in a manner similar to its original form, and circumvents the other issues that I mentioned.

Expanding the research efforts in this direction will be helpful in salvaging the future of this fascinating idea of skeletal muscle assistance to the failing heart.

12/8/68559

References

1. Silverman NA. Invited letter concerning: Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J THORAC CARDIOVASC SURG 1995;109:397-8.[Free Full Text]
   
2. Kratz JM, Johnson WS, Mukherjee R, et al. The relation between latissimus dorsi skeletal muscle structure and contractile function after cardiomyoplasty. J THORAC CARDIOVASC SURG 1994;107:868-78.[Abstract/Free Full Text]
   
3. Kalil-Filho R, Bocchi E, Weiss RG, et al. Magnetic resonance imaging evaluation of chronic changes in latissimus dorsi cardiomyoplasty. Circulation 1994;90:II102-6.
   
4. Watson JS, Craig RDP, Orton CI. The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1979;64:299-305.[Medline]
   
5. Heilman SJ, Carroll SM, Stremel RW, Tobin GR, Barker JH. Vascular delay improves muscle function for use in cardiomyoplasty. Abstracts of the Fortieth Annual Meeting of the Plastic Surgery Research Council, New York: Institute of Reconstructive Plastic Surgery, 1995:149-51.
   

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