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J Thorac Cardiovasc Surg 2004;127:1221-1223
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Cardiovascular Surgery, NTT East Corporation Sapporo Hospital, Sapporo, Japan
b Division of Medical Sciences, Health Science University of Hokkaido, Ishikari-Tobetsu, Japan
Received for publication September 22, 2003; revisions received October 17, 2003; accepted for publication October 23, 2003.
* Address for reprints: Yoshiro Matsui, MD, Department of Cardiovascular Surgery, NTT East Corporation Hospital, S1W15, Sapporo, Japan 060-0061
yoshirou_matsui{at}smc.mhc.east.ntt.co.jp
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We have previously reported on the overlapping cardiac volume reduction (OLCVR) operation1 and obtained acceptable clinical outcomes. To enhance remodeling effects by changing the shape of the ventricle elliptically, we performed papillary muscle plication (PMP) combined with the OLCVR operation in 8 recent cases. This brief communication reports the favorable early results.
Clinical summary
Eight patients (5 male and 3 female patients; mean age, 54 ± 6 years) underwent the OLCVR operation combined with PMP from March 2003. Underlying diseases were ischemic dilated cardiomyopathy (ICM) in 4 patients and idiopathic dilated cardiomyopathy (DCM) in 4 patients. All patients had grade 3 (n = 4) to grade 4 (n = 4) mitral regurgitation. The preoperative ejection fraction was 22% ± 5%, and the left ventricular (LV) diastolic dimension was 72 ± 4 mm, as evaluated by means of echocardiography. The LV end-diastolic volume index, assessed by means of left ventriculography, was 198 ± 42 mL/m2. Preoperative New York Heart Association functional class was III in 3 patients and IV in 5 patients, including 2 catecholamine and intra-aortic balloon pump (IABP)–dependent patients. Emergency operations were performed for 2 patients.
Informed consent was obtained before the operation and after full explanation. Mitral annuloplasty with an undersized artificial ring was performed in all patients during blood cardioplegic arrest. Next, a 10-cm-long incision was made along the left anterior descending coronary artery in the enlarged LV free wall. Through the incision, PMP was carried out with 3 autologous pericardium-pledgeted mattress sutures. These sutures were placed through the trabeculae around the bases of the anterior and posterior papillary muscles, with the deepest being just below the site of chordal attachment. The left marginal incision was then continuously sutured to the lower two-thirds height of the septal wall. The right marginal incision was attached to the epicardium to cover the ventricular free wall with pledgeted mattress sutures in DCM. In ICM a felt strip was placed between the left marginal incision and overlapped the right marginal incision (Figure 1). These procedures were followed by proximal anastomosis of coronary revascularization or tricuspid annuloplasty if necessary after declamping of the aorta. Concomitant procedures included aortic valve replacement in 2 patients, tricuspid annuloplasty in 7 patients, and coronary artery bypass grafting in 4 patients.
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Results
Seven of 8 patients were weaned from bypass without IABP or percutaneous cardiopulmonary bypass support (PCPS). Medical inotropic support was required in some cases using only noradrenaline and milrinone. One patient who had a cardiac arrest preoperatively required both IABP and PCPS postoperatively. Although this patient was weaned from IABP and PCPS postoperatively, the patient died 2 months after the operation as a result of irreversible cerebral damage. The other 7 patients recovered well and have been followed for 102 ± 26 days. The current New York Heart Association functional class is I in 6 patients and II in 1 patient (P < .01 vs preoperative status). Postoperative ventricular arrhythmias were rarely seen, even in patients with recurrent ventricular tachyarrhythmias preoperatively.
Postoperative hemodynamic data in survivors are as follows: ejection fraction of 37% ± 8%, LV end-diastolic volume index of 132 ± 20 mL/m2, and LV diastolic dimension of 64 ± 4 mm. These values were significantly improved postoperatively (P < .05). No mitral regurgitation was revealed in the latest echocardiography performed in survivors postoperatively. Figure 2 shows a postoperative echocardiographic image showing the papillary muscles remaining bundled together.
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The influences and clinical significance of partial left ventriculectomy on cardiac function are controversial.2 We have developed the OLCVR operation to avoid the resection of potentially viable myocardium and the left circumflex coronary artery.1
Recently, Buckberg and colleagues3 reported that the conversion of the elliptical to spherical LV substrate might be responsible for ICM or DCM. Enlargement of the apex with a thin wall might precipitate the converting process from the elliptical to spherical LV shape. Because our OLCVR operation doubles, in part, the LV anterior wall around the apex, it has the advantage of reducing the circumferential diameter and increasing the wall thickness.
However, the OLCVR operation alone could not reduce the basal dimensions of an enlarged left ventricle effectively because of its features. We thus added PMP to the OLCVR operation to enhance the remodeling effects of the ventricle. The procedure of PMP presented here has been reported as a new volume reduction surgery by Nair and associates.4 Meticanti and colleagues5 recently reported favorable results of the surgical approach, consisting of endoventricular mitral repair, ventricular reconstruction, and coronary artery bypass grafting. Our operative procedure is rather different from their procedure regarding the method of mitral repair and LV reconstruction, but the aim of operation is similar. We currently consider the OLCVR operation combined with PMP to be relatively safe and effective for selected patients with severely dilated failing hearts, although long-term follow-up is mandatory.
References
This article has been cited by other articles:
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  K.-u Fumimoto, T. Fukui, T. Shimokawa, and S. Takanashi Papillary muscle realignment and mitral annuloplasty in patients with severe ischemic mitral regurgitation and dilated heart Interactive CardioVascular and Thoracic Surgery, June 1, 2008; 7(3): 368 - 371. [Abstract] [Full Text] [PDF]
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 H. Yamamoto and R. Sakata Reply to the Editor J. Thorac. Cardiovasc. Surg., June 1, 2006; 131(6): 1420 - 1420. [Full Text] [PDF]
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M. H. Mandegar, F. Roshanali, M. A. Yousefnia, and M. Marzban Papillary muscle approximation combined with ventriculoplasty in patients with ischemic cardiomyopathy and functional mitral regurgitation: effects on mitral valve and LV shape Interactive CardioVascular and Thoracic Surgery, April 1, 2006; 5(2): 81 - 84. [Abstract] [Full Text] [PDF]
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G. Buckberg, L. Menicanti, S. De Oliveira, T. Isomura, and and the RESTORE team Restoring papillary muscle dimensions during restoration in dilated hearts Interactive CardioVascular and Thoracic Surgery, October 1, 2005; 4(5): 475 - 477. [Abstract] [Full Text] [PDF]
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