Asian Cardiovasc Thorac Ann 2003;11:99-101
© 2003 Asia Publishing EXchange Ltd
Left Ventricular Volume Reduction Surgery in the Middle East
Sami S Kabbani, FACS,
Mohammad Bashar Izzat, FRCS(CTh),
Hisham Jamil, MD,
Bassam Akasheh, FRCS1,
Daoud Hanania, FRCS2,
Hassan Raffa, MD3
Damascus University Cardiovascular Surgical Center, Syria
1 King Hussein Medical Center, Jordan
2 Arab Center for Heart and Special Surgery, Jordan
3 King Abdul-Aziz University, Saudi Arabia
For reprint information contact: Sami S Kabbani, FACS Tel: 963 11 2129437 Fax: 963 11 2129437 email: dam-uncv{at}net.sy Damascus University Cardiovascular Surgical Center, Damascus University, PO Box 2837 Damascus, Syria.
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ABSTRACT
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Heart transplantation is not yet socially acceptable in the Middle East, and left ventricular assist facilities are not generally available in this region. Therefore, left ventricular volume reduction surgery was attempted in 41 patients with end-stage heart failure (33 males; median age, 36.3 years) in 4 Middle Eastern tertiary referral centers between February 1996 and January 2001. Heart failure was due to idiopathic cardiomyopathy in 21 patients, ischemia in 11, rheumatic valvular disease in 8, and viral myocarditis in 1. Associated procedures were aortic valve replacement in 5 patients, mitral valve repair in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and coronary bypass grafting in 8. Hospital mortality was 31.7%. Five patients were lost to follow-up. The survival rate of hospital survivors at 18 months was 65.2%. Three of the surviving patients did not benefit from the operation. Although our results were somewhat disappointing, this operation remains an option for surgeons working in developing areas of the world. It is hoped that better patient selection and new techniques of left ventricular volume reduction that avoid resection of viable muscle will further improve the outcome of this operation.
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INTRODUCTION
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The past 5 years have seen a rise and fall of interest in left ventricular volume reduction (LVVR) surgery as a treatment modality for end-stage heart failure. Following the initial flare of attention, several centers in the west with heart transplantation and left ventricular assist facilities abandoned this procedure because the outcome in patients with idiopathic cardiomyopathy did not compare favorably with these alternative treatments. Notwithstanding, LVVR continues to be performed in Asia where a spectrum of heart failure etiologies is prevalent and where heart transplantation and left ventricular assist facilities are largely unavailable. It is possible that the outcome of LVVR surgery in Asian patients might differ from that in the west. Therefore, knowledge of the medium and long-term outcome of LVVR surgery in Asia is of great interest to surgeons practicing in this region. This report describes the midterm clinical experience with LVVR surgery in 4 tertiary referral centers in the Middle East.
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PATIENTS AND METHODS
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Between February 1996 and January 2001, 41 patients (33 males; median age, 36.3 years; range, 13 to 68 years) underwent LVVR surgery in these 4 centers. Preoperatively, all patients had advanced symptomatic congestive heart failure unresponsive to maximally tolerated medical therapy (angiotensin-converting enzyme inhibitors, diuretics, digitalis, and in 3 cases, inotropic and/or intraaortic balloon pump support); 20 were in New York Heart Association functional class III, and 21 were in class IV. The cause of heart failure was idiopathic cardiomyopathy in 21 patients, ischemic in 11, rheumatic valvular disease in 8, and viral myocarditis in one.
Surgery was performed on the beating heart in 13 cases and under cardioplegic arrest in 28. The technique of LVVR involved excision of a wedge of the lateral left ventricular wall between the left anterior descending and circumflex coronary arteries. The free wall of the left ventricle was reconstituted in a linear fashion with Teflon strips for reinforcement. The papillary muscles of the mitral valve were excised in 6 cases. Associated procedures were aortic valve replacement in 5, mitral valve repair (mostly by the Alfieri method) in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and multivessel coronary artery bypass grafting in 8.
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RESULTS
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Four patients (3 with ischemic and 1 with idiopathic cardiomyopathy) died intraoperatively of low cardiac output, and all other patients required inotropic support to be weaned off cardiopulmonary bypass. Another 9 patients (5 with ischemic, 3 with idiopathic, and 1 with valvular cardiomyopathy) died in the early postoperative period due to severe bleeding in 2, cardiogenic shock in 4, septicemia in 2, and liver failure in one. Thus, the overall in-hospital mortality rate was 31.7% (72% for ischemic, 19% for idiopathic, and 12% for valvular cardiomyopathy).
Five patients were lost to follow-up after discharge (4 with idiopathic and 1 with valvular cardiomyopathy); follow-up was complete in the other 23 hospital survivors. After discharge, 3 patients (2 with idiopathic and 1 with valvular cardiomyopathy) developed progressive congestive heart failure to which they subsequently succumbed between 1 and 6 months postoperatively, and 2 more patients (both with idiopathic cardiomyopathy) died within one year of surgery. At 18 months postoperatively, 3 additional patients (2 with ischemic and 1 with valvular cardiomyopathy) had died (due to arrhythmia in 2 cases). The overall survival rate at 18 months for hospital survivors was 65.2% (84% for valvular, 70% for idiopathic, and 33% for ischemic cardiomyopathy). Figure 1
depicts the actuarial survival curve for the group. Among patients still alive at 18 months, there was minimal or no symptomatic benefit from the procedure in 3 (20%) patients (1 with ischemic, 1 with valvular, and 1 with post-myocarditis cardiomyopathy), and moderate improvement in symptoms in 12 (80%) patients (3 with valvular, and 9 with idiopathic cardiomyopathy).
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Figure 1. Actuarial survival curve for 41 patients undergoing left ventricular volume reduction surgery.
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DISCUSSION
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Although heart transplantation remains the standard surgical treatment for patients with end-stage heart failure who are unresponsive to medical therapy, its application is limited by the inadequate (and dwindling) donor pool, the frequently inappropriate recipient characteristics, and social resistance to organ transplantation. In the Arabic-speaking Middle East where the last-mentioned obstacle is very strong, surgeons have to contend themselves with other options at their disposal.1 The intriguing concept of removing viable muscle from a dilated left ventricle to reduce its diameter and wall stress, initially proposed by Batista and colleagues,2 remains to be validated by sufficient clinical data. Although short-term clinical improvement in survivors has generally been observed, operative mortality was high in most reports, and the intermediate results and documentation of physiologic improvement have been less than optimal.3–8 Our experience with this operation in the Middle East mirrors that of most other series.
One way to enhance the results of LVVR might be to improve the selection of candidates. While certain echocardiographic criteria such as preoperative end-systolic wall stress may be helpful, more promising means of selection may have to be directed towards evaluation at the cellular level.9–11 Operative technique, which has not yet been standardized, seems to play a key role in the success of this procedure. Theoretically, extensive resections are more likely to attain the objectives of the operation but they are associated with higher mortality.12 An interesting concept advocated by Suma and colleagues13 is to perform selective ventriculoplasty whereby the weakest part of the cardiac muscle, as determined by intraoperative echocardiography-guided volume reduction testing, is excised or excluded. In the presence of mitral valve incompetence, concomitant mitral valve reconstruction is indispensable; indeed, some surgeons ascribe to it a primary role in the surgical management of end-stage heart failure.14 Several of our patients who deteriorated postoperatively had undergone Alfieri-type repairs without a ring, and actually succumbed to recurrent mitral regurgitation.7 Therefore, we believe that mitral valve repair should follow standard techniques and include the use of a stabilizing ring. This is supported by wider experience in the region published previously.5 If the mitral valve proves to be irreparable and requires replacement, we believe that it is advisable to retain the subvalvular apparatus by one of the now familiar techniques, in order to preserve ventricular function as much as possible.
The etiology of cardiomyopathy best suited for LVVR has not yet been determined. Early reports favored an etiology of idiopathic dilated cardiomyopathy and considered patients with ischemic cardiomyopathy as poor candidates; however, a recent study found that the risks and benefits of the procedure in both categories are comparable.15 Not enough data about valve-related cardiomyopathy, which is quite common in the developing world, are available. Our limited experience leads us to believe that LVVR in conjunction with valve repair or replacement in these patients may be of particular benefit, since our better results belonged to this category.5,7
It is quite possible that special techniques will be developed in the near future to reap the benefits of LVVR (reduced left ventricular volume and stress) without actually resecting viable muscle. Already two devices, the Myocor interventricular splint and the Acorn cardiac support system, have been introduced, as well as special surgical techniques such as realignment of the papillary muscles through a small apical cardiotomy.16,17 The aim of such alternative procedures is to reduce the high operative risk of LVVR surgery while gaining the benefits of reducing left ventricular volume and stress. We believe that LVVR will continue to be part of the cardiac surgeon’s armamentarium, especially in areas that lack the option of cardiac transplantation, even though questions related to selection and technique remain unresolved. It is hoped that randomized clinical trials comparing these procedures with current optimal medical and standard surgical therapy will further elucidate the actual role that LVVR surgery can play in the management of the various types of cardiomyopathy.
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REFERENCES
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ABSTRACT
INTRODUCTION
