Department of Cardiac Transplant
The Cleveland Clinic Foundation
9500 Euclid Avenue TT-31
Cleveland, OH 44195-5066
USA
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For more than 40 years, since the first aneurysm operations, surgeons have resected portions of the left ventricle in patients with ischemic cardiomyopathy. This decade has seen renewed clinical interest and enthusiasm for this procedure. Early experience with aneurysm repair was sometimes plagued by unpredictable outcomes fraught with hazard. With the extensive clinical experiences and careful analysis by Dor, and similar techniques by Jatene and Cooley, some of the mystery in reconstructing aneurysms was removed and more reliable clinical outcomes became more common. Dor also demonstrated the success of his operation for akinetic (not just dyskinetic) ventricles. At the same time, the limitations of cardiac transplantation were becoming more apparent, due to limited organ availability and the long-term side effects of chronic immunosuppression. Into this milieu came Dr. Randas Batista with the revolutionary idea of resecting non-infarcted ventricular muscle in patients with a dilated ventricle secondary to idiopathic cardiomyopathy, valvular cardiomyopathy, and Chagas' disease. This brought even more attention (and worldwide publicity) to the problems of end-stage cardiomyopathy and the need for surgical solutions.
Zytowski and colleagues are to be congratulated for their outstanding clinical results in a particularly difficult group of patients; those with ischemic dilated cardiomyopathy. In this group, as defined by the World Health Organization, the extent of coronary artery disease does not explain the dilated cardiomyopathy. Further evidence that these were not typical aneurysms is that 75% of their patients had posterior resection, certainly different from the classic anterior wall aneurysm reconstruction. The early clinical results, and outstanding late survival attest to the surgical judgment, perioperative skill of the team, and excellent late medical care. The clinical judgment required to treat these complex patients is probably the most important factor in success, and the hardest to quantitate. Un-fortunately, it is still true that some cases are so advanced that these surgical techniques will not return the patient to an acceptable quality of life, but they are far fewer than we thought 10 years ago.
This report by Zytowski and colleagues adds to the increasing body of evidence demonstrating the benefit of surgical techniques to reverse the deleterious effects of ventricular remodeling associated with late-stage heart failure. The direct reduction of wall stress can reduce the heart failure ‘syndrome’ characterized by elevated serum catecholamines and other neurohormones and signaling mechanisms activated by wall stretch. Also, surgeons can address other mechanical problems such as mitral regurgitation, that cause volume overload, and undertake revascularization of areas of myocardium that are ischemic, as seen in this report. In the modern era, this major surgical undertaking in patients with severely impaired ventricular function is safe and effective, and should always be considered instead of transplantation. The addition of contemporary medical therapy to patients after this type of surgery may optimize their long-term prognosis. Improving the ejection fraction does not cure heart failure, it just makes it easier to treat.
