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Left ventricular volume reduction and reshape – ‘Re‐STICHING’ the field

DOI:10.1002/ejhf.1748
Authors:
Michael J. Bonios at Onassis Cardiac Surgery Center
Michael J. Bonios
Nektarios Kogerakis at Onassis Cardiac Surgery Center
Nektarios Kogerakis
Stamatis N. Adamopoulos
Stamatis N. Adamopoulos
Stamatis N. Adamopoulos
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LETTER TO THE EDITOR
doi:10.1002/ejhf.1748
Left ventricular volume
reduction and
reshape – ‘Re-STICHING’
the eld
We read with interest the study by Klein
et al.1exploring the effect of a less invasive
device in inducing left ventricular reconstruc-
tion in failing hearts post-myocardial infarc-
tion. Left ventricular remodelling following an
anterior myocardial infarction has detrimental
effects to the efcacy of the left ventricle.
This stems not only from the Laplace law
but in addition from the impaired blood ow
kinetics within the remodelled left ventricle.
The concept of surgical volume reduction
of the dilated left ventricle is to exclude
the infarcted myocardial tissue, reshape and
increase the efcacy of the left ventricle.2
This strategy faces two major challenges.
First, the nal end-diastolic volume should
be reduced enough in order to allow the
Laplace low to take place effectively. How-
ever, the nal volume should not be that small,
otherwise restrictive phenomena will occur,
stroke volume will be reduced, left ventricular
lling pressures will rise and re-dilatation of
the left ventricle might occur. In those cases,
any potential benet from volume reduction
therapies will be eliminated.3,4 In order to
avoid the left ventricular excessive volume
reduction during the procedure, surgeons
are trying to keep the nal left ventricular
remaining volume close to 60 mL/m2using
the ‘balloon sizing’ technique. However, even
if it is true that a nal volume at that level is
sufcient for the normally working heart, we
....................................................................................................................................................................
still do not know whether this is also true for
an impaired left ventricle that has undergone
remodelling.
The second challenge for left ventricular
reconstruction surgeries is the restoration
of a more conical shape of the left ventricle.
Studies have shown that a conical shape
results in better outcomes since this shape
improves blood ow hydrodynamics. In the
STICH trial, left ventricular geometry wors-
ened after left ventricular reconstruction
surgery and the left ventricle became more
spherical.5Only those patients that obtained
a conical left ventricular shape demonstrated
improved outcomes.
Left ventricular reconstruction surgery
is not a one size ts all patients, and a
more individualized approach should be
implemented. Klein et al.1in a less invasive
approach attempted to reduce the volume
of the infarcted left ventricle, excluding the
non-functioning scarred myocardium. There
was a signicant reduction in left ventricular
volumes and a signicant increase in left
ventricular ejection fraction. A total of 46
out of 86 participants were characterized as
‘responders’ since they revealed improve-
ment in the 6-min walk test and in their
quality of life.
To the direction of a more individualized
approach for ventricular volume reduc-
tion and reshaping therapies, it would be
very helpful if authors could provide also
parameters of the shape of the left ventricle
before and following the application of the
device (apical conicity index, left ventricular
sphericity index). The device proposed by
Klein et al.1has the advantage of requiring
no cardiopulmonary bypass. In that way,
haemodynamic parameters obtained by a
Swan–Ganz catheter at the time of the
deployment of the device could provide
....................................................................................................................................................................
important prognostic information on the
short- and long-term adaptation of the left
ventricle to the newly acquired volume and
shape in a real time way.
Again, we nd the study of Klein et al.1a
very important step for a more quantitative
and personalized application of left ventricular
reshaping and volume reduction therapies.
Michael J. Bonios ∗,
Nektarios Kogerakis, and
Stamatis N. Adamopoulos
Heart Failure and Transplant Unit, Onassis Cardiac
Surgery Center, Athens, Greece
*Email: bo_mic@yahoo.com
References
1. Klein P, Anker SD, Wechsler A, Skalsky I, Neuzil P,
Annest LS, Bi M, McDonagh T, Frerker C,
Schmidt T, Sievert H, Demaria AN, Kelle S. Less
invasive ventricular reconstruction for ischaemic
heart failure. Eur J Heart Fail 2019;21:1638 –1650.
2. Athanasuleas CL, Buckberg GD, Stanley AW,
Siler W, Dor V, Di Donato M, Menicanti L, Almeida
de Oliveira S, Beyersdorf F, Kron IL, Suma H,
Kouchoukos NT, Moore W, McCarthy PM, Oz MC,
Fontan F, Scott ML, Accola KA. Surgical ventricular
restoration in the treatment of congestive heart
failure due to post-infarction ventricular dilation.
J Am Coll Cardiol 2004;44:1439– 1445.
3. Di Donato M, Fantini F, Toso A, Castelvecchio S,
Menicanti L, Annest L, Burkhoff D. Impact of surgi-
cal ventricular reconstruction on stroke volume in
patients with ischemic cardiomyopathy. J Thorac Car-
diovasc Surg 2010;140:1325– 1331.e1–2.
4. Bonios MJ, Anastasiou-Nana M, Perrea DN,
Malliaras K. A combined cellular and surgical
ventricular reconstruction therapeutic approach
produces attenuation of remodeling in infarcted
rats. Hellenic J Cardiol 2017;58:135– 142.
5. Choi JO, Daly RC, Lin G, Lahr BD, Wiste HJ,
BeaverTM,IacovoniA,MalinowskiM,FriedrichI,
Rouleau JL, Favaloro RR, Sopko G, Lang IM, White
HD,MilanoCA,JonesRH,LeeKL,VelazquezEJ,
Oh JK. Impact of surgical ventricular reconstruction
on sphericity index in patients with ischaemic
cardiomyopathy: follow-up from the STICH trial.
Eur J Heart Fail 2015;17:453–463.
© 2020 The Authors
European Journal of Heart Failure © 2020 European Society of Cardiology
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Less invasive ventricular reconstruction for ischaemic heart failure
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Article
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Background: Left ventricular reconstruction (LVR) has been shown to provide transient benefits in LV structure and function of infarcted hearts; however long-term results have been disappointing, as LVR-induced benefits are typically not sustained. We hypothesized that administration of cardiosphere-derived cells (CDCs), which promote myocardial repair and regeneration, may result in long-term preservation of the beneficial effects of LVR in ischemic cardiomyopathy. Methods: Wistar Kyoto rats underwent myocardial infarction (MI) and two weeks later were randomized into 3 groups: in Group 1 (n=9) LVR was performed by plication of the infarcted apex and CDCs were injected in the infarct border zone (IBZ); group 2 animals (n=9) underwent LVR and received vehicle solution in the IBZ. Group 3 animals (n=10) were injected with vehicle solution in IBZ, without undergoing LVR. Echocardiograms were performed at baseline, 4 days post-apex plication, and 3 months post-MI. Results: At baseline, all animal groups had comparable LVEF, LV end-diastolic volume (EDV) and LV end-systolic volume (ESV). Four days post-LV apex plication, Group 1 and Group 2 animals exhibited comparable significant improvement in EF and comparable significant reduction in LVEDV and LVESV. Three months post-MI, Group 1 animals had decreased LVEDV, decreased LVESV, less impaired CS, increased peak systolic torsion and increased EF compared to animals in Groups 2 and 3. Conclusion: In infarcted rat hearts, intramyocardial delivery of CDCs in conjunction with LVR resulted in significant and sustained amelioration of LV remodeling and improvement in LV function, compared to LVR alone.
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Impact of surgical ventricular reconstruction on sphericity index in patients with ischaemic cardiomyopathy: Follow-up from the STICH trial
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We sought to evaluate associations between baseline sphericity index (SI) and clinical outcome, and changes in SI after coronary artery bypass graft (CABG) surgery with or without surgical ventricular reconstruction (SVR) in ischaemic cardiomyopathy patients enrolled in the SVR study (Hypothesis 2) of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Among 1000 patients in the STICH SVR study, we evaluated 546 patients (255 randomized to CABG alone and 291 to CABG + SVR) whose baseline SI values were available. SI was not significantly different between treatment groups at baseline. After 4 months, SI had increased in the CABG + SVR group, but was unchanged in the CABG alone group (0.69 ± 0.10 to 0.77 ± 0.12 vs. 0.67 ± 0.07 to 0.66 ± 0.09, respectively; P < 0.001). SI did not significantly change from 4 months to 2 years in either group. Although LV end-systolic volume and EF improved significantly more in the CABG + SVR group compared with CABG alone, the severity of mitral regurgitation significantly improved only in the CABG alone group, and the estimated LV filling pressure (E/A ratio) increased only in the CABG + SVR group. Higher baseline SI was associated with worse survival after surgery (hazard ratio 1.21, 95% confidence interval 1.02 - 1.43; P = 0.026). Survival was not significantly different by treatment strategy. Although SVR was designed to improve LV geometry, SI worsened after SVR despite improved LVEF and smaller LV volume. Survival was significantly better in patients with lower SI regardless of treatment strategy. © 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.
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Impact of surgical ventricular reconstruction on stroke volume in patients with ischemic cardiomyopathy
Article
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Left ventricular end-diastolic volume is decreased and ejection fraction is increased after surgical ventricular reconstruction; however, the impact on left ventricular stroke volume is not well established. We analyzed 248 consecutive patients who underwent surgical ventricular reconstruction at a single center. There were 14 perioperative deaths (5.6%). The 234 surviving patients had pre- and postsurgical ventricular reconstruction echocardiographic measurement of end-diastolic volume, end-systolic volume, and stroke volume, each indexed to body size and ejection fraction. A total of 120 patients had echocardiography data at follow-up (median 8 months). Overall, surgical ventricular reconstruction resulted in reductions in end-diastolic volume index (-30% ± 18%) and end-systolic volume index (-37% ± 20%), and increases in ejection fraction (21% ± 18% relative increase). However, stroke volume index decreased from 35 ± 8 mL/m(2) preoperatively to 28 ± 7 mL/m(2) early postoperatively (a 17% ± 24% relative reduction, P < .0001); 165 patients (71%) exhibited a decrease and 69 patients (29%) exhibited an increase or no change in stroke volume index after surgical ventricular reconstruction. Stroke volume index reduction was strictly related to end-diastolic volume reduction. Patients who initially had a stroke volume index decrease showed recovery, so that at the time of chronic follow-up there was no significant difference between the groups. Notably, 4-year survival was approximately 85% and did not differ between patients with an increase or decrease in stroke volume index (P = .383). Although surgical ventricular reconstruction uniformly results in an impressive decrease in end-diastolic volume index and increase in ejection fraction, seemingly indicating beneficial remodeling and improved pump function, systolic volume index, which more directly indexes cardiac pump function, frequently decreases after surgical ventricular reconstruction. Further study is needed to identify baseline characteristics that predict those patients in whom cardiac performance is enhanced by surgical ventricular reconstruction and to clarify whether there is a beneficial impact on exercise tolerance and cardiac output at peak exercise.
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Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation
Article
Objectives: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team. Background: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. Methods: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified. Results: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF <or=30%, LVESVI >or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II. Conclusions: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.
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