Download Posterior restoration procedures and the long

ORIGINAL ARTICLE – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 725–731
doi:10.1093/icvts/ivv019 Advance Access publication 3 March 2015
Cite this article as: Isomura T, Hirota M, Notomi Y, Hoshino J, Kondo T, Takahashi Y et al. Posterior restoration procedures and the long-term results in indicated
patients with dilated cardiomyopathy. Interact CardioVasc Thorac Surg 2015;20:725–31.
Posterior restoration procedures and the long-term results in indicated
patients with dilated cardiomyopathy†
Tadashi Isomura*, Masanori Hirota, Yuichi Notomi, Joji Hoshino, Taichi Kondo,
Yu Takahashi and Minoru Yoshida
Department of Cardiovascular Surgery, Hayama Heart Center, Kanagawa, Japan
Received 9 September 2014; received in revised form 9 December 2014; accepted 7 January 2015
Abstract
OBJECTIVES: Non-transplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. We performed posterior
restoration for dilated akinetic or dyskinetic lesions in patients with DCM and obtained favourable outcomes. The early and long-term
results of the procedures are discussed.
METHODS: Between 2005 and 2013, posterior restoration procedures (PRPs) for DCM were electively performed in 58 patients (17 with
ischaemic and 41 with non-ischaemic DCM). There were 45 men and 13 women with a mean age of 56 ± 12 years old. The mean preoperative ejection fraction was 24% and the preoperative New York Heart Association functional class was Class III in 24 and Class IV in 34
patients with intravenous inotrope support. Indications for PRPs were determined by using speckle-tracking echocardiography of the posterior region of the left ventricle before surgery (GE ultrasound machine, Vivid 7 or Vivid E9). After cardioplegic arrest, mitral surgery or
coronary artery bypass grafting (CABG) was performed and the posterior left ventricular (LV) muscle between bilateral papillary muscles
was incised or resected. The LV apex was preserved and cryoablation was applied between the cut edge and the posterior mitral annulus.
All patients were followed up by transthoracic echocardiography.
RESULTS: In addition to PRP, mitral surgery was performed in 56 ( plasty 51, replacement 5), tricuspid annuloplasty in 21, CABG in 17,
cardiac resynchronization therapy in 6 and LV lead implantation in 27 patients. Perioperative intra-aortic balloon pumping was used in 9
patients and there was no hospital mortality. After the operation, 35 patients (60%) improved their functional class to Class I or II. In the
late follow-up, there were 14 cardiac deaths (congestive heart failure 10, ventricular arrhythmia 4). The 3- and 8-year survival rates were 77
or 66%, respectively.
CONCLUSIONS: DCM with posterior akinesis or dyskinesis indicated by speckle-tracking echocardiography can be surgically treated with
PRP. Our results demonstrated that 60% of the selected patients could avoid heart transplantation with relief of their symptoms.
Keywords: Posterior restoration procedures • Dilated cardiomyopathy • Speckle-tracking echocardiography • Non-transplant surgery
• Heart transplantation
INTRODUCTION
Although medical treatment including resynchronization therapy
is developing and showing marked improvement for the treatment of dilated cardiomyopathy (DCM), the prognosis is still poor
with a high mortality rate [1]. Because heart transplantation is
limited and expensive, and late survival is 60% at 10 years due to
chronic complications of immunosuppressant medication or coronary lesion. Alternative surgical procedures have been investigated for more than 10 years. Partial left ventriculectomy (PLV)
with reduction of left ventricular (LV) volume leads to reduced
†
Presented at the 28th Annual Meeting of the European Association for CardioThoracic Surgery, Milan, Italy, 11–15 October 2014.
wall tension, aims to restore the normal mass/volume ratio and
has been proposed as a treatment modality for heart failure in
DCM [2–4]. However, the operative and late mortality was high
and Cereceda et al. concluded that early and late failures precluded the widespread use of PLV. However, they also reported
that in view of its occasional beneficial effect, use in situations
that did not allow for transplantation or as a biological bridge to
transplantation might be appropriate.
In ischaemic DCM, left ventricular restoration (LVR) was first
described by Dor et al. [5] as an endoventricular circular patch
plasty (EVCPP). The procedure can totally exclude the akinetic or
dyskinetic scar of the LV, reshape the LV with the Fontan stitch encircling the transitional zone between the contractile and noncontractile myocardium, and then re-establish optimal ventricular
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ORIGINAL ARTICLE
* Corresponding author. Department of Cardiovascular Surgery, Hayama Heart Center, 1898-1 Shimoyamaguchi, Hayama, Kanagawa 240-0166, Japan.
Tel: +81-46-8751717; fax: +81-46-8753636; e-mail: [email protected] (T. Isomura).
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volume using the circular patch. Their procedures were repeated
in many institutes and showed early and late good outcome. The
difference of the surgical results between PLV and EVCPP arises
from the affected region of the LV and exclusion method used.
A major cause of ischaemic DCM is the occlusion of the left anterior descending artery (LAD) and the antero-septal wall becomes
akinetic or dyskinetic. EVCPP is the operative procedure that
excludes the antero-septal wall, which is the affected site. However,
in PLV the operative procedures are based on the concept that reduction in the LV volume leads to reduced wall tension and restoration of LV function. Although PLV may be effective in some cases,
the resected region of the LV is not always at the postero-lateral wall
of the LV.
In this paper, we introduced accurate detection of the affected
LV region before operation both in ischaemic and non-ischaemic
DCM and performed posterior restoration procedures (PRPs) in
case of the presence of postero-lateral akinesis or dyskinesis. The
purpose of this article is to assess the early and late outcome of
the PRP in indicated patients.
MATERIALS AND METHODS
Patients
Between July in 2005 and December in 2013, 275 patients with
DCM (90 with ischaemic and 185 with non-ischaemic) received
non-transplant cardiac surgery at Hayama Heart Center in Japan.
This study was approved by the Institutional Review Board of
Hayama Heart Center. The diagnosis of DCM was made by echocardiography, coronary angiography and/or myocardial biopsy.
Among them, 58 patients were evaluated to have severe posterior
akinesis or dyskinesis by speckle-tracking echocardiography
before operation and were indicated for the posterior restoration
of the left ventricle. The aetiology was ischaemic DCM in 17 and
non-ischaemic DCM in 41 patients including sarcoidosis and
muscular dystrophy. There were 45 men and 13 women and the
mean age was 56 ± 12 years (range, 15–77 years) with 16 patients
over the age of 65 years. All patients were in New York Heart
Association functional Class III (41%) or IV (59%). Preoperative
inotrope support was required in 37 patients.
Functional and geometric assessment of the left
ventricular
Two-dimensional echocardiography was used to evaluate cardiac
geometry, including dimensions and LV volume, valvular morphology and the subvalvular apparatus. Geometric parameters such
as LV end-diastolic and end-systolic diameter (LVEDD and LVESD),
and LVED- and LVES volume indices (LVEDVI and LVESVI) were
calculated by the modified Simpson method.
Regional assessment for left ventricular restoration
Patient selection was based on the preoperative findings of
speckle-tracking echocardiography, which showed severe akinetic
or dyskinetic lesion and dyssynchrony at the posterior wall of the
dilated LV. LVEDD >70 mm or LVESVI >80 ml/m2 as determined
by echocardiography was a prerequisite for LV restoration.
As previously reported, we utilized similar methods for echocardiography [6]. Echocardiography was carried out using a Vivid 7 or
Vivid E9 ultrasound machine (GE Medical Systems, Milwaukee,
WI, USA) with an M3S probe. Short-axis images from the midlevel (i.e. papillary muscle level) of the LV were obtained from the
parasternal window to assess myocardial segmental viability and
LV dyssynchrony (Fig. 1). Caution was greatly exercised to ensureshort-axis images with circular cross section and minimal outof-plane movement. Short-axis images were analysed by EchoPAC
platform (2DS-software package, GE Medical Systems), which
employed a speckle-tracking technique to derive rotation and strain
for selected regions of the myocardium. For assessing myocardial
viability of the posterior wall, we analysed the circumferential strain
profile, which was closely related to myocardial viability [7, 8].
Indication of cardiac resynchronization therapy was evaluated with a
radial strain profile of each segment as previously reported [9].
Surgical procedures
Using ordinary cardiopulmonary bypass (CPB) with tepid-to-warm
blood (34 degrees Celsius) cardioplegic heart arrest [10], coronary
Figure 1: Speckle-tracking echo and wall motion before and after posterior restoration procedures (PRPs): The dyssynchronous wall motion of the posterior wall
(arrow in pre-PRP) is removed after surgery and the wall motion becomes synchronous.
T. Isomura et al. / Interactive CardioVascular and Thoracic Surgery
Medical treatment and follow-up
Optimal medical therapy for heart failure was reinstituted as soon as
possible after surgery. An angiotensin-converting enzyme inhibitor,
diuretics, amiodarone and a β-blocker (carvedilol) were administered, if tolerated by patients. In case of the presence of significant
ventricular arrhythmia, implantable defibrillators or cardiac resynchronization therapy and defibrillators (CRT-D) were implanted
before operation or hospital discharge. Cardiac echocardiography
was performed before discharge and the patients were followed up
every 6–12 months. The regular follow-up was made by the outpatient clinic, and by telephone calls or mailed questionnaires. The
follow-up completion rate was 96% and the mean follow-up was
44 ± 29 months and encompassed 213 patient-years. The longest
follow-up extended to 8.6 years. Among surviving patients, 26%
have been followed up for 5 or more years, 53% have been followed
up for 3 or more years and 83% for more than 1 year.
Statistical analysis
Continuous variables are expressed as the mean ± standard error.
Cumulative survivals were calculated by the Kaplan–Meier estimation with the dates of the operation and of the most recent followup. P-values were obtained by paired or unpaired Student’s t-test,
Wilcoxon’s signed-rank test, the Mann–Whitney test and one-way
analysis of variance followed by Tukey–Kramer’s post hoc test. The
differences in the survival rate were determined by log-rank analysis. A P-value of <0.05 was considered statistically significant.
RESULTS
Concomitant procedures included mitral surgery in 56 patients,
tricuspid surgery with the Edwards MC3 annuloplasty ring
(Edwards Life Sciences, Irvine, CA, USA) in 21 and CABG in 17.
With regard to mitral surgery, 51 patients received mitral valve
Figure 2: Intraoperative finding and surgical procedures. (A) Gross findings showed a very thin and fibrotic posterior wall of the LV. (B) The posterior and anterior leaflets of the mitral valve were observed through the left ventriculotomy after resection of the posterior LV wall between both papillary muscles. (C) The posterior LV wall
between the end of the ventriculotomy and the mitral annulus was cryoablated to prevent late fatal ventricular arrhythmia. (D) Both papillary muscles were preserved
and were approximated during closure of the LV.
ORIGINAL ARTICLE
artery bypass grafting (CABG), mitral or tricuspid surgery was performed, followed by posterior restoration of the LV (PRPs).
As previously reported, details of PRP were described and
similar techniques were performed [6]. PRP consisted of posterior
restoration with preservation of bilateral papillary muscle and the
LV apex, and the prevention of late occurrence of ventricular arrhythmia. A representative operative image is shown in Fig. 2A.
The LV was opened at 1–2 cm at the left side of the LAD and the
bilateral papillary muscles were carefully inspected. The incision
was then extended forwards between bilateral papillary muscles
to the mitral annulus before reaching 1–2 cm from the annulus
(Fig. 2B). The posterior wall of the LV between both papillary
muscles was then resected. Cryoablation was performed inside
the LV muscle between the edge of the incision and the mitral
annulus (Fig. 2C). The bilateral papillary muscle was reapproximated during closure of the LV (Fig. 2D). The incised LV wall was
closed in two layers to secure haemostasis.
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plasty (MVP) using one or two under-sized Carpentier–Edwards
Physio rings. In addition, the free edges of the anterior and posterior mitral leaflets were approximated (Alfieri stitch) in 2 patients.
Five patients received mitral valve replacement (MVR) with bioprosthesis and aortic valve replacement with bioprosthesis in 3
patients. In 4 patients with intraoperative echocardiographic
Table 1: Preoperative echocardiography
Variables
(n = 58)
LV ejection fraction (%)
LV end-diastolic diameter (mm)
LV end-systolic diameter (mm)
Mitral regurgitation
Grade 0
Grade I
Grade II
Grade III
Grade IV
Tricuspid regurgitation
>Grade II
25 ± 7
74 ± 8
65 ± 10
Values are expressed as means ± SE.
LV: left ventricular.
1
1
6
25
24
24
21
findings, biventricular pacemaker implantation was introduced
during the surgery, and maze procedures for atrial fibrillation
were performed in 8 patients.
After weaning from CPB, echocardiography showed less-thantrivial MR in all patients. The mean aortic cross-clamping time was
87 ± 30 min and the mean CPB time was 130 ± 35 min. Intra-aortic
balloon pumping was perioperatively required in 7 patients and it
was withdrawn in 1–3 days after the operation. There were no
patients requiring a left ventricular assist system (LVAS) and the
30-day mortality was zero (0%).
Functional and geometric parameters are summarized in Table 1.
After the operation, LVEF remained unchanged (25 ± 7% before operation and 24 ± 7% at discharge after operation), but improved to
28 ± 9% during the follow-up period (P = 0.024) (Fig. 3A). LVEDD was
significantly reduced after the operation (before vs after, 74 ± 8 vs
65 ± 8 mm; P < 0.0001). The LV was not re-dilated during a follow-up
period of 44 ± 29 months (Fig. 3B). After the operation, MR was not
detected in 55 patients, but only in 3 patients, being of Grade II. In
the late follow-up, less than trivial MR was detected in most patients,
except 5 patients, with Grade II in 3 and Grade III in 2 of them
(Fig. 3C). At the late follow-up, 5 patients with more-than-moderate
MR showed a redilated LV with LVEDD >70 mm (mean 73 ± 3 mm)
at the late follow-up period.
During the follow-up, the New York Heart Association (NYHA)
functional class improved to Class I or Class II in 35 patients. Late
Figure 3: (A) Functional alteration of the left ventricular ejection fraction (LVEF). Although the LVEF was unchanged in the early period from the surgery, it was significantly improved at the late follow-up. (B) Dimensional alteration of the LV end-diastolic diameter and end-systolic diameter (LVEDD and LVESD). Both LVEDD and
LVESD were significantly reduced by surgery in the early period from the surgery and at the late follow-up. (C) Changes in mitral regurgitation (MR). The degree of MR
was significantly reduced by surgery in the early period from the surgery and at the late follow-up. (D) Changes in right ventricular systolic pressure (RVSP). RVSP was
significantly reduced by surgery in the early period from the surgery and at the late follow-up. *P < 0.05 among the groups, error bars indicate standard error of the
mean.
Figure 4: Kaplan–Meier curves of overall patients. The 3- and 8-year survival
rates are 77 and 66%, respectively.
cardiac deaths were noted in 14 patients caused by congestive
heart failure in 10 (7 in non-ischaemic DCM, 3 in ischaemic DCM)
and ventricular arrhythmia in four (3 in non-ischaemic DCM, 1 in
ischaemic DCM). There was no statistical significance in long-term
survival between ischaemic and non-ischaemic DCM (P > 0.1).
In 10 patients with late mortality (non-responders), the LVEDD
was reduced from 80 ± 6 to 72 ± 8 mm (P = 0.032), but the LVEF
remained unchanged (before vs after, 20 ± 8 vs 20 ± 5%; P > 0.1) at
the late follow-up. Right ventricular systolic pressure (RVSP) was
also unchanged after the operation (before vs after, 50 ± 17 vs
42 ± 8 mmHg; P > 0.1) (Fig. 3D).
In contrast, in 48 survivors (responders), the LVEDD was
reduced at the late follow-up compared with before operation
(73 ± 8 vs 64 ± 6 mm, P < 0.0001) and the LVEF was significantly
improved (27 ± 7 vs 30 ± 9%, P = 0.0042). RVSP was significantly
reduced from 44 ± 17 to 32 ± 15 mmHg (P = 0.0035). On comparison of functional geometric parameters between non-responders
and responders, the LVEDD was larger (80 ± 6 vs 73 ± 8 mm,
P = 0.0068) and the LVEF was poorer (20 ± 8 vs 27 ± 7%, P = 0.0059)
before operation and also the LVEDD larger (72 ± 8 vs 64 ± 6 mm,
P = 0.0095) and the LVEF poorer (20 ± 5 vs 30 ± 9%, P < 0.0001) at
the late follow-up in non-responders.
The defibrillator or CRT-D was not implanted in all 4 patients
with ventricular arrhythmia as the cause of late death. The longest
survivor was alive at 103 months after this procedure, and the 3and 8-year survival rates were 77 and 66%, respectively (Fig. 4).
DISCUSSION
LVR using non-heart transplant surgical approaches due to shortage of donors for heart transplantation was first reported in forms
of PLV by Batista et al. [2] or EVCPP by Dor et al. [5]. The procedures involved either a posterior approach or anterior approach.
The concept of PLV was reduction of wall tension by LV volume
reduction with removal of a large portion of the posterior wall of
the LV. The procedures failed because of improper detection of
the affected region of the LV before operation and random resection of the posterior LV muscle. If severe akinesis or dyskinesis is
present at the postero-lateral wall, the procedures may be effective, but injured and dysfunctional regions of the LV vary in DCM.
On the other hand, EVCPP excludes the antero-septal wall that
is mostly affected by antero-septal infarction. Moreover, most
papers showed the successful treatment using LVR for ischaemic
cardiomyopathy (ICM) with EVCPP, except the surgical treatment
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for ischaemic heart failure (STICH) trial, which showed no benefit
of LVR in combination with CABG in ICM [11]. However, the STICH
trial might fail to identify the correct scar area and to gain optimal
volume reduction. A precise and feasible methodology for viability and scar evaluation on magnetic resonance imaging (MRI)
could provide a benchmark for preoperative evaluation [12]. In
that trial, there was only a 19% volume reduction in the 33% of
patients who might have had an inadequate end point [13]. We
reported that LVR achieved no benefit if <15% volume reduction
retained a residual LVESVI of >90 ml/m2 [14].
Therefore, both preoperative assessment of the region of the LV
and adequate reduction of the LV volume seemed to be the major
factors for successful LVR in non-heart transplantation treatment of
patients with DCM. The scar area due to myocardial infarction is accurately detected by an enhanced MRI method; however, the region
of non-ischaemic DCM is difficult to detect by not only conventional
cardiac echocardiography, scintigram or left ventriculogram, but also
by MRI examination. As previously reported, we found that this
region of the LV can be detected accurately by use of speckletracking echocardiogram. Several articles [7, 8, 15, 16] have shown
significant association between myocardial viability and myocardial
strain using speckle-tracking echocardiography. We also reported
that a PRP with preoperative scar identification using speckletracking echocardiography improved early outcome [6]. We should,
however, mention the advantage and disadvantages or limitations of
speckle-tracking echocardiography. Although tracking accuracy has
been validated [15], sufficient 2D echo image quality is necessary for
correct tracking, and so we meticulously obtained short-axis images
of the LV. To facilitate the crucial decision-making (preoperative determination as to whether the region is removable or not), robust
evidence that shows the relationship between myocardial strain and
myocardial scar is required. Although we confirmed it with macroscopic inspection and semiquantative microscopic evaluation, this
has not been shown in humans. Indirect evidence [7, 16] and animal
experiments [8] were reported. Finally, we should know that determining the strain–stress relationship is an ideal approach for myocardial viability assessment theoretically.
The findings after the removal of the dyskinetic site by the posterior restoration showed the removal of the dyssynchronous area of
the LV (Fig. 1), suggesting a mechanical or surgical resynchronization
which contributed to the improvement of LV function. Functional
MR is one of the major factors to cause the deterioration of congestive heart failure in DCM. The aetiologies of functional MR are both
mitral leaflet tethering and annular dilatation due to a dilated LV [17].
Therefore, LV remodelling surgery or correction of the inter-papillary
muscle distance in addition to mitral ring annuloplasty is required to
repair functional MR [18, 19]. Usually, mitral valve annuloplasty with
a down-sized ring was performed for more-than-moderate MR to
regulate both the non-planarity angle and the antero-posterior
diameter. MVR is also considered in patients with greater-than or
equal-to-severe (≥severe) MR with severe mitral tethering.
Papillary muscle approximation combined with LVR in patients
with DCM and functional MR demonstrated excellent results in
restoring mitral valve function [20, 21]. However, the PRP technique applied for the postero-lateral region, which excludes the
akinesis or dyskinesis between both papillary muscles, can reduce
the inter-papillary muscle distance. We, therefore, did not need to
perform mitral subvalvular apparatus correction. Furthermore,
>90% of the patients showed no recurrent MR in the late followup period after ring annuloplasty and PRP. However, MR recurred
in 5 patients greater than Grade II and they showed redilatation of
the LV with an LVEDD of >70 mm.
ORIGINAL ARTICLE
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We operated on the mitral valve when the MR grade was
greater-than or equal-to-moderate. A Japanese surgical ventricular reconstruction group [22, 23] reported that a preoperatively
higher MR grade was significantly associated with poor prognosis
in survival after LVR for patients with ICM. The mechanism of
functional MR is multifactorial, and the severity might possibly be
underestimated in patients with an extremely enlarged LV.
For functional MR due to marked mitral leaflet tethering, MVR
can be recommended to achieve no recurrent MR. However, we
think that the procedures with the preservation of papillary
muscle to maintain the continuity between papillary muscle and
the mitral leaflet can contribute to maintain mitral function and to
prevent the deterioration of LV function after MVP. In PRP, the
papillary muscles were preserved and they were approximated by
closing the posterior wall of the LV. Furthermore, MVP with both
ring annuloplasty and papillary muscle approximation during LV
closure showed <10% recurrence of MR greater than Grade II in
the late follow-up up to 8.6 years after surgery.
In this series, we selected the patients with posterior akinesis or
dyskinesis by preoperative examination and restored the posterior
wall of the LV with preservation of bilateral papillary muscles and by
cryoablation of the posterior mitral annulus. The operative results
were 0% of 30-day mortality and the degree of MR was alleviated in
all patients. The LVEDD decreased from 74 to 65 mm and the NYHA
class improved from Class 3.6 to Class 1 or 2 in 60% of all patients.
The 3- and 8-year survival rates were 77 or 66%, respectively.
Because of the shortage of donors for heart transplantation and
the limitation of age of recipients, an implantable LVAS, developed
for the treatment of patients with end-stage heart failure as a
bridge to transplant, has been widely accepted as a destination
therapy even in patients with lower levels of clinical compromise.
The use of an implantable LVAS has yielded successful outcomes
[24, 25], and is now increasing because of good outcomes in
patients with early implantation.
Our study was not designed to assert that non-heart transplant
approaches were superior to destination therapy with an implantable
LVAS. This is a retrospective study and the patients in this study were
heterogeneous, with 17 patients with an ischaemic and 47 with nonischaemic pathology. However, as in our late outcome in indicated
patients with posterior akinesis or dyskinesis, they can avoid mechanical support by an implantable LVAS as destination therapy and subsequent complications such as infection and thrombo-embolism.
CONCLUSIONS
Both ischaemic and non-ischaemic DCM with posterior akinesis
or dyskinesis indicated by speckle-tracking echocardiography can
be surgically treated with PRP. In the late follow-up up to 8.6 years
after surgery, the improvement of surgical results may encourage
a posterior LV restoration procedure and our results suggest that
60% of selected patients could avoid heart transplantation with
relief of their symptoms.
Conflict of interest: none declared.
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APPENDIX. CONFERENCE DISCUSSION
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Dr H. Suma (Tokyo, Japan): 18 years ago, you and I and our colleagues started
out with the Batista operation, which excises a large amount of posterior ventricular wall for idiopathic dilated cardiomyopathy in Japan. Since then, we kept
trying to improve the surgical result, which was very poor in the beginning.
One of the things we found in the meantime was that the extent of myocardial
damage was not uniform, but it is heterogeneous in idiopathic dilated cardiomyopathy. Consequently, we came up with selection criteria for the Batista operation in which the patient should have a good septum and a bad posterior
wall. Then we got an improved result. Today you have shown us a brushed-up
result by using speckle-tracking echo evaluation to determine the site to be
excluded. As a result, there was no operative mortality and a 75% 5-year survival rate, which is outstanding.
I have three questions. First, you mixed ischaemic and non-ischaemic pathological aetiologies for the same surgical strategy, which excludes akinetic posterior wall and stops mitral regurgitation. Do you think the surgical outcome is
about the same in those aetiologies or different?
Second, you reported surgical results of 41 patients among 185 patients with
non-ischaemic dilated cardiomyopathy. What happened with the rest of the
144 patients? What kind of procedure did you perform and how were their
results? Was it about the same as you reported today or different?
Finally, the surgical strategy you mentioned today is very complicated as a
mixture of ventricular reconstruction, valve surgery, coronary bypass, CRT, et
731
cetera. What makes you believe that the ventricular downsizing with mitral
repair or replacement is better than a mitral procedure alone?
Dr Isomura: As Dr Suma said, we collaborated for almost 20 years, and we
are progressing.
The first question regarding to ischaemic and non-ischaemic cardiomyopathy, I would say that ischaemic cardiomyopathy has statistically good late survival after this kind of surgical ventricular restoration because of the very
easily-detected region of the akinesia. I would say there is almost a 70% survival
rate at 8 years in the ischaemic one.
The second question, in a total of 185 non-ischaemic lesions, we have done
this kind of posterior restoration in 41. The rest of the patients, maybe 100
patients received mitral surgery but no surgical ventricular restoration
because we could not detect any focal lesion to reduce the size of ventricle,
and the 5-year survival rate was about 50%. This is worse than these kinds of
procedures.
The last question, I think that there are very complicated operations, and we
did many, like, mitral plasties, CABG, and/or tricuspid, maze procedures, et
cetera. But I think, generally speaking, mitral regurgitation during the follow-up
of dilated cardiomyopathy is a major factor of rapid progression of congestive
heart failure. Also mitral regurgitation is caused by not only annular dilatation,
but also the dilated left ventricle. With the posterior lesion, the mitral regurgitation is more severe than other functional mitral regurgitation. So I think the
procedures might cure the mitral regurgitation, plus, as I have shown, the surgical resynchronization therapy by excluding the desynchronized lesion works
well in this type of operation.
Dr G. Somasundram (Kuala Lumpur, Malaysia): I saw in your presentation
that you actually used cryoablation as an adjunctive measure in your linear
section. Did this group of patients actually have electrophysiological studies
preoperatively, or was it just a prophylactic, blind procedure?
Dr Isomura: If cardiologists have an EP study and we have information about
the place of the cryoablation. I put the cryoablation at the site of the lesion, but
in other patients, you cryoablate the site between the cut edge and the mitral
annulus as prophylactic procedures.
ORIGINAL ARTICLE
T. Isomura et al. / Interactive CardioVascular and Thoracic Surgery