17 Left ventricular rconstruction surgery

Abstract

Acute myocardial infarction and ischaemic cardiomyopathy are important causes of heart failure (HF). With ageing populations in developed nations, the incidences can be expected to rise in the coming decades. Stretch of a left ventricle (LV) scar results in detrimental ventricular remodelling, LV dilatation and a change in geometry from elliptical to spherical. These result in higher wall stress and less effective ventricular contractions. Surgical techniques to restore the shape of the remodelled ventricle were introduced in early 1980s.1 The RESTORE registry and others reported favourable outcomes in >5000 patients.2 However, the NHLBI and NIH-funded prospective randomised STICH Trial found no additional benefit of LV reconstruction in addition to coronary bypass grafting.3 The STICH Trial was well conducted. The neutral findings did curb enthusiasm for LV reconstruction surgery. However, the interpretation of STICH was not incontrovertible and had sparked heated debates.4 Subsequent re-analysis of STICH confirmed significant survival benefit when adequate LV volume reduction was achieved.5 New data from experienced centres continued to demonstrate efficacy of LV reconstruction surgery.6 7 The 2013 ACCF/AHA Guideline for the Management of Heart Failure recommended LV reconstruction for HF with reduce ejection fraction with a recommendation class IIb, level of evidence B.8 Unsurprisingly, the field remains confused about the role of this treatment. In order to facilitate appropriate sizing of the LV during reconstruction, graduated balloons are now available for use as templates. A new device has been developed for less invasive off-pump LV reconstruction and a Phase 2 clinical trial is now underway. References Dor V. Reconstructive left ventricular surgery for post-ischemic akinetic dilatation. Semin Thorac Cardiovasc Surg 1997;9:139–145. 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; RESTORE group. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. J Am Coll Cardiol 2004;44:1439–1445. Jones RH, Velazquez EJ, Michler RE, Sopko G, Oh JK, O’Connor CM, Hill JA, Menicanti L, Sadowski Z, Desvigne-Nickens P, Rouleau JL, Lee KL; STICH Hypothesis 2 Investigators. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009;360:1705–1717. Buckberg GD, Athanasuleas CL. The STICH trial: misguided conclusions. J Thorac Cardiovasc Surg 2009;138:1060–1064. Michler RE, Rouleau JL, Al-Khalidi HR, Bonow RO, Pellikka PA, Pohost GM, Holly TA, Oh JK, Dagenais F, Milano C, Wrobel K, Pirk J, Ali IS, Jones RH, Velazquez EJ, Lee KL, Di Donato M; STICH Trial Investigators. Insights from the STICH trial: change in left ventricular size after coronary artery bypass grafting with and without surgical ventricular reconstruction. J Thorac Cardiovasc Surg 2013;146:1139–1145. Dor V, Civaia F, Alexandrescu C, Sabatier M, Montiglio F. Favorable effects of left ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial. J Thorac Cardiovasc Surg 2011;141:905–916. Calafiore AM, Iaco’ AL, Kheirallah H, Sheikh AA, Al Sayed H, El Rasheed M, Allam A, Awadi MO, Alfonso JJ, Osman AA, Di Mauro M. Outcome of left ventricular surgical remodelling after the STICH trial. Eur J Cardiothorac Surg 2016;50:693–701. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e147–239.