D OSSIER thématique

Thérapeutiques ! Assistance biologique de l’insuffisance cardiaque par cardiomyoplastie (tissulaire et cellulaire) et aortomyoplastie alternatives J.C. Chachques, B. Cattadori,A. Berrebi, M.C. Iliou, P. Meimoun,A. Carpentier dans le domaine ! Chirurgie valvulaire mitrale chez les patients atteints de cardiomyopathie dilatée - J.P. Couetil de la ! Resynchronisation atrio-biventriculaire - C.Alonso,T. Lavergne, transplantation J. Ollitrault, J.Y. Le Heuzey, M.Aitsaid, J.M. Darondel, L. Guize cardiaque " Reduction ventriculoplasty - R.J.V. Batista ! Ventricular containment (Acorn Wrap) - M.Acker ! Left ventricular assist device as a bridge to transplantation: the Cleveland Clinic experience J.L. Navia, P.R.Vega, C. Faber, N.G. Smedira, P.M. McCarthy Coordinateur : J.C. Chachques, hôpital Européen Georges-Pompidou, 75015 Paris. Reduction ventriculoplasty ! R.J.V. Batista*

The partial left-sided ventricular resection in dilatative Abstract cardiomyopathy is aimed at improving the ejection effi- ciency of the heart by reducing the ventricular volume. Accor- Abstract ding to Laplace's law reducing the left ventricular diameter decreases wall tension. The operation was conceived to remove LV muscle and, therefore, decrease the LV radius. It was designed for patients with end-stage heart disease with LV dilatation secondary to ischemic and non-ischemic cardiomyopathies, as well as for Cha- gas disease cardiopathy. The partial left has shown promising results in patients suffering clinically from severe CHF. Reduction ventriculoplasty has been used worldwide as an alternative to cardiac transplantation, principally in countries presenting limitations to develop programs. Key words : Partial left ventriculectomy - - Congestive heart failure - .

eduction ventriculoplasty is a sur- more muscle. M=4.R (3) (M=muscle R gical technique based on a prin- mass; R=radius). Consequently, when a ciple stated by a frenchman, Pierre patient’s heart increases in size, for each Simon. He was born in Normandie in increment of a centimeter in its diameter, 1749. Because of his accomplishments in his heart will require 1,000 gr. of muscle mathematics he became the “Marquis of to maintain a normal function. This does Laplace”! not happen, because a human heart can- His principle applied to is: not build that much muscle. That’s why WT=3DxP/2H (WT=wall tension; the patient’s heart fails. Decreasing the D=diameter; P=intracardiac pressure; heart’s diameter restores the normal dia- H=ventricular thickness). meter/muscle mass ratio and conse- quently normalizes wall tension (2, 4, 5, A normal buffalo heart is 10 times bigger 8). For instance, a normal buffalo heart than a snakes’ heart but has 1,000 times has a diameter of 10 cm, weighs 5,000 gr. and the wall tension is 20 mN (milli-

* Fundação Vilela Batista, Rua Carlos Razera #8, Newtons) which is normal. A patient’s Curitiba, 80.810-310, Brazil. failing heart also has a diameter of 10 cm,

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but it weighs only 800 gr. and has a wall tension of 120 mN of. After resection of Transversal section of ventricles 100 gr. of his (muscle mass comes down to 700 gr.), his new heart diameter is reduced to 5 cm., and the wall tension comes down to 30 mN (figure 1). That’s why the with the latissimus dorsi muscle works as well. It increases the heart thickness and conse- Right quently decreases wall tension (same ventricle Left ventricle principle applied by Drs. J.C. Chachques and A. Carpentier to treat heart failure)!

Many scientists came to Brazil to collect data from my patients (13). They did pre and postoperative pressure/volume loops with special catheters introduced directly into the left ventricle through the apex. The hearts preoperatively spent a lot of energy to produce an insufficient work and, after reduction of the ventricles, they did more work and spent much less energy, that is, they became more effi- Figure 1. Surgical tech- cient! nique of reduction ven- Left ventricle * triculectomy : partial Pr. Paul Lunkenheimer, from Münster resection of the left ven- (Germany), measured the wall stress with tricular lateral wall special needles inserted directly into the (arrow) under cardio- pulmonary bypass myocardium. The needles, at least 6, (extracorporeal circula- were connected to a computer by wires. tion), followed by the He collected the data from 80 patients: surgical closure using a there was a significant postoperative drop continuous suture*. in wall stress and, simultaneously, myo- cardium oxygen consumption dropped (10, 17, 18).

Many surgeons came to my hospital and ter. They have applied this concept on 20 patients differently. First, we did the performed many operations with me. 75 patients at the Cleveland Clinic with mitral valvuloplasty, came off bypass and Eventually, their results improved, and 100% hospital survival and 95% one-year evaluated the result by TEE: all patients many symposiums took place during survival. Eighty percent of patients went had a worsened ventricular function and these past years (9, 10, 17, 18). The most home in Class I of the NYHA. Their ven- 80% required inotropes to be severed recent results are as follows: tricle reduction results are comparable to from cardiopulmonary bypass! Then, we their heart transplantation’s. If the went back on bypass and performed the In the USA, the first surgical center that patients on the waiting list are taken into ventricular volume reduction. The ven- recognized our work was Dr. Tomas account, then heart transplantation results tricular function improved and only 20% Salerno at the New York State University become worse (only 70% survival in one of patients required inotropes. The ejec- at Buffalo. He has operated forty patients year). Excluding patients with coronary tion fraction always improved after with 85% hospital survival, and 60% of artery disease, Pr. R. Dowling in Louis- reduction of the left ventricle volume. these patients went home in Class I of the ville (USA) obtained the same results These series of twenty patients proved NYHA. (10, 18). that the improvement of the ventricular function was due to the diameter reduc- Prs. P. McCarthy and R. Starling, from It was suggested that such good results tion and not to the . the Cleveland Clinic (USA), also came to were due to the mitral valvuloplasty and Dr. H. Suma, from Japan, recently publi- Brazil, collected data from the patients not to the ventricle volume reduction (5)! shed a paper that confirmed this state- they saw and used the Swan-Ganz cathe- This doubt led us to approach a series of ment (20).

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In accordance with the concept, Pr. could even document the decrease in pul- REFERENCES H. Frazier, from the Texas Heart Institute, monary vascular resistance in two patients disconnected two patients from their left refused for heart transplantation (12). 1. Angelini GD et al. The Batista Procedure for end ventricular assistance device. He pro- stage heart failure. Lancet 1997; 350: 489. poses to let these ventricles rest on # Pr. A. Jatene, from São Paulo, opera- 2. Batista RJV et al. Ventriculectomia parcial. Um LVADS for an initial period of six ted 50 patients, with a hospital survival novo conceito no tratamento cirúrgico de cardiopatias months. Once the myocites have recove- of 85%. The 4-years survival is the same em fase terminal. Rev Bras Cir Cardiovasc 1996; 11: 1. red the organelles rearrange themselves as the 6-months survival (60%). Seventy 3. Bellotti G, Moracs A, Bocchi E et al. Effects of par- tial ventriculectomy on left ventricular mechanical pro- and go back to normality, afterwards the percent of the patients are in Class I of perties, shape, and geometry in patients with dilated left ventricle diameter should be reduced the NYHA. He demonstrated that the cardiomyopathy. Arq Bras Cardiol 1996; 67: 395-400. (10, 11, 18). ventricles get thicker postoperatively, 4. Schreuder JJ, Steendijk P, van der Veen FH et al. which get EF even better (3). He corre- Acute and short-term effects of partial left ventriculecto- In Japan, Pr. H. Suma, from the Tokyo lated mortality to myocite thickness. That my in dilated cardiamyopathy : assessment by pressure- volume loops. J Am Coll Cardiol 2000; 36: 2104-14. Heart Center, operated 65 patients with is, myocites thicker than 22 microns have 90% hospital survival and 85% one-year 5. Bolling SF et al. Early outcome of mitral valve a significantly higher mortality (7). reconstruction in patients with end-stage cardiomyo- survival (Class I of the NYHA: 70%). For pathy. J Thorac Cardiovasc Surg 1995; 109: 676. patients operated in emergency, survivals # Dr. R. Bombonato, from Sobral, also 6. Bombonato R et al. Experiência inicial com a ventri- were only 13%. He follows these patients presented good clinical results with culectomia parcial esquerda no tratamento da insuficiên- with MRI (10, 18). 6 patients (6). More recently, he presen- cia cardíaca terminal. Arch Bras Cardiol 1996; 66: 189. ted similar results during the Cardiac Sur- 7. Congresso Brasileiro de Cirurgia Cardíaca, Porto Alegre, 1994. Pr. W. Konertz, from Berlin (Germany) gery Meeting in Fortaleza. operated 95 patients with 95% hospital 8. Dreyfus G et al. Left ventricular reduction survival and 90% one-year survival (Batista Procedure): A new surgical option in dilated Our results are based on 780 patients cardiomyopathy. Arch Mal Cœur 1997; 90: 1521. (Class I of the NYHA: 80%). The three- operated between 1983 and 2000. 9. First Symposium on the “Batista Procedure”, year survival is the same as the one- Seventy percent were males and the age Lima, Peru, 1995. year’s. He routinely implants defibrilla- varied between 6 months and 95 years 10. Fourth Symposium on the “Batista Procedure”, tors, which allows him to evaluate these with a mean age of 46 years. These Kyoto, Japan, 1998. patients’ arrhythmias. Eightly percent of patients were in Class IV of the NYHA 11. Frazier OH et al. Improved left ventricular func- his patients have a coronary artery tion after chronic left ventricular unloading. Ann preoperatively, with EF less then 18% Thoracic Surg 1996; 62: 675. disease. His results are slightly different by echo. Some of them went to the ope- from those obtained by the Buffalo Cli- 12. Newspaper “Jornal Zero Hora”, Outubro 1995; rating room under cardiac massage. primeira página. nic and the Cleveland Clinic (10). This Postoperatively, their EF improved 100 13. Kawaguchi AT, Batista RJV. Partial left ventri- difference is probably due to the defi- to 300% by transesophageal echocar- culectomy in patients with dilated failing ventricle. brillators implantation. diography and digital angiography. In: B. Buxton, O.H. Frazier; S. Westaby (Eds): They improved significantly postopera- Ischemic heart disease: surgical management. Pr. G. Angelini, from Bristol (England), Mosby International Ltd, London, England, 1999 tively: 60% shiffed to Class I of the operated more than 30 patients with simi- (chapter 28): 361-7. NYHA; 25% to Class II; 10% to Class lar results (1). 14. Luchese F et al. Ventriculectomia parcial III and 5% remained to Class IV. The esquerda: ponte para transplante em pacientes con most common pathologies were coro- insuficiência cardíaca refratária e hipertensão pul- Pr. S. Gradinac (10), from Belgrade monar. Rev Bras Cir Cardiovasc.1997; 12: 221. nariopathy (30%); valvular (20%); post- (Yugoslavia), applied this concept on 15. McCarthy PM et al. Early results with partial 46 patients before the war and 4 after the viral cardiomyopathy (20%); idiopathic left ventriculectomy. J Thorac Cardiovasc Surg war, with a hospital survival of 90% and (20%); Chagas’ disease (5%); others 1997; 114: 755. 80% of patients in Class I of the NYHA. (5%). The most common complications 16. Moreira LFP et al. Existe lugar para a ventri- were renal failure (20%); arrhythmia culectomia parcial esquerda no tratamento da car- (15%); bleeding (10%); others (5%). diomiopatia dilatada? Rev Bras Cir Cardiovasc Pr. T. Yen, from Taiwan, operated 1998; 13: 89. Operating room survival was 95%; hos- 15 patients with similar results (10, 17). 17. Lunkeinheimer PP, Redmann K, Cryer CW et al. So did Pr. H. Tarmisi, from (Jakarta, pital survival 80%; one year survival Late ventricular structure after partial left ventricu- Indonesia). He operated 11 patients, and 65%; 2 years survival 60%; 3 years sur- lectomy. Ann Thorac Surg 2000; 69: 1257-9. all went home in good health. vival 50%; 4 and 5 survival years 18. Second Symposium on the “The Batista remained at 50%. Without intervention, Procedure”, Tokyo, Japan, 1996. In Brazil, this concept has been applied all these patients would have been dead 19. Third Symposium on the“Batista Procedure”. in many centers: within 6 months to 1 year. Besides, if Chietti, Italy, 1997. # Pr. F. Luchese, from Porto Alegre (12) we had operated only patients on the 20. Suma H, Isomura T, Hori T, Sato T, Kikushi N, Hosokawa G. Isolated effect of partial left ventricu- was the first one to accept my ideas and ope- transplant list, the results would have lectomy for dilated cardiomyopathy: a case report. rated many patients with this concept. He been much better (14, 17)! $ J Cardiol 1999; 33: 273-7.

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