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Acute and Short-Term Effects of Partial Left Ventriculectomy in Dilated Cardiomyopathy Assessment by Pressure-Volume Loops Jan J

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Acute and Short-Term Effects of Partial Left Ventriculectomy in Dilated Cardiomyopathy Assessment by Pressure-Volume Loops Jan J CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector Journal of the American College of Cardiology Vol. 36, No. 7, 2000 © 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00 Published by Elsevier Science Inc. PII S0735-1097(00)01036-6 Acute and Short-Term Effects of Partial Left Ventriculectomy in Dilated Cardiomyopathy Assessment by Pressure-Volume Loops Jan J. Schreuder, MD, PHD,†§ Paul Steendijk, PHD,࿣ Frederik H. van der Veen, PHD,‡ Ottavio Alfieri, MD,† Theo van der Nagel, MS,§ Roberto Lorusso, MD, PHD,§ Jan-Melle van Dantzig, MD, PHD,‡ Kees B. Prenger, MD,§ Jan Baan, PHD,࿣ Hein J. J. Wellens, MD, PHD,‡ Randas J. V. Batista, MD* Campina Grande do Sul, Brazil; Milan, Italy; Maastricht and Leiden, The Netherlands OBJECTIVES The aim of this study was to evaluate the short-term effects of partial left ventriculectomy (PLV) on left ventricular (LV) pressure-volume (P-V) loops, wall stress, and the synchrony of LV segmental volume motions in patients with dilated cardiomyopathy. BACKGROUND Surgical LV volume reduction is under investigation as an alternative for, or bridge to, heart transplantation for patients with end-stage dilated cardiomyopathy. METHODS We measured P-V loops in eight patients with dilated cardiomyopathy before, during and two to five days after PLV. The conductance catheter technique was used to measure LV volume instantaneously. RESULTS The PLV reduced end-diastolic volume (EDV) acutely from 141 Ϯ 27 to 68 Ϯ 16 ml/m2 (p Ͻ 0.001) and to 65 Ϯ 6 ml/m2 (p Ͻ 0.001) at two to five days postoperation (post-op). Cardiac index (CI) increased from 1.5 Ϯ 0.5 to 2.6 Ϯ 0.6 l/min/m2 (p Ͻ 0.002) and was 1.8 Ϯ 0.3 l/min/m2 (NS) at two to five days post-op. The LV ejection fraction (EF) increased from 15 Ϯ 8% to 35 Ϯ 6% (p Ͻ 0.001) and to 26 Ϯ 3% (p Ͻ 0.003) at two to five days post-op. Tau decreased from 54 Ϯ 8to38Ϯ 6ms(pϽ 0.05) and was 38 Ϯ 5 ms (NS) at two to five days post-op. Peak wall stress decreased from 254 Ϯ 85 to 157 Ϯ 49 mm Hg (p Ͻ 0.001) and to 184 Ϯ 40 mm Hg (p Ͻ 0.003) two to five days post-op. The synchrony of LV segmental volume changes increased from 68 Ϯ 6% before PLV to 80 Ϯ 7% after surgery (p Ͻ 0.01) and was 73 Ϯ 4% (NS) at two to five days post-op. The LV synchrony index and CI showed a significant (p Ͻ 0.0001) correlation. CONCLUSIONS The acute decrease in LV volume in heart-failure patients following PLV resulted at short-term in unchanged SV, increases in LVEF, and decreases in peak wall stress. The increase in LV synchrony with PLV suggests that the transition to a more uniform LV contraction and relaxation pattern might be a rationale of the working mechanism of PLV. (J Am Coll Cardiol 2000;36:2104–14) © 2000 by the American College of Cardiology Batista et al. (1) introduced surgical reconstruction of the dure. The procedure aims to restore the normal relationship heart by partial left ventriculectomy (PLV) as a treatment between ventricular mass and dimension to normalize wall for end-stage heart failure in patients with dilated cardio- stress throughout the cardiac cycle. From a multiple com- myopathy. Often, PLV is combined with mitral valve and partment elastance model study, in which the effects of PLV tricuspid valve reconstruction (1–5). The procedure has were simulated, it was concluded that PLV leads to a reduction in wall stress (WS) for any level of LV pressure See page 2115 (6). This implies an improvement of the efficiency by which WS is transferred to intraventricular pressure. been performed in patients with dilated cardiomyopathy, In patients with dilated cardiomyopathy, impairment of with or without known etiology, and who are grouped in cardiac performance is generally associated with impaired New York Heart Association (NYHA) functional classes III LV relaxation and diastolic and systolic wall motion abnor- and IV. Initial reports (2–5) indicated improved left ven- malities (7–9). Nonuniformity in wall motion reduces the tricular (LV) ejection fraction (EF), and decreased LV mechanical efficiency of ventricular ejection and contributes end-diastolic pressure (EDP) following the surgical proce- to regional diastolic abnormalities (10). In a previous study we observed marked LV nonuniformity in patients with dilated cardiomyopathy before undergoing cardiomyoplasty. From the *Hospital Angelina Caron, Campina Grande do Sul, Brazil; †Depart- Six months after cardiomyoplasty, WS was decreased by the ment of Cardiac Surgery, San Raffaele Hospital, Milan, Italy; ‡Department of Cardiology and the §Cardiovascular Research Institute Maastricht, Maastricht, The wrapped latissimus dorsi muscle and the decreased Netherlands; and the ࿣Department of Cardiology, Leiden University Medical Center, LVEDV, whereas LV nonuniformity was markedly de- Leiden, The Netherlands. This study was funded by the Cardiovascular Research creased (7). Because PLV should lead to a decrease in WS, Institute, University of Maastricht, Maastricht, The Netherlands. Manuscript received April 7, 1999; revised manuscript received April 27, 2000, PLV should also improve the mechanical efficiency of LV accepted September 19, 2000. ejection by reducing LV nonuniformity. JACC Vol. 36, No. 7, 2000 Schreuder et al. 2105 December 2000:2104–14 P-V Loops in Partial Left Ventriculectomy Before surgery as well as up to five days after the operation, Abbreviations and Acronyms the patients were catheterized. All operations were per- CI ϭ cardiac index formed by R.J.V.B. The study was approved by the medical EDP ϭ end-diastolic pressure ethics committee of the hospital. Informed patient consent ϭ EDV end-diastolic volume was obtained for insertion of the catheters and the measure- EF ϭ ejection fraction ESV ϭ end-systolic volume ments. ESP ϭ end-systolic pressure Surgical procedure. The surgical technique has been de- LV ϭ left ventricle/ventricular scribed previously by Batista et al. (1). After inducing PLV ϭ partial left ventriculectomy anesthesia, a midline sternotomy was performed. Bypass ϭ SNP sodium nitroprusside was routinely instituted, using double venous cannulas. All SV ϭ stroke volume WS ϭ wall stress procedures with exception of the autotransplantation (Table 1) were performed on a beating heart. In seven patients a tricuspid valvuloplasty was done by a modified De Vega The conductance catheter was used to study LV nonuni- plasty. Subsequently, in all cases the posterolateral wall was formity by measuring regional synchrony of contraction and excised, starting near the apex of the heart. The incision was relaxation. With this technique, the volume changes occur- performed down to the crux of the heart, excising the obtuse ring in five LV segments, perpendicular to the long heart marginal coronary artery, and in between the papillary axis, can be measured throughout the cardiac cycle (11). By muscles to preserve the mitral valve. The mitral valve was comparing changes in LV segmental volumes with total LV reconstructed using the Alfieri repair technique, approxi- volume changes, the LV synchrony, representing mechani- mating the mid-portion of the free edge of the anterior and cal efficiency, can be calculated throughout the cardiac cycle. posterior leaflets with a single suture (12). The ventriculot- To evaluate the acute hemodynamic effects of PLV in omy was closed with absorbable sutures. patients with dilated cardiomyopathy, we measured LV Anesthesia. All patients received 0.05 mg/kg of lorazepam pressure-volume (P-V) loops and LV synchrony before, as oral premedication 2 h before surgery. Anesthesia was during, and up to five days after the operation. induced with hypnomidate (0.25 mg/kg) and maintained by ethrane (0.2% to 0.5%) and fentanyl (3␮g/kg/h). For muscle METHODS relaxation, 0.1 mg/kg of pancuronium bromide was given. The patients were ventilated with an oxygen/air mixture ϭ Patients. Eight consecutive patients, 45 to 60 years old, (FiO2 0.5) at a ventilatory rate of 12/min and ventilatory scheduled to undergo PLV were studied preoperatively, volume was adjusted to maintain arterial CO2 tension during the procedure, and up to five days postoperatively. between 32 and 42 mm Hg. Sodium-nitroprusside (SNP), All patients had dilated cardiomyopathy, either idiopathic isoprenaline and adrenaline were used during surgery before or related to postischemic damage, or Chagas disease (Table and after bypass as needed to maintain systolic blood 1). At the time of the PLV procedure, seven patients were pressure between 80 to 100 mm Hg and heart rate between in NYHA functional class IV, and one in class III (patient 90 to 120 beats/min. 8). All patients were receiving chronic treatment with Instrumentation. Patients were sedated and heparinized diuretics, digoxin, and angiotensin-converting enzyme before catheterization. A Swan-Ganz thermodilution cath- (ACE) inhibitors at the time of PLV. The patients studied eter was placed via a subclavian vein into the pulmonary were operated on in the Hospital Angelina Caron, Brazil. artery. A dual-micromanometer transducer conductance Table 1. Patient Characteristics Age; CI Associated Area Mass Rhythm Pts Gender Origin l/min/m2 Surgery exc cm2 exc g Pre–Post 1 59; F Idiopathic TR, MR, RAR 42 48 SR-SR 2 58; M Idiopathic 1.6 TR, MR 42 69 SR-SR 3 47; M Ischemic 1.35 TR, MR, Th, 73 92 SR-SR CABG 1X 4 52; M Idiopathic 1.05 TR, MR, RAR, 39 86 AF-AF LAR, AT 5 60; M Ischemic 1.07 TR, MR, 33 66 AF-SR CABG 2X 6 45; M Chagas 1.54 TR, MR, RAR, 43 70 AF-SR RVR 7 57; M Idiopathic 1.4 TR, MR, AVR 74 83 AF-SR 8 50; M Idiopathic 2.44 26 46 SR-SR AF ϭ atrial fibrillation; AT ϭ autotransplant; AVR ϭ aortic valve reconstruction; CABG ϭ coronary artery bypass grafting; CI ϭ cardiac index; LAR ϭ left atrial reconstruction; MR ϭ mitral valve repair; RAR ϭ right atrial reconstruction; RVR ϭ right ventricular reduction; SR ϭ sinus rhythm; Th ϭ thrombectomy; TR ϭ tricuspid valve repair.
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