REVIEW Cardiovascular Surgery Circ J 2009; Suppl A: A-1 – A-5

Surgical Treatment of Ischemic Failure The Dor Procedure

Marisa Di Donato, MD*,**; Serenella Castelvecchio, MD*; Lorenzo Menicanti, MD*

Despite the improvements in the treatment of myocardial infarction that have translated into a decline in mortality rates, the incidence of has increased and, because of the limited number of cardiac donors, non- transplant heart surgery has developed in the past 10 years. Surgical ventricular reconstruction was launched by Dor and defined as endoventricular circular patch plasty repair. It represents a relatively novel surgical approach aiming to restore (bring back to normal) the dilated, distorted left ventricular (LV) cavity in order to improve function. The term ‘surgical ventricular reconstruction/restoration’ includes operative methods that reduce LV volume and restore its shape. The concept of reducing wall stress through surgical restoration of chamber size and geometry remains the guiding principle behind this innovative technique. Results from different Institutions are uniform and show an improvement in cardiac and clinical status and in survival. The present review will approach the rationale to re-shape the heart on the basis of pathophysiology and cardiac architecture, and will describe the efficacy of the Dor procedure in ischemic dilated cardiomyopathy, as well as some technical aspects and patient selection pathway. (Circ J 2009; Suppl A: A-1 – A-5) Key Words: Ischemic heart failure; Patient selection; Surgical ventricular restoration

oronary artery disease in Western countries is respon- or have comorbidities that preclude transplantation; more- sible for more than 75% of heart failure (HF) over, the scarce number of donors makes the treatment C cases.1,2 Despite the improvement in the treatment unavailable for most patients on a waiting list. of myocardial infarction (MI) over the past 4 decades, Given these limitations, non-transplant heart surgery has which has translated into a decline in mortality rates after developed in the past 10 years and the role of cardiac sur- MI, the incidence of HF in recent decades has increased geons in treating HF patients has changed, although cardi- and greater salvage of high-risk MI patients in recent times ologists are still reluctant to send patients for non-transplant may have contributed to this trend.3 The clinical syndrome surgical alternatives and guidelines for CHF do not even of congestive HF (CHF) progresses from no or scarce mention some strategies, such as the Dor procedure. symptoms (compensated) to moderate or severe symptoms (decompensated). Decompensated HF has advanced struc- tural cardiac disease with symptoms at rest (New York The Dor Procedure Heart Association (NYHA) class IV or stage D HF) despite In 1985 Jatene described a new technique of performing optimal medical therapy, and carries an extremely poor a circular endoventricular suture (Fontan stitch) to exclude prognosis. In the Rematch study, only 8% of patients in the the dyskinetic scar of an ,6 and in the same year medically treated group were alive at 2 years, with signifi- Dor et al described the use of the endoventricular Fontan cant costs and resource consumption.4 Increased chamber suture to rebuild a failing with an endoventricular sphericity and the presence of mitral regurgitation are patch after extended endocardectomy for ventricular tachy- markers of poor prognosis and are determined by severe cardia.7 Dor was the first surgeon to demonstrate that the abnormalities in chamber geometry that subtend the pro- endoventricular patch plasty repair could be applied not gression of the disease, according to the biomechanical only to left ventricular (LV) aneurysm but also to a dilated model of HF.5 Advanced, stage D HF affects between 300,00 akinetic ischemic LV. He emphasized the concept of reduc- and 800,000 patients in the United States, which generates ing the LV size and reconstructing a more elliptical cavity, an enormous economic burden without obtaining substan- treating the dilatation in all its components (anterior, apical tial symptomatic benefit or improvement in prognosis. For and septal), as opposed to linear resection of the aneurysm endstage HF patients, cardiac transplantation is the treat- that left an untouched septal dilatation, creating a distortion ment of choice, but most patients are over 65 years of age of the residual chamber. The concept of excluding all the diseased tissue from the cavity, especially the septum, is 7 (Received November 20, 2008; revised manuscript received February the basis of the good results. 19, 2009; accepted March 11, 2009; released online May 27, 2009) The Dor technique is a relatively novel surgical approach *Department of , IRCCS San Donato Hospital, Milan, to restoring (bringing back to normal) the dilated, distorted **Department of Critical Care Medicine, University of Florence, LV cavity in order to improve function. It implies knowl- Florence, Italy edge and understanding of the remodeling infrastructure, Mailing address: Marisa Di Donato, MD, Department of Cardiac Surgery, IRCCS, San Donato Hospital, Via Morandi 30, 20097 San the structural changes leading to geometry abnormalities, Donato, Milanese (Milan), Italy. E-mail: [email protected] the role of compensatory, remote muscle and of stretching All rights are reserved to the Japanese Circulation Society. For permis- mechanisms that lead to electrical disadvantage.8 sions, please e-mail: [email protected] The procedure includes coronary grafting and mitral

Circulation Journal Supplement A 2009 A- DONATO MD et al.

Figure 1. (Left) Use of internal sizing and shaping device and the position of the patch are shown. Notice that the patch is obliquely oriented towards the aortic tract, parallel to the septum. (Right) Mammary artery graft is in place and the venous sequential distal anasto- mosis already performed. The opening of the ventricle is shown at the end of the procedure. Notice the everting suture to close the opening with the patch that is tailored during the closure. repair when needed, so it has the potential to treat the 3 for posterolateral dilatation caused by inferior/lateral MI components of HF: the ventricle, the vessels and the valve with the occlusion of the circumflex or right coronary artery. (“triple V” as defined by Buckberg).9 The term surgical ven- In our experience, nearly 98% of patients need concomitant tricular reconstruction/restoration (SVR) includes operative coronary artery bypass grafting (CABG), and many also methods to reduce LV volume and restore the ventricular undergo repair (20–25% of cases). elliptical shape. The concept of reducing wall stress through surgical restoration of the LV chamber size and geometry remains the guiding principle behind this innovative tech- Surgical Details of Anterior SVR nique. The SVR operation, as performed in our institution, is Since the first description by Dor, the procedure has been conducted on the heart arrested with antegrade crystalloid, adopted by many surgeons, but its use is it is not widespread or cold blood introduced in 2001. CABG is because surgeons have been unwilling to incise and exclude performed first, as completely as possible, almost always the akinetic segments that may appear normal on the surface; on the left anterior descending coronary artery to preserve this finding is often encountered after successful early reper- the upper part of the septum and to guarantee complete fusion that savages the epicardial and myocardial layers but revascularization. The LV is opened in the middle of the the scar remains in the subendocardial layer and is visible scar on the anterior wall, with an incision parallel to the left only if the ventricle is opened. The technique has not been anterior descending artery, starting from the mid portion standardized yet, and surgeons use essentially 4 variations towards the apex. The LV cavity is accurately checked and of LV reconstruction: linear closure by Jatene;10 modified thrombi are removed if present; the mitral valve is repaired, linear closure by Mickleborough et al;11 circular closure with when necessary, through the ventricular opening.14,15 Since a patch by Menicanti and Dor;12 and double circling closure 2001 we have been using a sizer/shaper device (Chase without a patch by O’Neill et al.13 These different techniques Medical, Richardson, TX, USA) filled to 50–60 ml/m2 to may all be successfully performed when the disease involves optimize the size and shape of the new ventricle (Figure 1). mainly the antero-apical wall, but when the septum is deeply The choice of 50 ml is made if the transverse diameter (as involved or the dilatation is only at the septal level, the taken below the mitral valve) is not very enlarged (<65 mm) original Dor technique is the only one that ensures complete and 60 ml is chosen if it is >65 mm. This choice is some- treatment of the underlying disease. To date, the technique what empirical, but we think that it is advisable to leave a described by Dor has been applied to all kinds of dilatation residual chamber with a normal volume (52±13 ml/m2 in a involving all segments (anterior, apical and septal). series of 52 normal subjects from our More recently, Menicanti et al14 introduced the use of a lab).16 sizer/shaper intraventricular device as a refinement of the The Fontan suture is performed with the sizer inside the Dor technique, emphasizing the importance of re-shaping ventricle, following the conical curvature of the dummy, the LV cavity through patch positioning, which should be starting at the level of the new apex, going deep into the inserted deep in the septum and obliquely towards the aortic septum towards the aortic valve, in an oblique plane, flow tract in order to obtain an elliptical new cavity. The running towards the lateral wall and reaching again at the positioning of the patch follows the Fontan suture that is new apex. The suture is tied onto the dummy in order to performed in an oblique plane parallel to the septum, at the reduce the cavity; the dummy is removed and the patch is level of the transitional zone. In this way, the risk of making sutured along the Fontan suture if the opening of the ven- the new cavity too spherical, as can happen with the stan- tricle is 3 cm or greater; if the opening is less than 3 cm the dard Dor technique, was potentially overcome. closure is direct, without the patch. The excluded tissue is Moreover, LV surgical reconstruction can be also used folded to reinforce the suture.

Circulation Journal Supplement A 2009 HF and Surgical Ventricular Restoration A-

Figure 2. Mitral procedure. Views from inside the ventricle. The cavity is carefully explored and thrombi are removed if present (1,2). The papil- lary muscles are checked (3) and the pledgets at the 2 trigones are shown (4). The sizing device is in place (5) and the patch is sutured (6).

Figure 3. Posterior lesions are shown. (Left) Dilatation is mainly between the papillary muscles. (Right) Dilatation is between the posteromedial papillary muscle and the septum. The schema shows 2/0 prolene suture being initiated at the level of the beginning of the dilatation and continuing towards the apex, excluding all the damaged tissue from the cavity (Left). After the opening of the wall, continuous suturing is performed between the posteromedial papillary muscle, bring- ing the posterior wall against the septum (Right).

Mitral Repair becomes completely bounded by the suture (Figure 2). In We repair the valve if mitral insufficiency is moderate/ order to undersize the mitral annulus, avoiding valve con- severe or if it is mild but accompanied by mitral annulus striction, a sizer (26 mm) is introduced within the mitral dilatation (>38/40 mm). An atrial approach is avoided orifice and the suture is tied against the second pledget. because our technique reduces the mitral annulus by access- ing it through the same ventricular incision that is used to Posterior SVR perform SVR. Limited data are available on surgical repair of LV dila- After opening the LV cavity, each papillary muscle head tation caused by inferior/lateral MI. Two types of posterior is identified and the mitral valve leaflets and chords are lesion may occur after inferior MI: (1) dilatation is mainly inspected. The posteromedial fibrous trigone is visualized, between the 2 papillary muscles or (2) dilatation between and a pledgetted 2/0 polyester suture is placed from the the posteromedial papillary muscle and the septum. Figure 3 ventricle side to the atrial side. Progression of the 2 arms of shows the 2 different techniques of linear suture that are this stitch is made with a running suture and the course direc- used in our hospital for LV dilatation after inferior MI. tion extends towards the anteromedial trigone. The 2 arms of the suture are placed through the anterolateral trigone Patient Selection Decision-Making and a second pledget is inserted; the entire posterior annulus Patients with symptoms of HF should be referred to a

Circulation Journal Supplement A 2009 A- DONATO MD et al.

Survival in NYHA class 4 nary vessels, (2) myocardial structure, (3) cardiac function, size and geometry, (4) viability, (5) oxygen consumption, following SVR (6) comorbidities such as respiratory, renal or liver insuffi- 1.00 ciency. The appropriate candidates for LV reconstruction are patients who suffered a MI, have a dilatation of the LV and 0.75 64% an area of asynergy (either dyskinetic or akinetic) of 35% or more of the ventricular perimeter. Patients should have 51% symptoms of HF and/or or intractable ventricular 0.50 . n=308 The LV should be carefully evaluated during coronary angiography (ventricular angiography in right and left ante- 0.25 rior oblique projections) or during a complete echocardio- graphic study in 4CH, 2CH, parasternal long- and short-axis views, with nuclear or magnetic resonance study. The objec- tive with any imaging technique being used for patient 0.00 selection, treatment planning and follow-up is to assess the 0 12 24 36 48 60 72 84 96 108 120 status of the infarcted and remote regions, their viability, the months extent of geometric abnormalities, the extent and severity of regional wall motion abnormalities, and valvular compe- Figure 4. Kaplan-Meier survival curve in patients with preoperative advanced functional class. Notice that the 5-year survival rate is 51%; tence (especially the mitral valve). the expected survival rate in this population is 25% at 3 years. NYHA, New York Heart Association; SVR, surgical ventricular reconstruction. Outcome Results from LV reconstruction have been favorable and cardiologist for assessment of the aetiology and severity of consistent between different groups.18–27 SVR improves LV dysfunction. Coronary angiography and echocardiog- symptoms and long-term survival for patients with isch- raphy should be performed at this stage to differentiate emic cardiomyopathy and severe HF. Its beneficial effect in between ischemic or non-ischemic disease; young and very reducing LV volume, improving cardiac function, reducing symptomatic patients are referred to a transplant center or to ventricular arrhythmias and reducing mitral regurgitation an invasive cardiologist to undergo percutaneous coronary has been largely accepted. A reduction in mechanical intra- angioplasty, internal cardioverter defibrillator (ICD) implan- ventricular dyssynchrony has also been demonstrated.28,29 tation or resynchronization therapy or CABG, mitral repair The acute beneficial effects on systolic function are largely or ventricular reconstruction or mechanical support.17 maintained chronically, so SVR induces a significant reverse Patients should be carefully evaluated by a multidisci- remodeling associated with clinical improvement and plinary team in order to decide the best therapeutic strategy improved survival. Interestingly, the entity of both ejection and detailed information should be obtained on (1) coro- fraction (EF) improvement and LV volume reduction is

Rate and causes of hospitalization (FUP 2-89 m)

Stroke

MI

Angina

A EF30% HF

Hospit/yr

Hospitalization

0 20 40 60 80 %

Rate and type of cardiac procedures during FUP (2-89 m)

Total Figure 5. Rate of cardiac events at FUP in patients undergoing surgical ventricular recon- Re-do (Mitral) struction. (Top) Rate and causes of hospitaliza- ICD tion. (Bottom) Rate and type of cardiac proce- EF30% Notice the low rate of ICD implantation in MADIT II matching patients (EF ≤30%). EF, CRT ejection fraction; Hosp/yr, rate of hospitaliza- tion per year; HF, heart failure; A, arrhythmias; PTCA MI, myocardial infarction; FUP, follow-up; PTCA, percutaneous coronary angioplasty; 0 10 20 30 40 50 % CRT, cardiac resynchronization therapy; ICD, San Donato Hospital, Milan 2001-2008 internal cardioverter defibrillator.

Circulation Journal Supplement A 2009 HF and Surgical Ventricular Restoration A- uniform in all the reported series, varying from +6 to +15 14. Menicanti L, Di Donato M, Frigiola A, Buckberg G, Santambrogio absolute points for EF, and from 30% to 45% reduction for C, Ranucci M, et al. Ischemic mitral regurgitation: Intraventricular LV end-systolic volume. Also, survival rates appear uniform papillary muscle imbrication without mitral ring during left ventricu- lar restoration. J Thorac Cardiovasc Surg 2002; 123: 1041 – 1050. among different studies, being near 80% at 5 years and 60% 15. Di Donato M, Castelvecchio S, Brankovic J, Santambrogio C, at 10 years, on average.30 Moreover, the rate of re-hospital- Montericcio V, Menicanti L. Effectiveness of surgical ventricular ization for HF is reported to be low.31,32 These results are restoration in patients with dilated ischemic cardiomyopathy and similar to those reported at 6 months after heart transplanta- unrepaired mild mitral regurgitation. J Thorac Cardiovasc Surg 2007; 134: 1548 – 1553. tion, and a study from Cotrufo et al showed no differences 16. Di Donato M, Dabic P, Castelvecchio S, Santambrogio C, Brankovic in mortality, clinical improvement or survival rate between J, Collarini L, et al. Left ventricular geometry in normal and post-ante- a comparable group of patients with dilated ischemic car- rior myocardial infarction patients: sphericity index and ‘new’ conicity diomyopathy who underwent either SVR or heart transplan- index comparisons. Eur J Cardiothorac Surg 2006; 29(Suppl 1): 32 S225 – S330. tation. 17. Hetzer R, Müller J, Weng Y, Wallukat G, Spiegelsberger S, Loebe M. The 5-year survival rate in patients with preoperative Cardiac recovery in dilated cardiomyopathy by unloading with a left advanced HF (NYHA class IV) operated in our hospital ventricular assist device. Ann Thorac Surg 1999; 68: 742 – 749. is shown in Figure 4. Follow-up in a series of our patients 18. Dor V, Sabatier M, Di Donato M, Maioli M, Toso A, Montiglio F. Late hemodynamic results after left ventricular patch repair associ- operated on between 2001 and 2008 demonstrated a low ated with coronary grafting in patients with postinfarction akinetic or rate of hospitalization for cardiac causes and a low rate of dyskinetic aneurysm of the left ventricle. J Thorac Cardiovasc Surg cardiac procedures following SVR; in particular, the rate of 1995; 110: 1291 – 1301. ICD implantation in a series of 116 patients with a pre- 19. Williams JA, Weiss ES, Patel ND, Nwakanma LU, Conte JV. Out- operative EF 30% (Madit II matching) was extremely low comes following surgical ventricular restoration for patients with clini- ≤ cally advanced congestive heart failure (New York Heart Association (6.8%) (Figure 5). Class IV). J Card Fail 2007; 13: 431 – 436. In conclusion, SVR for post-MI dilated cardiomyopathy 20. Maxey TS, Reece TB, Ellman PI, Butler PD, Kern JA, Tribble CG, et is an effective option treatment, applicable not only for al. Coronary artery bypass with ventricular restoration is superior to dyskinetic aneurysm but also for diffusely dilated cardio- coronary artery bypass alone in patients with ischemic cardiomyopa- thy. J Thorac Cardiovasc Surg 2004; 127: 428 – 434. myopathy. Although randomized data are not available yet, 21. Mikleborough LL, Merchant N, Ivanov J, Rao V, Carson S. Left ven- observational results are all in full agreement and they only tricular reconstruction: Early and late results. J Thorac Cardiovasc need to be confirmed by the ongoing STICH trial (Surgical Surg 2004; 128: 27 – 37. Treatment of Ischemic heart disease) that will definitely 22. Di Donato M, Toso A, Maioli M, Sabatier M, Stanley AW Jr, Dor V. Intermediate survival and predictors of death after surgical ventricu- demonstrate whether SVR added to CABG improves 3-year lar restoration. Semin Thorac Cardiovasc Surg 2001; 13: 468 – 475. survival free of hospitalization when compared with CABG 23. Dor V, Sabatier M, Di Donato M, Montiglio F, Toso A, Maioli M. alone.33 Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: Comparison with References a series of large dyskinetic scar. J Thorac Cardiovasc Surg 1998; 116: 50 – 59. 1. Mc Murray JJ, Stewart S. Epidemiology, aetiology and prognosis of 24. Patel ND, Barreiro CJ, Williams JA, Bonde PN, Waldron M, Natori heart failure. Heart 2000; 83: 596 – 602. S, et al. 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Circulation Journal Supplement A 2009