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Background— In ischemic cardiomyopathy, dyssynchrony of left ventricular (LV) mechanical contraction produces adverse hemodynamic consequences. This study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. Methods and Results— A prospective study of the global and regional components of dyssynchrony was conducted in 30 patients (58±8 years of age) undergoing SVR at the Cardiothoracic Center of Monaco. The protocol used simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Angiograms were done before and after SVR to study a 600-ms cycle during atrial pacing at 100 bpm. Mean QRS duration was similar, at 100±17 ms preoperatively and 114±28 ms postoperatively (NS). Preoperative LV contraction was highly asynchronous, because P/V loops showed abnormal isometric phases with a right shifting. Endocardial time motion was either early or delayed at the end-systolic phase so that P/L loops were markedly abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized to allow a better contribution of single regions to global ejection. The hemodynamic consequences of SVR were improved ejection fraction (30±13% to 45±12%; P =0.001); reduced end-diastolic and end-systolic volume index (202±76 to 122±48 and 144±69 to 69±40 mL/m 2 ; P =0.001); more rapid peak filling rate (1.75±0.7 to 2.32±0.7 EDV/s; P =0.0001); peak ejection rate (1.7±0.7 to 2.6±0.9 Sv/s; P =0.0002), and mechanical efficiency (0.56±0.15 to 0.65±0.18; P =0.04). Conclusions— SVR produces a mechanical intraventricular resynchronization that improves LV performance.

Myocardial infarction leaves a spectrum of LV shape abnormalities. Surgical Ventricular Restoration(SVR) can be applied to any but there are no data that relates its effectiveness to pre-op LV shape. Aim. To assess cardiac function and survival following SVR in patients with different post-MI shape abnormalities. Methods. Ninety-eight patients (69 ± 9yrs) submitted to SVR for heart failure and/or angina. LV shape was classified by Echo 2CH: Type 1 ( true aneurysm): LV shape is geometrically delimited by two “borders” identified by an abrupt change in curvature; Type 2 ( Intermediate ): shape is delimited by one “border” most often at the inferior region; Type 3 ( dilated cardiomyopathy ): LV shape is without borders ( i.e. the curvature is flattened along the overall LV perimeter). Results. Average FUP was 23 ± 13 months. Table 1 and Graph show that all types benefit from SVR and survival is not significantly different. Conclusions. This study relates the effectiveness of SVR to shape abnormalities and demonstrate that results are good not only in the true aneurysm but also in dilated cardiomyopathy (type 2 and 3).

Background. Experimental studies and theoretical considerations suggest that reduction of left ventricle (LV) stroke volume (SV) following Surgical Ventricular Restoration (SVR) is a consequence of diastolic dysfunction. Aim. To analyze changes in SV following SVR and assess if SV reduction is related to diastolic dysfunction. Patients. 134 consecutive patients submitted to SVR for symptoms of HF and/or angina. Patients with mitral regurgitation were excluded. Results. SV improved in 43 patients (54 ± 13 to 60 ± 15 ml; p 0.0001)-G1- and decreased in 91 patients (69 ± 19 to 48 ± 13 ml, p 0.0001)-G2-. The greater EDV reduction, the greater SV reduction (r = 0.609) and the greater EF improvement (r = 0.402)(Graph). Preoperatively, EF and SV were lower in G1 (31 ± 8 vs 35 ± 8%, p 0.002 and 54 ± 13 vs 69 ± 19 ml, respectively); no differences in LV volumes and Diastolic Filling Pattern (DP). Post surgery G2 shows smaller EDV and ESV and lower SV. DP significantly increased in G1 (from 1.42 ± 0.8 to 1.7 ± 0.7, p 0.01) and was higher than in G2, after surgery (p 0.008). NYHA class at FUP improved (2.4 ± 0.6 to 1.6 ± 0.6 in G1 and 2.4 ± 0.7 to 1.7 ± 0.6 in G2, p 0.001) Post-operative data Conclusions. Post-SVR stroke volume reduction is not related to diastolic dysfunction; paradoxically, diastolic function is more impaired in patients with SV improvement and larger residual volumes.

Background. LV-End diastolic volume (EDV) following surgical ventricular restoration (SVR) is highly dependent on surgical induced changes in ventricular chamber. Aim. To investigate the role of pre and post-operative EDV on SVR induced changes in cardiac function. Methods. We analyzed 298 patients submitted to SVR following an anterior MI. All had an echo study pre and post-operatively. SVR was conducted on arrested heart using an endoventricular sizing. Results. Post-op EDV was directly related to pre-op EDV, r=0.63; P Conclusions. EF improvement was relatively greater in patients with greater pre-op EDV and greater surgical reduction, although the absolute values of post-op EF are mainly linked to post-op EDV. Our results underline the need for a correct pre-op estimate of EDV reduction in each single patient. Tab. 1

Background— The effects and efficacy of surgical ventricular restoration (SVR) in ischemic cardiomiopathy caused by chronic anterior myocardial infarction (MI) are well established. Normally, SVR is delayed at least 3 months after MI to allow the healing of infarcted tissue. Some patients have instability Objectives— This study tests the safety and efficacy of SVR in the setting of subacute complicated anterior MI, in terms of early and late outcome. Methods and Results— 74 patients (62±10 years) were submitted to SVR at ≤30 days after anterior MI for clinical instability and were retrospectively selected from a series of 430 patients undergoing SVR at our center, between 1998 and 2001. The surgical indications included: angina (60%); New York Heart Association class 4 (62%); clinical signs of heart failure (18%); life-threatening arrhythmias (12%); and cardiogenic shock in 4% (or 3) patients. Follow-up is available for 93% of patients. All patients had coronary artery bypass grafting (CABG) (3.1±1.2) with internal mammary artery (IMA) utilization. An endoventricular patch was used in 17 patients (23%); direct ventriculotomy closure was used in the remaining patients. Operative mortality was 5.4% (4/74). Hemodynamic parameters improved significantly in patients with dilated hearts and reduced ejection fraction. Mitral regurgitation that resulted was significantly reduced. Survival at 3 years was 87% in the overall population and 85% in patients 70 years or older. Conclusions— This study reports the largest series of patients with complicated, recent anterior MI treated with SVR. The results show that SVR is feasible, has acceptable in-hospital mortality, and has good early and late outcome. Further experience is needed to establish whether SVR, which excludes the infarcted region, can prevent the long-term adverse remodeling of LV dilated hearts after anterior infarction.