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Objective: Nontransplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. Anterior restoration for anterior akinesis has shown favourable outcome. Posterior restoration and surgical results are also discussed., Methods: At the Hayama Heart Center in Japan, between 2005 and 2009, posterior restoration for DCM was performed in 36 patients (10 with ischaemic and 26 with nonischaemic, including muscular dystrophy in three). There were 32 men and four women with a mean age of 53 years. The mean preoperative ejection fraction was 23% and the preoperative New York Heart Association (NYHA) classification was class III in 16 patients and class IV in 20 with eight emergent operations. To identify the posterior lesion before operation, speckle-tracking echocardiography was used, with a Vivid 7 ultrasound machine. The short-axis images from the middle level of the left ventricle (LV) were obtained to assess myocardial segmental viability. Based on the results of speckle-tracking echocardiography, posterior restoration was performed in patients with postero-lateral akinesis and septal kinesis. After the cardioplegic arrest, mitral plasty or coronary artery bypass grafting (CABG) was performed and the posterior LV muscle between bilateral papillary muscles was partially resected under beating heart. The LV apex was preserved and cryoablation was applied between the cut edge and the mitral annulus. All the patients were followed with cardiac echocardiography., Results: In addition to LV restoration, mitral plasty was successfully performed in all the patients. Concomitant CABG was performed in seven, tricuspid surgery in 11 and cardiac resynchronisation therapy (CRT) in eight. Perioperative intra-aortic balloon pumping (IABP) was used in six and there was no hospital mortality, including eight emergent operations. After the operation, 29 patients (80.6%) improved their functional class into class I or II. In the late follow-up, there were two cardiac deaths and one noncardiac death and the 4-year survival rate was 85.8%., Conclusions: The site selection with speckle-tracking echocardiography demonstrated the accurate akinetic lesion of the posterior LV wall. The posterior restoration with preservation of bilateral papillary muscles and LV apex based on the site selection improved operative and mid-term results in the selected patients with DCM., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: A poor functioning dilated left ventricle with mitral regurgitation is the worst condition in chronic ischemic heart failure. Our 7-year experience in combined mitral valve and left ventricular reconstruction was evaluated., Materials and Methods: Among 246 patients having undergone a left ventriculoplasty for postinfarction left ventricular dysfunction in our experience, there were 76 patients with advanced heart failure due to dilated ischemic cardiomyopathy with mitral regurgitation (70 males and 6 females with a mean age of 60 years). All patients had NYHA class III (n = 41) or IV (n = 35) heart failure, including 26 patients (34%) with inotropic support before the operation. All patients had a mitral regurgitation of more than 2+ and 46 patients (61%) had 3+ or more. Mitral reconstruction (61 repairs, 15 replacements) and left ventriculoplasty (Dor 34, SAVE 36, PLV 6) were undergone in combination with CABG (74%)., Results: Operative mortality was 7.9% (5.0% in 60 elective and 18.8% in 16 emergency operations). The ejection fraction and cardiac index increased from 24.9 +/- 7.0% to 33.3 +/- 8.7%, and 2.0 +/- 0.4 l/min/m2 to 2.6 +/- 0.4 l/min/m2, respectively (p < 0.001). The endodiastolic and endosystolic volume indices, and diastolic dimension decreased from 165.9 +/- 43.2 ml/m2 to 121.2 +/- 31.1 ml/m2, 123.3 +/- 38.9 ml/m2 to 74.0 +/- 27.5 ml/m2, and 69.5 +/- 7.7 mm to 61.2 +/- 7.1 mm, respectively (p < 0.001). Late deaths were noted in 13 patients (17.1%), with 10 cardiac deaths. One- and 5-year survival rates were 80.2% and 67.7%, respectively. The mean NYHA class improved from 3.5 to 1.4 among the survivors. Multivariate analysis showed that patients with a mitral regurgitation of 3+ or more and preoperative endosystolic volume index were significant predictors for postoperative mortality. However, age, preoperative inotropes and pulmonary hypertension did not show any significant differences., Conclusion: Combined mitral and left ventricular reconstruction is effective in treating advanced heart failure with endstage ischemic cardiomyopathy associated with a dilated left ventricle and mitral regurgitation.

Background: To treat advanced heart failure due to idiopathic dilated cardiomyopathy, surgical ventricular restoration with mitral reconstruction was conducted and evaluated., Methods: In 95 patients (81 men, mean age: 54 years), New York Heart Association class III/IV was 44/51, and 33 patients (36%) were inotropic dependent preoperatively. Mitral regurgitation (>or=2+) was noted in all patients. All patients underwent left ventriculoplasty (septal anterior ventricular exclusion in 38, partial left ventriculectomy in 57) and mitral reconstruction (repair 53, replacement 42). Fifty-two patients (55%) had concomitant tricuspid repair. Intra-aortic balloon pumping and left ventricular assist device was used in 24 patients and two patients, respectively., Results: Hospital mortality was 11.6% (11 of 95), with 6.6% (5 of 76) in elective and 31.6% (6 of 19) in emergency operations. The ejection fraction and cardiac index increased from 22.3+/-6.3% to 27.2+/-8.0% and from 2.3+/-0.5 ml/m2/min to 2.8+/-0.5 ml/m2/min, respectively (p<0.001). The endodiastolic volume index, endosystolic volume index and diastolic dimension decreased from 232.9+/-56.1 ml/m2 to 160.0+/-49.8 ml/m2, from 178.9+/-46.7 ml/m2 to 113.8+/-44.7 ml/m2 and from 82.0+/-9.0 mm to 68.9+/-11.6 mm, respectively (p<0.001). Late death occurred in 27 patients with 22 cardiac deaths. The mean NYHA class was 1.7 among the survivors. One-, 3- and 5-year survival rates were 72.8%, 61.4% and 50.5%, respectively. In the 62 patients who were non-inotropic dependent preoperatively, 1-, 3-, and 5-year survival rates (81.8%, 73.7% and 62.9%) were significantly better than the inotropic-dependent group (55.3%, 37.3% and 28.0%). Patients with mitral annuloplasty showed a significantly higher 5-year survival rate than patients with mitral valve replacement (59.6% vs 43.6%) in univariate analysis. By application of the exclusion site selection method, the two different ventriculoplasty procedures did not show significant difference in survival rates. Multivariate analysis showed that preoperative inotropes and old age were significant predictors for postoperative mortality., Conclusion: The selected ventriculoplasty in combination with mitral annuloplasty is a useful option for patients with an extremely dilated left ventricle in idiopathic dilated cardiomyopathy. Surgery should be considered before inotropic dependency occurs when prior medical treatment has failed.

Objective: Restoration of left ventricle size and shape is an effective surgical procedure in patients with dilated cardiomyopathy. This report defines early and intermediate results following the reshaping of the left ventricle from spherical to ellipsoid configuration in patients with ischemic cardiomyopathy, employing a technique for LV restoration (LVR) that uses form rather than disease as the endpoint for oblique patch placement., Methods: Between 1998 and 2004, a cohort of 83 patients with dilated ischemic cardiomyopathy underwent an operation to reshape the left ventricle. In 54 patients the Dor procedure was done, and 29 underwent the septal anterior ventricular exclusion (SAVE) procedure to emphasize the elliptical shape, whereby patch placement followed an oblique trajectory between the LV apex and septum below the aortic valve. Ventricular form, rather than the disease scar marked the suture placement site endpoint to create an ellipse. The mean age was 58+/-27, but SAVE patients had larger end systolic volume index (135+/-38 vs 95+/-25). Overall preoperative NYHA functional class III was in 69% and IV in 31 patients, but more SAVE patients were in class IV (38% vs 28%). The procedures were elective in 72 and emergent in 11, with similar entry criteria for each procedure., Results: In combination with LVR operation, mitral surgery was performed in 49/83 and tricuspid annuloplasty in 23/83 patients, but these procedures were more common after SAVE (59% vs 44% and 45% vs 19%, respectively), because of larger LV volumes in SAVE patients; 2.8+/-1.3 coronary artery bypass grafts were used. Perioperative use of IABP or LVAD was 15 and 1, respectively in 83 patients. Hospital death was in 1/11 or 9% after emergent operations and 3/72 or 4% in elective procedures, with no difference between groups. After discharge from the hospital, NYHA class improved to class I or II in 57 patients, class III/IV in 14 patients, with 10 late deaths. The 5-year survival rate after the elective operation was 80.3% in SAVE and with elective operation and 77.4% in the Dor procedure., Conclusion: The SAVE or Pacopexy technique is easy to reshape the dilated left ventricle from spherical to ellipsoid form after the LVR, and the resultant improved configuration may contribute to the overall results for patients with ischemic dilated cardiomyopathy.

Objective: Left ventricular restoration is used to treat patients with chronic progressive heart failure caused by nonischemic dilated cardiomyopathy. This study addresses the use of site selection to determine either lateral wall or septal exclusion., Methods: Evolution of intraoperative echocardiography to define the site of poorest contraction and use of multiple biopsies to show the nonhomogeneous nature of damage are reviewed. To address the heterogeneity of extent of fibrosis in nonischemic cardiomyopathy, target selection was used to determine the mode of left ventriculoplasty. Either the lateral wall was excluded by partial left ventriculectomy (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was employed if the septum was primarily diseased. Surgical results in 107 high-risk (43% NYHA (New York Heart Association) class III and 57% class IV) patients with idiopathic dilated cardiomyopathy over the past 9 years are reviewed., Results: Overall hospital mortality was 7.1% in 84 elective operations and 60.9% in 23 emergency operations, and fell from 42.8% (6 of 14) to 15.0% (14 of 93), when site selection for the area of left ventricular excision or exclusion was determined by the intraoperative echocardiography test. The SAVE/Pacopexy procedure was performed in 36 patients with 62.2% 5-year survival rate. For the entire cohort of PLV and SAVE/Pacopexy population, overall ejection fraction increased from 20 to 31%, and NYHA class improved from 3.6 to 1.8. The 1-, 5-, and 7-year survival rates were 66.9, 46.0, and 36.2%, respectively. In patients having the operation before inotropic dependent, the survival rate was 78.1, 58.0, and 50.2%, respectively., Conclusions: Left ventriculoplasty is effective for patients with idiopathic dilated cardiomyopathy with heart failure by proper patient selection, appropriate timing of the operation, and choice of the surgical procedure (exclusion site selection).

Objective: Association of mitral regurgitation (MR) with ischemic cardiomyopathy (ICM) increases the degree of heart failure and its surgical management remains controversial. The aim of this study was to report the surgical results in patients with or without MR in association with ICM., Patients and Methods: Ninety-two patients with ischemic cardiomyopathy (left ventricular [LV] ejection fraction less than 30% with global akinesis) underwent LV restoration. Pre-operative New York Heart Association (NYHA) functional class was either in class-3 or -4 in all patients. MR was moderate to severe in 38 patients (MR-group) and none or mild in 54 patients (noMR-group). Moderate to severe MR was repaired in addition to the complete coronary artery bypass (CABG) and LV restoration. All patients were followed up and echocardiogram was repeated every 6 months after the surgery., Results: The procedure of LV restoration was selected pre- and intra-operative examination and endoventricular circular patch plasty was performed in 76, partial left ventricle resection in three, and septal anterior exclusion in 13. CABG was performed in 85 patients with mean 2.4+/-1.1 grafts in MR-group and 3.2+/-0.4 grafts in noMR-group (P<0.0001). In MR-group mitral valve plasty was performed in 24 and replacement in 14. Undersized (26 or 28 mm) circumferential mitral ring was used in 16 patients for mitral plasty. Emergent operation required in 15 patients (13 in MR-group and two in noMR group) and the hospital mortality was 18.4% in MR-group and 3.7% in no MR-group. Mitral regurgitation recurred in two patients with posterior ring annuloplasty and they underwent valve replacement. The post-operative NYHA functional class improved to class-1 or -2 in 65 patients and cumulative survival in 5 years including emergent and hospital deaths was 60.9% in MR-group and 70.1% in noMR-group., Conclusion: In association of MR to ICM, emergent operation required more often and perioperative mortality rate was high. However, the aggressive combined mitral operation in addition to CABG and LV restoration showed the improvement of clinical symptom and quality of life after the surgery.

Objective: In order to treat ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction, the mid-term effect of the endoventricular circular patch plasty (EVCPP) was studied., Materials and Methods: EVCPP has been performed on 54 patients (46 men and eight women with a mean age of 61 years) during 4 years from March 1997 to December 2000. Thirty-two patients (59%) were NYHA class III and 22 patients (41%) were class IV. Nine patients (17%) had mild angina pectoris before the operation but others had no chest pain. Single, double, triple, and left main disease were noted in six, 13, 32, and three patients, respectively. Mean left ventricular ejection fraction was 23.3 +/- 6.3% (6--30%). Coronary artery bypass grafting was concomitantly undergone by 51 patients (94%) and mitral valve reconstruction was done on 19 patients (35%)., Results: Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of 45 patients who underwent elective operation died of stroke and heart failure. Five patients (55.5%) out of nine patients who required emergency operation died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia and heart failure in each of three patients. Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study before and after operation, ejection fraction increased from 22.8 +/- 6.6 to 36.2 +/- 8.0% and mean left ventricular end-diastolic volume and left ventricular end-systolic volume indices reduced from 152.8 +/- 24.6 to 105.0 +/- 36.5 and from 113.6 +/- 45.7 to 66.4 +/- 28.4 ml/m(2), respectively. Mean pulmonary wedge pressure decreased from 19.1 +/- 8.8 to 14.9 +/- 6.8 mmHg. One-, 2-, and 3-year actuarial survival rates were 87.9, 82.7 and 77.2%, respectively., Conclusion: Left ventriculoplasty using EVCPP is effective to exclude the akinetic LV segment, and left ventricular function and clinical status improve in patients with ischemic cardiomyopathy.

Objective: The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined., Patients and Methods: Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization., Results: PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2)., Conclusions: The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

Background: The partial left ventriculectomy (PLV) is known to work in some patients with dilated cardiomyopathy (DCM), although this procedure does not work well in all patients and the operative mortality is higher than the other cardiac surgeries. In addition to PLV, left ventriculoplasty to exclude antero-septal wall or valvular surgery without left ventricle (LV) surgery can be also effective in patients with DCM. To improve the surgical results for dilated cardiomyopathy, we introduced echo-guided volume reduction test and evaluated the surgical procedures and the results on the surgery for DCM., Methods: Between December 1996 and July 1999, 56 patients with DCM (50 with idiopathic DCM, six with dilated hypertrophic cardiomyopathy) were surgically treated. Under the standard cardiopulmonary bypass, left ventricular motion was determined with color kinesis of echocardiogram and the lesion of akinetic wall was removed or excluded., Results: After the initial PLV in 18 patients (initial group), operative procedures were selected in 21 with PLV, five with LV plasty, or 12 with valve surgery without LV surgery according to the findings of the LV wall motion by intraoperative echogram (select group). There were six hospital deaths and late follow-up deaths within 1 year in initial group, however, the mortality decreased significantly after the selection of the operative procedures; three hospital deaths and two late deaths in the select-group (P<0.05). Significant decrease of left ventricular diameter, the LV ejection fraction and endosystolic volume index were demonstrated after the LV surgery. The survival rate improved significantly after the selection of the operative procedures; 14 months survival rates was 50.0% in initial group and 73.1% in select group (P<0.05)., Conclusion: Operative mortality decreased and late follow-up results improved after the selection of operative procedures according to the intraoperative volume reduction test.

A simple and effective technique is described here for harvesting the gastroepiploic artery (GEA) and radial artery (RA) using the Harmonic Scalpel. The mean time of harvesting GEA was 9 min and that of RA was 17 min. There were no injuries or spasms of those grafts and the postoperative angiograms performed in 28 patients. This shows 100% patency of the conduits. The GEA and RA are safely harvested by using the Harmonic Scalpel and the use of arterial conduits in coronary artery bypass grafting (CABG) seems to be easily achieved.

Kawasaki disease is an acute febrile illness affecting mainly infants and children. The fatal complication of Kawasaki disease is coronary involvement pertaining to coronary artery aneurysms. Surgical experience of adults that had childhood Kawasaki disease with coronary lesion has been rarely reported. We experienced coronary artery bypass grafting in a 44 year old man with no risk factors for atherosclerosis but with coronary lesions possibly secondary to Kawasaki disease. Coronary artery sequelae of Kawasaki disease may become part of a cause of coronary disease in young adults and we should recognize this condition in such patients with coronary disease but no coronary risk factors.

Continuous warm blood cardioplegia has been used with good clinical outcome in both antegrade and retrograde delivery. However, the continuous delivery of cardioplegia is sometimes interrupted for adequate visualization and flow is not constant with heart manipulation during operation. We studied the effects of interrupted antegrade delivery of warm blood cardioplegia on myocardial metabolism and clinical results after surgery. Fifty-five patients undergoing isolated coronary bypass surgery received warm blood cardioplegia (n = 29) or cold crystalloid cardioplegia (n = 26) in an antegrade fashion. During reperfusion, myocardial oxygen consumption, lactate extraction, creatinine kinase isoenzyme (CK-MB), and malondialdehyde (MDA) were measured. Post-operatively, serum CK-MB and cardiac output (CO) were determined over a period of time. Myocardial oxygen extraction in the warm group was significantly greater than in the cold group 1 min after reperfusion (P < 0.02). The results revealed a tendency for patients in the warm group to have prior lactate extraction, although the difference did not reach statistic difference (P < 0.10). After removal of the aortic cross-clamp, the heart returned to sinus rhythm spontaneously in 90% of the patients with warm cardioplegia and 15.4% of those with a cold heart (P < 0.01). Postoperatively, there was no significant CK-MB or MDA release in either group except for one patient with perioperative myocardial infarction. After operation inotropic support was required for two and one patient in the warm and cold groups, respectively, although there were significantly more patients with poor left ventricular function in the warm, than in the cold, group (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

To study the long-term results of the St. Jude medical prosthesis in the mitral position, 520 patients were evaluated who had undergone mitral valve replacement with St. Jude medical (SJM) prosthesis. Eighteen patients or 3.5% died in the early postoperative period (within 30 days after operation). The total follow-up was 2872 patient-years and late deaths occurred in 23 cases. Postoperative cerebral embolism occurred in six, bleeding complication in five, and thrombosed valve in two patients. Postoperative anti-coagulant therapy was initiated with both dipyridamole (300 mg/day) and warfarin potassium. After discharge from our hospital the patients underwent routine examination of their thrombo-tests or prothrombin times at least every 2-3 months, and the major thromboembolic or bleeding complication rate was 0.45%/100 patient-years. In a period of 12 years, severe hemolysis following implantation was seen in seven patients. The cause of this hemolysis was perivalvular leakage in two patients but there were no leakages in the other five patients, although preoperative moderate to severe liver dysfunction was noted. Ninety-three percent of the patients were followed up, and their postoperative New York Heart Association functional classes were I or II in 88.6% of the cases. Their clinical results after mitral valve replacement with SJM prosthesis in the anti-anatomical position showed excellent durability and a low incidence of valve-related complications.

Between April 1988 and August 1991, the right gastroepiploic artery (RGEA) was used as a pedicled arterial graft for coronary arterial bypass grafting (CABG) in 44 patients. Their ages ranged from 8 to 72 years (mean: 58.7 years), and body size was small for 21 patients (body surface area < 1.6 m2). The mean number of distal anastomoses was 3.2 +/- 0.7 per patient. The RGEA was anastomosed to the right coronary system in 35 patients and to the left in 9 patients. Perioperative vasospasm of the RGEA occurred in 4 patients, but no vasospasm was seen after intraluminal injection of diluted papaverine hydrochloride was used in the last 9 patients. The size of the RGEA at the site of anastomosis was 1.9 +/- 0.4 mm in diameter. The RGEA was harvested in 48 patients; however, two of the RGEAs were smaller than 1.0 mm in diameter and two showed severe calcification with stenosis of more than 75%. Consequently, those conduits were not used. Indications for the use of the RGEA were: relatively young age for 17, matching size of the coronary artery and the RGEA for 11, poor quality of the internal thoracic artery (ITA) or saphenous vein graft (SVG) for 10, lower leg atherosclerosis in 3, a diseased ascending aorta in 2, and Kawasaki disease in 1. The patency rate of the RGEA for 36 patients was 94.4% and relief of angina 95.5%. An exercise tolerance test performed within 2 months after operation showed improved capacity (mean 7.2 metabolic units).(ABSTRACT TRUNCATED AT 250 WORDS)