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Background: Mitral valve surgery is a recommended treatment for congestive heart failure; however, its effect for idiopathic dilated cardiomyopathy (DCM) with an extremely enlarged left ventricle (LV) is not well documented. We examined our long-term results of mitral valve surgery for idiopathic dilated cardiomyopathy., Methods: Fifty-five patients of idiopathic dilated cardiomyopathy have undergone mitral valve surgery to treat intractable congestive heart failure since 1998. Forty-two patients were male with an average age of 55. Preoperative New York Heart Association functional class was III in 25, IV in 30, and 19 were dependent on inotropic infusion. The mitral valve was repaired in 37 patients and replaced in 18. The tricuspid valve was repaired in 35 patients and replaced in 3. We divided 46 elective cases into two groups by LV end-systolic volume index., Results: Postoperatively, an intraaortic balloon pump was required in 2 patients and a left ventricular assist device in 1; both were emergent cases. Hospital mortality was noted 4.3% in elective cases (2 of 46) and 14.5% in overall cases (8 of 55). One-year, 3-year, and 5-year survival rate of elective cases was 73.3%, 58.2%, and 51.7%, respectively. Left ventricle size has decreased and LV contractility has increased in a small LV group year by year, but those in a large LV volume group have not changed subsequently after surgery. There was a significant difference noted in the survival rate of the two groups divided by LV end-systolic volume index., Conclusions: Mitral valve surgery for idiopathic dilated cardiomyopathy to treat end-stage heart failure is relatively safe and effective in elective status. However, isolated mitral reconstruction without any other type of surgery may not suffice for an extremely enlarged LV.

Background: Eight-year experience with the septal anterior ventricular exclusion procedure for congestive heart failure due to idiopathic dilated cardiomyopathy was evaluated., Methods: In 36 patients (27 men and 9 women with a mean age of 60 years) with heart failure; New York Heart Association class III/IV (21/15); and mitral regurgitation 2+ or greater, the procedure was indicated when the diastolic dimension was 75 mm or greater, and the septum was akinetic. A long, narrow oval patch was sutured to form a downsized elliptical left ventricle by excluding the septum and anterior wall. Mitral reconstruction was combined for all patients (26 repairs with undersized ring and 10 replacements with bioprosthesis) and tricuspid repair was added for 16 patients (44%)., Results: Hospital mortality was 13.8% (5 of 36), with 6.5% (2 of 31) in elective and 60% (3 of 5) in emergency operations. Ejection fraction increased from 20.9% +/- 6.4% to 27.5% +/- 8.8%, left ventricular diastolic dimension decreased from 81.9 +/- 9.2 mm to 70.1 +/- 10.0 mm, and left ventricular endodiastolic and endosystolic volume indices decreased from 236.5 +/- 65.0 mL/m2 to 183 +/- 60.5 mL/m2 and from 181.3 +/- 55.4 mL/m2 to 133.5 +/- 54.1 mL/m2, respectively. Left ventricular endodiastolic pressure decreased from 24.3 +/- 9.7 mm Hg to 19.4 +/- 7.6 mm Hg. Brain natriuretic peptide decreased from 975 +/- 866 pg/mL to 404 +/- 366 pg/mL at 1 to 6 postoperative months. Eleven late deaths were noted and were due to heart failure (6), sudden death (4) and stroke (1). The mean New York Heart Association class was 1.7 among the survivors. One- and 3-year survival rates were 67.5% and 60.7%, respectively., Conclusions: The septal anterior ventricular exclusion procedure with mitral reconstruction is a useful option for the treatment of advanced idiopathic dilated cardiomyopathy in extremely dilated left ventricle with akinetic septum.

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).

Patients with ischemic cardiomyopathy (ICM) are at an extremely high risk of death and ischemic events. This study aims to evaluate the impact of left ventricular restoration (LVR) and mitral valve surgery on the cardiac and clinical functional status of the patients with ICM. Twenty-six patients (46-80 years, mean: 64 years) with severely dilated heart (left ventricular end-systolic volume index: LVESVI > or = 100 ml/m2) who had coronary artery bypass grafting (2.8+/-1.3), mitral valve surgery, and LVR were enrolled in this study. Left ventricular end-diastolic volume index and LVESVI significantly decreased (from 169+/-44 to 130+/-41 ml/m2, P=0.0005, from 120+/-33 to 89+/-43 ml/m2, P=0.0012). Left ventricular ejection fraction showed no change. MR showed significant improvement (from 2.7+/-0.6 to 1.0+/-0.4, P<0.0001) and NYHA functional class showed improvement (from 3.2+/-0.8 to 1.5+/-0.9, P<0.0001). A 5-year survival rate was 71.2%. In conclusion, this aggressive approach with LVR aiming to treat end-stage ICM by relief of ischemia, reduction of LV wall tension by decreasing LV volume and stopping mitral leak, is effective for LV volume reduction and improvement of clinical functional status.

Background and Methods: An international registry of left ventricular volume reduction (LVVR) procedures, including partial left ventriculectomy, has been expanded, updated, and refined to include 568 cases voluntarily reported from 52 hospitals in 12 countries., Results: Gender, age, ventricular dimension, ethnology, myocardial mass, presence or absence of mitral regurgitation, as well as transplant indication, had little effect on event-free survival, which was defined as either absence of death or ventricular failure requiring mechanical assist or transplantation. Poor preoperative patient condition such as New York Heart Association classification IV, depressed contractility and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included an early surgery date, lack of experience, dilated cardiomyopathy as the underlying pathology and extended myocardial resection. Performance of LVVR reached a peak by 1998, but was largely abandoned by 2001, except in Asia, where experienced institutes continue to perform it in patients in better condition with preserved myocardial contractility., Conclusion: Avoidance of risk factors appears to have contributed to the recent survival improvement and may help stratify patients for LVVR. While performance has been decreasing, the concept has been extended to other LVVR and less invasive procedures, which are now under clinical trials.

This is the presentation of coronary artery bypass grafting with gastroepiploic artery (GEA) in both skeletonized GEA harvesting technique and anastomosis: After median sternotomy and harvesting internal thoracic artery, the median incision is extended less than one inch. Following laparotomy, dissection of GEA is started from two third distal of the great curvature of the stomach and ended above the pylorus. The GEA is passed into pericardial cavity through a small tunnel in the diaphragm. The most common site of the anastomosis is distal right coronary artery (postero-descending or atrioventricular branch or both). The suture starts from the left side of the "heal" of the GEA and proceeds in a counter-clockwise fashion for three stitches until pulling down the GEA to the coronary artery. After the completion of the anastomosis, the clamp of the GEA is released to check the anastomotic hemostasis. The technique for harvesting skeletonized GEA is shown and an overview of the literature of the CABG using GEA is presented.

Objectives: The aim of this study is to evaluate the relationship between left ventricular (LV) wall property and the results of LV volume reduction surgery (LVR) to treat dilated cardiomyopathy (DCM) in an experimental model., Methods: DCM was introduced in 18 Lewis rats by autoimmunization with cardiac myosin. Among them, 12 rats underwent LVR and the rest were served as controls. They were subjected to echocardiography and cardiac catheterization for dimensional and functional measurements. The animals were sacrificed 4 weeks after surgery, and the fraction of myocardial fibrosis was calculated in 4 divided parts of the LV wall., Results: Percent fibrosis varied widely from 4.7 to 45.2%. LV volume reduction surgery improved cardiac function immediately after surgery in all rats (Emax, 0.28+/-0.14 to 0.48+/-0.18 mmHg/microl; LV end-diastolic pressure, 21.0+/-6.1 to 13.3+/-5.1 mmHg, P<0.05, respectively). Four weeks later, 6 hearts remained in good shape with smaller LV end-diastolic dimension (Dd) than baseline values (LV Dd, 9.7+/-0.6mm; fractional area change (FAC), 40.3+/-8.4%) and the other 6 had more redilation in diameter and more deterioration in function than baseline values (LV Dd, 10.9+/-0.6mm; FAC, 25.8+/-6.9%; P<0.05, respectively). Percent fibrosis in the septum differed 11.1+/-3.4 vs. 27.8+/-2.8% between the two groups (P<0.01). There was a significant correlation between the ratio of LV redilatation after surgery and percent fibrosis in the septum (r=0.951, P<0.01)., Conclusions: Although the initial benefit of LVR was confirmed, the long-term result was affected by the amount of residual fibrosis. This information suggests that surgical site selection is important to achieve a good result of LV restoration surgery for DCM.

Objectives: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team., Background: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments., Methods: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified., Results: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II., Conclusions: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.

Ventriculoplasty was introduced to treat patients with chronic progressive heart failure from end-stage non ischemic dilated cardiomyopathy, which was presumed to be a homogeneous disease. However ventriculoplasty is not commonly used today, because variable results follow using only lateral ventriculoplasty as the treatment tool. This report traces our evolution in surgical management, defines that the homogeneous disease concept is not correct, and centers upon the importance of site selection, appropriate timing, and methods of patient selection. Left ventriculoplasty by either partial left ventriculoplasty (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was performed in 96 high risk (44% NYHA Class III, and 56% Class IV) patients with idiopathic dilated cardiomyopathy over the past 8 years. Overall hospital mortality was 8% in elective operations and 57% in emergency operations. Hemodynamic and functional improvement was evident from ejection fraction rising from 20% to 31%, and improved NYHA Class 3.6 to 1.8. The global series showed 1, 5 and 7 year survival rate was 66.4, 44.7 and 41.3%, respectively. However surgical results improved as experience allowed development of a strategy for timing, and defining proper exclusion site selection. Non homogeneous ventricular disease was identified, and 69% 4 year survival resulted from our intraoperative definition of the most diseased segment (septum or lateral wall), and then exclusion of this site. This evolving experience indicates that left ventriculoplasty is effective treatment for patients with end-stage cardiomyopathy, provided proper patient selection, appropriate timing of the operation, and choice of procedure are used as keys to a successful outcome.

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. The international RESTORE group applied SVR in a registry of 1198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined and risk factors identified.Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair, p < .001) Perioperative mechanical support was uncommon (< 9%). Global systolic function improved postoperatively, as ejection fraction increased from 29.6 +/- 11.0% to 39.5 +/- 12.3% (p < .001) and left ventricular end systolic volume index decreased from 80.4 +/- 51.4 ml/m(2) to 56.6 +/- 34.3 ml/m(2) (p < .001). Overall 5-year survival was 68.6 +/- 2.8%, Logistic regression analysis identified EF < or = 30%, LVESVI > o = 80 ml/m(2), advanced NYHA functional class, and age > or =75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postoperatively 85% were class I or II.SVR improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5-year outcome.

Enteroviruses have been implicated in the pathogenesis of idiopathic dilated cardiomyopathy (IDC). Recently, the association of adenovirus or parvovirus with IDC has been reported. Viral infection in the myocardium of American and Japanese patients with end-stage IDC was evaluated. Myocardial specimens from 30 American patients with IDC and 47 Japanese patients with IDC were analyzed for the presence of cardiotropic viruses. The strand-specific detection of enteroviral ribonucleic acid (RNA) was performed to determine viral activity in hearts with IDC. Established reverse transcription-polymerase chain reaction (PCR) or PCR techniques were used to detect genomic sequences of influenza viruses, mumps virus, adenovirus, parvovirus, herpes simplex viruses, varicella-zoster virus, and Epstein-Barr virus. Enteroviral RNA was detected in 7 of the 30 American patients (23%) and in 15 of the 47 Japanese patients (32%). Minus-strand enteroviral RNA, an indicator of active enteroviral RNA replication, was demonstrated in 5 of 7 plus-strand-positive American patients (71%) and in 12 of 15 plus-strand-positive Japanese patients (80%). Sequence analysis revealed that the viruses detected were Coxsackie B viruses. No genomic sequences of other viruses were detected in the myocardium of either American or Japanese patients with IDC. Therefore, active group B Coxsackie virus RNA replication in the myocardium was demonstrated in a significant proportion of American and Japanese patients with end-stage IDC. There was no evidence of persistent infection by other viruses in hearts with IDC. Specific therapy should be designed for Coxsackie virus positive patients with IDC., (Copyright 2004 Excerpta Medica, Inc.)

Objective: We have developed a technique for biologic coronary artery bypass grafting, which is a revival of a classic concept with modern biotechnology., Methods: Acute myocardial infarction was created by ligating the major branch of the circumflex artery in rabbits. Animals were divided into four groups: a nontreated group (group N), a group in which omentum was used to wrap the infarcted area (group G), a group in which a gelatin hydrogel sheet incorporating 100 microg basic fibroblast growth factor was placed over the infarcted area (group F), and a group in which the infarcted area was similarly treated with basic fibroblast growth factor followed by omental wrapping (group FG). Cardiac function was subsequently assessed by echocardiography. Postmortem angiography through the gastroepiploic artery was done in groups G and FG. Infarct size and arteriolar density were evaluated., Results: Group FG showed a better fractional area change than did the other groups (group N P <.001, group G P =.002, group F P <.001). Angiography revealed that communication from the gastroepiploic artery to the coronary artery was created through a rich bed of neovascularization in all 7 animals of group FG, whereas poor collaterals were recognized in only 2 of 7 animals in group G. Infarct size was reduced to a greater extent in group FG than in groups F, G, and N (10% +/- 3%, 16% +/- 5%, 19% +/- 7%, 23% +/- 2%, respectively, group F P =.04, groups G and N P <.01). The number of arterioles 20 to 100 microm in diameter was increased to a greater extent in group FG than in groups F, G, and N (23 +/- 5 arterioles/mm(2), 14 +/- 3 arterioles/mm(2), 10 +/- 1 arterioles/mm(2), 4 +/- 2 arterioles/mm(2), respectively), with the differences being significant., Conclusions: These results show that bypass from the gastroepiploic artery to coronary arteries can be achieved without surgical anastomosis through slow release of basic fibroblast growth factor in this rabbit acute myocardial infarction model. This new revascularization concept, biologic coronary artery bypass grafting, could be applicable for revascularizing many tiny coronary vessels in patients who are difficult to treat with conventional surgery or catheter intervention.

We present a case of acute pulmonary embolism (APE) after cesarean section. A cesarean section was performed on a 27-year old woman with normal course. However, one day after operation, she suddenly developed syncope and dyspnea. Soon after the symptom, she developed hypotension 60 mmHg. As a result of various examinations, her illness was diagnosed as APE with right ventricular dysfunction after cesarean section. She was consulted to our hospital for treatment. Soon after her arrival, we treated her for both APE and cardiogenic shock. The combined with antithrombotic therapy using heparin sodium, was successfully treated the patient from cardiogenic shock due to APE with right ventricular dysfunction after cesarean section.

Purpose and Methods: There is increasing evidence that inflammatory cytokines play an important role in the development of heart failure. To evaluate the role of cytokines in nonischemic DCM, we analyzed the relative quantity of cytokine mRNA expression in the hearts from DCM patients with refractory heart failure, using the ABI PRISM7700 real-time PCR system. We used heart tissues resected from 32 DCM patients at the time of elective partial ventriculectomy (PLV), and five biopsy specimens with normal histological findings as control., Results and Discussion: Interleukin (IL)-1beta, IL-10, and Tumor Necrosis Factor (TNF)-alpha mRNA were expressed at low levels in all normal hearts. The number of IL-10-positive DCM cases was significantly smaller than normal controls (P = 0.0036). One (10%) of 10 DCM patients with IL-10 mRNA expression died after PLV, and 10 (45%) of 22 DCM patients without IL-10 mRNA expression died. IL-1beta mRNA was overexpressed (over twice the mean of control subjects) in 15 of 32, and TNF-alpha mRNA in 10 of 32 patients. We propose the classification of DCM patients into subgroups on the basis of cytokine mRNA expression. Anticytokine therapy or cytokine therapy may have potential in improving the condition of heart failure in certain subgroups of DCM patients., Conclusions: We suggest that DCM patients with heart failure deteriorate without IL-10 mRNA expression in the myocardium. The classification of DCM patients into subgroups on the basis of cytokine mRNA expression may have great value in considering the treatment of this heterogeneous disease state.

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.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare congenital heart disease characterized by atrioventricular (AV) and ventriculo-arterial discordance;(1) that is, the left ventricle supports the pulmonary circulation and the right ventricle supports the systemic circulation. The most common cardiac anomalies in CCTGA include ventricular septal defect, pulmonary outflow tract obstruction and abnormalities of the systemic AV valve. (1) The dysfunction of the systemic ventricle occurs with increasing frequency in older patients with CCTGA, independent of their commonly associated structural defects.(2-4) We report a patient with CCTGA undergone the partial ventriculectomy for his systemic ventricular dysfunction.

From December 1996 to May 2001, we have performed 82 cases of left ventriculoplasty (LVP) for nonischemic dilated cardiomyopathy (DCM). Surgical procedure was partial left ventriculectomy in 70 patients and septal anterior ventricular exclusion in 12 patients with evaluation by utilizing intraoperative echocardiography. There were 70 men and 12 women with a mean age of 49, varying from 14 to 76. All patients had medically refractory heart failure with New York Heart Association (NYHA) Functional Class III in 33 patients and NYHA IV in 49; 34 patients were supported by inotropic infusion prior to the operation. Intra-aortic balloon pump (IABP) and left ventricle assist device (LVAD) were used in 12 and 2 patients at perioperative period, respectively. Hospital mortality was 8.2% in elective operation (5/61), 57.1% in emergency operation (12/21), and 20.7% overall. One- and four-year survival rates were 75.5% and 69.3% in elective cases, 37.9% and 0 in emergency cases, and 64.7% and 3.6% overall, respectively. Left ventricular (LV) ejection fraction increased from 22.3% to 29.0% at the time of surgery and has maintained around 33% up to two years. LV diastolic dimension and LV end diastolic pressure decreased from 83.8 mm to 65.0 mm; from 31.7 mmHg to 22.0 mmHg have maintained around 70 mm and 22.1 mmHg up to two years, respectively. Over one year most of the survivors were medically controlled within NYHA Class I-II. In conclusion, careful choice of surgical procedure by utilizing intraoperative echocardiography enables left ventriculoplasty to effectively treat severe heart failure with nonischemic cardiomyopathy.

In the 35 years of coronary artery bypass grafting, several kinds of conduits have been utilized and assessed. It is clear now that the saphenous vein graft deteriorated with time mainly due to atherosclerosis in the graft called "vein graft disease." The internal thoracic artery graft, on the contrary, stays patent very well in the long-term period and this evidence directly related to the superior later outcome in terms of longevity and postoperative cardiac events. To extend the use of arterial conduits for myocardial revascularization, several autologous arteries have been investigated and utilized clinically. With proper use of these new arterial conduits in addition to internal thoracic artery, coronary artery bypass grafting with multi-arterial grafts can be performed safely, and better long term result can be expected., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

In failing hearts, cardiomyocytes degenerate and interstitial fibrosis, which indicates cardiomyocyte loss, becomes more prominent in the myocardium. However, the precise mechanism of cardiomyocyte degeneration that leads to cell death is still unclear, although it is presumed that lysosomal function and autophagy play an important role because lysosomal activity increases under stress such as hypoxia. Myocardium that had been resected during partial left ventriculectomy performed in patients with dilated cardiomyopathy (DCM) was examined. Under light microscopy, some cardiomyocytes had a marked scarcity of myofibrils and had prominent cytoplasmic vacuolization. Atrophic and degenerated cardiomyocytes were often observed adjacent to replacement fibrotic tissue. Immunohistochemistry showed positivity for lysosome-associated membrane protein and a lysosomal catheptic enzyme in vacuoles of various sizes in the cardiomyocytes and these lysosomal markers were markedly increased in atrophic and degenerated cardiomyocytes. Electron microscopy revealed that degenerated cardiomyocytes had many vacuoles containing intracellular organelles, such as mitochondria, and were considered to be autophagic vacuoles. In DCM hearts, autophagy appeared to be associated not only with degradation of damaged intracellular organelles but also with progressive destruction of cardiomyocytes. It is possible that autophagic degeneration is one of the mechanisms of myocardial cell death.

Surgical treatment of nonischemic dilated cardiomyopathy is a new field in cardiac surgery. Although current pharmacologic therapy has shown improved survival rates, many patients still need heart transplantation. To reduce the shortage of donors, there is a demanding need for effective nontransplant cardiac surgery. In the past 5 years, partial left ventriculectomy (PLV) has emerged with initial enthusiasm, but is not used because of high surgical mortality and late return of heart failure. There are several examples of improved clinical status and ventricular function with the procedure. By refining patient selection and surgical modification, ventriculoplasty will become a realistic option in the treatment of heart failure caused by nonischemic cardiomyopathy., (Copyright 2001 by W.B. Saunders Company)

Partial left ventriculectomy (PLV) can be used to treat refractory congestive heart failure caused by dilated cardiomyopathy (DCM). In order to understand the relationship between the underlying myocardial injury and early clinical outcomes after PLV, histopathologic, immunohistochemical and virologic studies of the resected myocardium were performed. The posterolateral left ventricular walls from 27 patients with idiopathic DCM were examined. Cardiomyocyte diameter, degree of myocardial fibrosis, degree of cardiomyocyte degeneration, and degree of inflammatory cell infiltration were compared with mortality rates. Polymerase chain reaction was performed to detect enterovirus genome in the myocardium. Some patients had inflammatory cell infiltrates with focal accumulations of lymphocytes and macrophages, including both cytotoxic/suppressor T-cells and helper/inducer T-cells. The number of inflammatory cells (activated lymphocytes plus macrophages/mm2) was significantly greater in patients who died of cardiac insufficiency after surgery (27.8 +/- 5.7; n = 7) than in the survivors (11.1 +/- 2.5; n = 15). There was no significant difference in the degree of myocardial fibrosis, cardiomyocyte diameter or degree of cardiomyocyte degeneration between the 2 groups. Enterovirus genome was detected in the myocardium of 9 (38%) of 24 patients examined and 5 of these enterovirus-positive hearts had severe inflammatory cell infiltrates (37.9 +/- 2.5/mm2). Early survival in patients undergoing PLV for DCM is significantly affected by the degree of myocardial inflammation, so patients with more severe or ongoing inflammation may have poor clinical outcomes. Chronic myocarditis may play an important role in the etiology and pathophysiology of idiopathic DCM.

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.

Objective: Partial left ventriculectomy has been performed without standardized inclusion/exclusion criteria. A registry has been established to accumulate experience with this procedure to identify indications, risks and benefits., Methods: In response to a mailed inquiry, 90 cases were voluntarily registered from 28 Japanese institutions., Results: Males (n = 67, 74.4%) predominated, and 29 (32.2%) patients were over 60 years old. The underlying cardiac pathologies included dilated cardiomyopathy (n = 75, 83.3%), valvular disease (n = 8, 8.9%), the dilated phase of hypertrophic cardiomyopathy (n = 4, 4.5%), and others (n = 3, 3.3%). Gender, age, etiology, papillary muscle excision and absent transplant indication did not significantly affect survival. Poorer preoperative condition, reduced contraction and decompensation necessitating emergency operation were each associated with a significantly higher risk. Hospitals performing less than 5 cases had poorer results than more experienced institutions (p = .0019), which showed a tendency towards improved survival in the second half of their experience (p = .096). Hospital mortality (n = 29, 32.6%) and late death (n = 10, 11.2%) were mainly from ventricular failure with few sudden deaths over a period of 63.6 patient years follow-up. Late mortality was equally distributed in the first year and leveled off with significantly improved cardiac functional class in survivors., Conclusion: Partial left ventriculectomy was associated with better survival in less symptomatic patients with better contractile reserve undergoing an elective operation preserving the papillary muscles. Avoidance of identified risk factors may allow better patient selection and improved survival in the current environment where rescue transplantation is not readily available. Long-term follow-up is warranted with more registry data.

Objectives: Treatment of cardiac failure due to non-ischemic cardiomyopathy by left ventriculoplasty using partial left ventriculectomy (Batista operation) or septal anterior ventricular exclusion was evaluated., Methods: Left ventriculoplasty was performed in 70 patients (59 men and 11 women with a mean age of 51 years) from December 1996 to June 2000. Preoperative New York Heart Association (NYHA) functional class was IV in 43 patients including 29 receiving inotropic support, and class III in 27 patients. Nineteen patients required emergency surgery because of on-going shock and 51 patients were operated electively. Combined cardiac procedures were mitral valve reconstruction in 62 patients (45 replacements, 17 repairs), tricuspid annuloplasty in 37, and aortic valve replacement in 4. The initial 24 patients underwent typical Batista operation regardless of myocardial viability. The other 46 patients underwent selective ventriculoplasty to excise or exclude the weakest part according to the findings of the intraoperative echo-guided volume reduction test., Results: The intraaortic balloon pump was used in 12 patients and the left ventricular assist device in 2 patients. Three (5.9%) of the 51 patients who underwent elective operation and 12 (63.2%) of the 19 patients with emergency operation died in the hospital, giving an overall hospital mortality of 21.4% (15/70). Hospital mortality was reduced from 33.3% (8/24) in the initial 24 patients to 15.2% (7/46) in the recent 46 patients with the volume reduction test. Mean ejection fraction increased from 22.2 +/- 6.7% to 29.6 +/- 6.0%. Diastolic dimension decreased from 81.1 +/- 9.5 to 69.8 +/- 19.2 mm. End-diastolic and systolic volume indices decreased from 199.0 +/- 47.9 to 124.1 +/- 34.9 ml/m2 and from 154.0 +/- 41.2 to 89.3 +/- 31.7 ml/m2, respectively, at one postoperative month in the 55 hospital survivors. The mean pulmonary capillary wedge pressure decreased from 25.6 +/- 7.8 to 13.6 +/- 4.5 mmHg. Serum brain natriuretic peptide decreased from 999 +/- 647 preoperatively to 547 +/- 362 pg/ml one month after the operation. Thirteen patients (18.6%) died in the late period mainly due to heart failure. Among the 42 survivors, 37 patients returned to NYHA functional class I-II, and cardiac events were rare after one postoperative year. Actuarial survivals at 3 years in elective and emergency operations were 71.9% and 33.3%, respectively., Conclusions: Left ventriculoplasty is acceptably safe for elective operation and clinical improvement can be obtained by proper surgical procedures and careful postoperative medical treatment.

Objective: Recently, attention has been focused on enteroviral infection of the heart in the genesis of dilated cardiomyopathy (DCM). To determine the location of enteroviral RNA in the myocardium, we performed light microscopic in situ hybridization (ISH) and virological analyses of myocardial specimens obtained at partial left ventriculectomy (PLV)., Methods: Posterolateral walls of the left ventricle from 26 DCM patients were examined. Myocardial specimens were tested for the presence of enteroviral genomes by polymerase chain reaction (PCR). We selected two age-matched groups (10 patients each) in which enteroviruses were either present (EV-plus group) or not (EV-minus group). For both groups, we examined in situ localization of enteroviral RNA in the myocardium by ISH., Results: In PCR studies, both sense and antisense enteroviral RNA were detected in the myocardium of seven patients in the EV-plus group. The presence of this RNA indicates active viral replication in the myocardium. Five of seven patients who exhibited both sense and antisense enteroviral RNA died early after surgery. On ISH, three patients had evidence of active replication of enteroviral genomes. Viral genomes were present in myocardial lesions, especially in endocardial sites. Viral signals were found in degenerating myocardial cells, interstitial inflammatory cells, and endothelial cells of small vessels. These positive signals were not detected in the myocardium of the EV-negative group., Conclusions: We detected both sense and antisense enteroviral RNA in various myocardial lesions. This suggests that active enteroviral replication plays a role in the development of myocardial lesions in DCM patients. Active viral replication appears to be a prognostic factor for DCM after PLV. Further study of active viral replication in myocardial lesions will provide information useful for evaluating different therapeutic strategies for DCM.

Heart failure is an increasing problem because of successful therapies in younger age groups and an overall increase in age in the general population. Ischemic cardiomyopathy secondary to myocardial infarction is the most prevalent entity among the several causes for cardiac failure. Among the surgical options for these patients, neither transplantation nor current ventricular assist devices are able to treat a sufficient number of patients. Ventricular restoration, however, may evolve as a surgical option to treat myocardial failure secondary to postinfarction ventricular dilatation. This procedure must be undertaken in high-risk coronary artery bypass graft (CABG) patients in heart failure. We describe the techniques for both the conventional procedure (CABG +/- mitral valve [MV] repair) using cardioplegic methods, and the beating open heart for surgical anterior ventricular restoration (SAVR) for dyskinetic and akinetic areas in ischemic cardiomyopathies. This combined approach allows safe restoration of the ventricular geometry with minimal use of mechanical support (ie, intra-aortic balloon pump [IABP]) in 195 consecutive patients undergoing this procedure by members of an international team called the RESTORE group.

Background: Partial left ventriculectomy (PLV) has been performed without standardized inclusion or exclusion criteria., Methods: An international registry of PLV was expanded, updated, and refined to include 287 nonischemic cases voluntarily reported from 48 hospitals in 11 countries., Results: Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation, presence or absence of mitral regurgitation, and transplant indication had no effects on event-free survival, which was defined as absence of death or ventricular failure that required a ventricular assist device or listing for transplantation. Preoperative patient conditions, such as duration of symptoms (> 9 vs < 3 years; p = 0.001), New York Heart Association (NYHA) class (Class IV vs < Class IV; p = 0.002), depressed contractility (fractional shortening [FS] < 5% vs > 12%; p = 0.001), and refractory decompensation that required emergency procedure (p < 0.001) were associated with reduced event-free survival. Five or more cases in each hospital led to significantly better outcomes than the initial four cases. Rescue procedures for 14 patients nonsignificantly improved patient survival (2-year survival 52%) over event-free survival (2-year survival 48%; p = 0.49), with improved NYHA class among survivors (3.6 to 1.8; p < 0.001). Outcome was better in 1999 than in all series before 1999 (p = 0.02) most likely due to patient selection, which was refined to avoid known risk factors such as reduced proportion of patients in NYHA Class IV, FS < 5%, and hospitals with experience in 10 or less cases. A combination of these risk factors could have stratified 17 high-risk patients with 0% 1-year survival and 26 low-risk patients with 75% 2-year event-free survival., Conclusion: Avoidance of risk factors appears to improve survival and might help stratify high- or low-risk patients. Although less symptomatic patients with preserved contractility had better results after PLV, change of indication requires prospective randomized comparison with medical therapies or other approaches.

was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.

Objectives: The aim of this study was to evaluate the viral etiology of idiopathic dilated cardiomyopathy (DCM)., Background: The demonstration of enteroviral genome in hearts with DCM has reinforced the importance of enteroviruses in the pathogenesis of DCM. However, there is uncertainty about the character and activity of enteroviruses detected in the myocardium. Recently, the association of hepatitis C virus or adenovirus with DCM has been reported., Methods: Myocardial specimens from 26 patients with idiopathic DCM, which were obtained at partial left ventriculectomy (PLV), were examined virologically. Strand-specific detection of enteroviral RNA was performed to differentiate active viral replication from latent persistence. Polymerase chain reaction was used to detect genomic sequences of hepatitis C virus, adenovirus, cytomegalovirus, influenza viruses, mumps virus, herpes simplex viruses, varicella-zoster virus and Epstein-Barr virus., Results: Plus-strand enteroviral RNA was detected in 9 (35%) of the 26 patients. Minus-strand enteroviral RNA was determined in seven (78%) of these nine plus-strand RNA-positive patients. Sequence analysis revealed that the enteroviruses detected were coxsackie B viruses, such as coxsackievirus B3 and B4. However, genetic material from other viruses was not detected. Six (86%) of seven minus-strand enteroviral RNA-positive patients died of cardiac insufficiency within the first six months after PLV., Conclusions: Coxsackie B viruses were seen in hearts with idiopathic DCM. Active viral RNA replication appeared to be present in a significant proportion of these cases. Minus-strand coxsackieviral RNA in the myocardium can be a marker for poor clinical outcome after PLV. There was no evidence of persistent infection by other viruses in hearts with DCM.

To achieve high quality off-pump coronary artery bypass grafting (CABG), thermal coronary artery imaging using a new generation infrared camera was used and anastomotic status was assessed intraoperatively. In 12 patients who underwent off-pump CABG, 18 grafts (11 internal thoracic, 2 radial, 2 gastroepiploic arteries, and 3 saphenous veins) were evaluated following completion of anastomoses. All grafts were clearly visualized and anastomotic and flow status were observed with local epicardial cooling by CO2 blower in the normothermic heart. Seventeen grafts had no problems and one internal thoracic artery graft showed anastomotic failure that was successfully revised. All grafts were restudied by conventional catheter angiography postoperatively, and all were patent. Intraoperative coronary imaging with a highly sensitive infrared camera is noninvasive and effective for real time evaluation in the operating room. This results in more successful off-pump CABG.

We examined whether transmyocardial revascularization (TMR) relieves myocardial ischemia by increasing regional perfusion via the transmural channels in acute canine experiments. Regional blood flow during transient coronary ligation (2 min) was compared before and 30 min after TMR, and at the third transient ischemia the mid-left ventricle (LV) was cut and immediately frozen along the short axis for the analysis of NADH fluorescence in the regions around the TMR channels. In low-resolution analysis (2-4 g tissue or 2-3 cm(2) area), regional perfusion was not significantly altered after TMR, and NADH fluorescence was observed throughout the ischemic region without significant spatial variation. High-resolution analysis (2.8 mg, 1 mm x 1 mm) revealed that the flow after TMR was lower, and NADH fluorescence was higher in the regions close to the channels (1-2 mm) than in the regions 3-4 mm away from them. Creating TMR channels did not improve the regional perfusion and rather aggravated the local ischemia in the vicinity of the channels in the immediate phase.

Objective: The angiographic patency of the right gastroepiploic artery graft used for coronary artery bypass grafting was studied during the late (5-10 years) postoperative period., Methods: Among 936 patients undergoing a gastroepiploic artery graft for coronary artery bypass grafting between 1986 and 1999, postoperative angiographic restudy was conducted on 685 patients within 1 year (mean, 2.2 months), on 102 patients between 1 and 5 years (mean, 2.3 years), and on 52 patients between 5 and 10 years (mean, 7.8 years)., Results: The patency rate of the gastroepiploic artery graft was 94%, 88%, and 83% in each restudy group. The cumulative patency rate estimated by the Kaplan-Meier method was 96.6% at 1 month, 91.4% at 1 year, 80.5% at 5 years, and 62.5% at 10 years. Causes of late occlusion were primary anastomotic stenosis and anastomosis to a less critically stenosed coronary artery. Once the gastroepiploic artery was perfectly anastomosed to the coronary artery, which has tight stenosis and good runoff, late patency was good, and new stenosis in both the gastroepiploic artery trunk and the anastomotic site was uncommon., Conclusion: The gastroepiploic artery graft can be used effectively for coronary artery bypass for the long term with proper target selection.

Objectives: To evaluate the efficacy of off pump coronary artery bypass grafting (CABG), results in the initial consecutive 200 patients were reviewed., Methods: Between October 1996 and December 1999, 200 patients underwent CABG without cardiopulmonary bypass. There were 146 men and 54 women aged from 27 to 89 years (mean 68 years). Single, double, triple and left main disease were noted in 94, 55, 33 and 18 patients, respectively, with a mean ejection fraction of 51%. Preoperative complications were previous stroke in 34 patients, chronic renal failure in 22 patients, previous CABG in 18 patients, and aortoiliac aneurysm or occlusive disease in 14 patients. Fifty-five patients (28%) were 75 years or older. Surgical approach was made through a midsternal incision including lower half small sternotomy in 105 patients, left anterior small thoracotomy in 92 and small epigastric incision (gastroepiploic-right coronary anastomosis) in 3. Mean number of distal anastomoses was 1.3 (range 1-4). Anastomosis was performed in 189 left anterior descending, 13 diagonal, 27 circumflex and 41 right coronary arteries. The conduits were 174 internal thoracic, 10 internal thoracic-inferior epigastric composite, 22 right gastroepiploic and 5 radial arteries, and 50 saphenous vein grafts. Four patients underwent combined off pump CABG and transmyocardial laser revascularization, and 36 patients underwent hybrid (off pump CABG and angioplasty) revascularization., Results: Four patients (2.0%) died in the hospital due to intestinal necrosis in 2 patients, postoperative aortic dissection in one, and multiorgan failure with stroke in one. No serious ventricular tachyarrhythmia or use of intraaortic balloon pump occurred. Perioperative myocardial infarction was noted in one patient. Stroke occurred in 4 patients (2.0%) but 3 patients recovered in a short period. Three-year survival and cardiac event free rate were 90.3% and 81.1% by the Kaplan-Meier method. Postoperative angiographic study showed excellent patent graft in 92% of grafts (192/209), stenosed (> or = 50%) graft in 5% (10/209) and occlusion in 3% (7/209)., Conclusions: Off pump CABG can be performed safely and effectively in both high risk and low risk patients with coronary artery disease. Refinement of surgical technique and equipment will make this procedure more useful.

Between January 1997 and November 1999, 31 patients underwent combined valve and coronary artery bypass grafting (CABG) surgery in our institute. There was no hospital death and clinical symptom improved in all patients after surgery. Mean follow-up was 16.3 months. The actuarial survival rate was 96.8% at 1 year. There were 4 late deaths (CHF in 3, arrhythmia in 1). Tepid blood cardioplegia was effective for those operations. Operation of CABG combined with valve surgery or LV surgery could be safely performed. We therefore considered that complete correction of the lesion with not only CABG but also combined valve surgery or LV surgery was the procedures of choice in patients with complicated lesions.

Objective: To treat end-stage cardiomyopathy, we evaluated endoventricular circular patch plasty, partial left ventriculectomy, and valvular reconstruction alone in our 2-year experience., Methods: Among 86 patients with heart failure evaluated between December 1996 and February 1999, 33 patients with ischemic cardiomyopathy (25 men and 8 women; mean age 61 +/- 7.8 years; New York Heart Association class 3.5 +/- 0.5) were treated with endoventricular circular patch plasty combined with coronary bypass grafting (84%) and mitral reconstruction (36%). The other 53 patients with nonischemic cardiomyopathy (45 men and 8 women; mean age 48 +/- 14.3 years, New York Heart Association class 3.7 +/- 0.5), were treated by left ventricular reduction by partial left ventriculectomy (n = 37) or patch plasty (n = 3) and valve reconstruction alone (n = 13). The first 24 patients (group I) underwent ventriculectomy with or without valve reconstruction; the more recent 29 patients (group II) underwent left ventricular reduction (n = 16) or valve reconstruction alone (n = 13) on the basis of the intraoperative echocardiographic evaluation to observe changes of wall motion and thickness during cardiopulmonary bypass., Results: Ischemic Group: Hospital mortality in elective (n = 26) and emergency (n = 7) operations was 4% and 43%, and 3 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.5 +/- 0.5 to 1.5 +/- 0.7 and from 23% +/- 7.7% to 36% +/- 8.6%, respectively. Left ventricular end-diastolic and end-systolic volume indexes decreased from 162 +/- 46 mL/m(2) to 110 +/- 39 mL/m(2) and from 130 +/- 47 mL/m(2) to 70 +/- 32 mL/m(2), respectively. Nonischemic Group: In 40 patients with left ventricular reduction, hospital mortality in elective (n = 33) and emergency (n = 7) operations was 6% and 86%, and 5 patients died in the late postoperative period. Mean New York Heart Association class and ejection fraction improved from 3.7 +/- 0.5 to 1.7 +/- 0.6 and from 18% +/- 6.4% to 31% +/- 5.9%. Left ventricular end-diastolic and end-systolic volume indexes decreased from 203 +/- 45 mL/m(2) to 110 +/- 37 mL/m(2) and from 164 +/- 40 mL/m(2) to 79 +/- 33 mL/m(2), respectively. In 13 patients undergoing valve reconstruction alone (12 mitral with or without tricuspid and 1 tricuspid plus left ventricular assist device), hospital mortality in elective (n = 9) and emergency (n = 4) operations was 0% and 50% with no late deaths. Mean New York Heart Association class and ejection fraction improved from 3.6 +/- 0.5 to 2.0 +/- 0.5 and from 22% +/- 6.0% to 30% +/- 14.5%, respectively. Mean left ventricular end-diastolic and end-systolic volume indexes decreased from 170 +/- 34 mL/m(2) to 150 +/- 50 mL/m(2) and from 140 +/- 38 mL/m(2) to 104 +/- 40 mL/m(2), respectively. Overall mortality decreased from 50% in group I to 10% in group II. The survival estimates at 2 years were 77% (confidence limits 57%-88%) in the ischemic group and 63% (confidence limits 47%-75%) in the nonischemic group (no significant difference). The analysis of our data showed that the factors influencing the surgical results for dilated cardiomyopathy were presence of severe mitral regurgitation, preoperative New York Heart Association functional class IV with emergency operation, and operative procedures with randomly performed partial left ventriculectomy without an intraoperative echo test., Conclusion: Endoventricular circular patch plasty, partial left ventriculectomy, and solo valve reconstruction can be performed with an acceptably low risk as elective operations. The selection of operative procedures in idiopathic dilated cardiomyopathy and avoidance of emergency surgery improved operative mortality and morbidity. Among patients who survived at least 1 year, there were no late deaths up to 30 months' follow-up.

Background: The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis., Methods: Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography., Results: There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II., Conclusion: The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.

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.

Background: To achieve better results after coronary artery bypass grafting (CABG), arterial conduits are the first choice in multiple CABG for younger patients. We present here the early results of CABG with gastroepiploic artery (GEA) composite graft with free radial artery (RA) to revascularize right coronary artery or left circumflex artery in addition to internal thoracic artery to left anterior descending artery., Methods: Between July 1997 and June 1998, 13 patients received CABG with GEA (larger caliber than 2.0 mm) composite graft. We have assessed the early results., Results: There was no postoperative death or major morbidity. Postoperative angiogram was performed in 11 patients and all conduits were patent. Postoperative exercise stress test was done in 13 cases and showed no ischemia., Conclusions: Multiple CABG with arterial conduit can be performed by this procedure. The free RA functioned from secondary branches derived from proximal GEA. In conclusion, this procedure seems to be safe and effective, and both long-term patency and better quality of life may be expected.

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

This study was conducted to investigate therapeutic methods for end-stage renal disease (ESRD) by retrospectively analyzing in-hospital outcome and long-term outcome in patients who underwent either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Ninety-two patients underwent PTCA and 47 underwent CABG, and the initial success rates were 87% and 85%, respectively. As major in-hospital complications, in the PTCA group 1 died (1%), 2 required emergency CABG (2%), and 2 had Q-wave myocardial infarction (2%); in the CABG group, 7 died (15%) and 3 had Q-wave myocardial infarction (6%). As for the long-term outcome, although there were no differences in the incidence of death or the incidence of cardiac death between the 2 groups, the cumulative proportion of patients free of death, myocardial infarction, CABG and repeat PTCA was lower in the PTCA group, which was mainly due to a higher incidence of repeat PTCA in that group. The incidence of cardiac death was low for both groups among the patients attaining complete revascularization. Twenty-three percent of the patients required cross-over implementation of PTCA and CABG. In conclusion, it is necessary to aim for complete revascularization using both treatments for a better prognosis in patients with ESRD.

Background: We report our early experience with partial left ventriculectomy done by a group of cardiac surgeons in the Asia-Pacific region., Methods: Partial left ventriculectomy was done in 48 patients (mean age, 43 years) with advanced symptomatic cardiomyopathy. The origin of cardiomyopathy was idiopathic in 30 patients, valvular in 10, ischemic in 3, peripartum in 3, sarcoidosis in 1, and viral myocarditis in 1. Procedures performed on the mitral valve were repair with Alfieri method in 8 patients, ring annuloplasty in 2, and replacement in 25., Results: Seventy-seven percent of patients required myocardial support for weaning from cardiopulmonary bypass, and the overall in-hospital mortality rate was 27%. Mean follow up was 6.5 months (range, 1 to 18 months), and patient survival at 1, 3, and 6 months after discharge was 91%, 88%, and 84%, respectively. Sixty-five percent of survivors with idiopathic and valvular disease achieved significant and sustained improvement in ventricular contractility and symptoms, but there were no clear symptomatic benefits from partial left ventriculectomy in patients with cardiomyopathy from other causes. Most cases of late recurrence of heart failure symptoms (90%) appeared to be related to the development of progressive mitral incompetence., Conclusions: After partial left ventriculectomy left ventricular function improved in patients with idiopathic and valve related cardiomyopathies. Late deterioration was related to the development of significant mitral valve incompetence postoperatively, hence definitive mitral valve repair or replacement at the time of the partial left ventriculectomy procedure is advised.

During the last three decades, coronary artery bypass grafting (CABG) emerged, was developed and has progressed. The search for suitable conduits has been investigated aggressively and several venous, arterial and artificial grafts have been utilized clinically. It is clear now that the saphenous vein graft deteriorates with time and the occlusion rate reaches up to 50% at 10 years after CABG mainly due to atherosclerosis in the graft called "vein graft disease." The internal thoracic artery (ITA) graft, on the contrary, has very good long-term patency and this evidence directly relates to the superior outcome in terms of longevity and postoperative cardiac events in the long run. Based on this evidence, the use of arterial conduits for myocardial revascularization has been extended. Several autologous arteries have been investigated and utilized clinically such as the right gastroepiploic artery, the inferior epigastric artery, and the radial artery. With proper use of these new arterial conduits in addition to ITA, higher quality CABG can be performed safely, and a better long-term result can be expected.

A 38-year-old man underwent the Batista operation to treat end-stage dilated cardiomyopathy. There was no associated mitral regurgitation, so only partial left ventriculectomy was performed. The patient recovered successfully. His New York Heart Association (NYHA) class improved from IV to I, ejection fraction increased from 8% to 37% and left ventricular diastolic dimension decreased from 89 to 68 mm. Cardiac output and stroke volume increased from 3.8 to 6.7 l/min and from 52 to 85 ml/min, respectively. This case shows the isolated positive effect of partial left ventriculectomy without mitral valve reconstruction.

Objective: Partial left ventriculectomy was introduced for the treatment of refractory dilated cardiomyopathy (DCM). To determine the presence and degree of inflammatory cell infiltrates in DCM and the correlation between the underlying myocardial injury and early clinical outcomes after the operation, we performed histopathological, immunohistochemical, and virological studies of the resected myocardium., Methods: Posterolateral walls of the left ventricle from 13 idiopathic DCM patients (9 males and 4 females; mean age = 53+/-14 years) were examined. Qualitative and quantitative analyses of the interstitial fibrosis and of the infiltrating inflammatory cells were conducted. For the immunohistochemistry, leukocyte surface markers and antibodies to adhesion molecules and cytokines were used. The histopathological findings were compared with the clinical results, including outcome within 1 year, and pre- and postoperative hemodynamic data. Genomic analysis of the myocardium with polymerase chain reaction was performed for enterovirus, mumps, influenza A, cytomegalovirus, and hepatitis C virus., Results: (1) The three patients who died of cardiac insufficiency after surgery had a higher count of infiltrating inflammatory cells than the eight survivors (32.1+/-10.4 vs 16.3+/-11.9 cells/mm2, p = 0.07). The severity of interstitial fibrosis (percent fibrosis) did not differ significantly between these two groups (28.3+/-15.0 vs 24.0+/-11.7%). (2) In patients who died of myocardial dysfunction, focal accumulations of lymphocytes were common, in which cytotoxic/suppressor T cells and helper/inducer T cells were observed. (3) Enterovirus genome was detected in the myocardium of two patients, both of them died after surgery., Conclusions: Inflammatory cell infiltrates or active myocarditis appear in some cases to play an important role in the etiology and pathophysiology of clinically diagnosed DCM. There is a possibility that those patients with a more severe or ongoing inflammatory process might have poor outcomes after partial left ventriculectomy.

Between December 1996 and October 1998, 34 patients with nonischemic dilated cardiomyopathy (DCM) received cardiac volume reduction surgery. The patients' ages ranged from 14 to 67 years (mean = 48 years) and included 28 males and 6 females. Associated mitral regurgitation was present in 31 patients, tricuspid regurgitation in 19 patients, and aortic regurgitation in 4 patients. We performed a partial left ventriculectomy (PLV) using antegrade intermittent warm blood cardioplegia in 15 patients (group A), and in 19 patients (group B) PLV was performed using the on-pump beating heart technique. In group A, the mean aortic clamping time was 79+/-33 minutes and the total cardiopulmonary bypass time was 155+/-58 minutes. In group B the mean cardiopulmonary bypass time was 121+/-43 minutes. There were eight hospital deaths (five in group A and three in group B). Five of 10 survivors of group A required inotropic support for 13.8+/-25.3 days after the operation, while 5 of 12 survivors in group B required inotropes for 4.2+/-3.1 days. Hospital mortality was 86% in 7 emergent cases and 7% in 27 elective cases. Echocardiographic study showed that the left ventricular ejection fraction improved from a mean of 18.7% to 30.3% and the left ventricular diameter decreased from a mean of 80.2 mm to 62.3 mm after the operation. All 26 hospital survivors were followed for 1 to 20 months. Three patients died at early follow-up because of congestive heart failure, thrombosed valve, and hepatic failure, respectively. Nineteen patients were in New York Heart Association (NYHA) Class I or II and four were in NYHA Class III. In conclusion, cardiac volume reduction surgery is effective when the operative technique and proper judgment of patient selection are established, and emergent operation is avoided.

The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation.

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.