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La insuficiencia cardíaca (IC) es uno de los problemas de salud de mayor importancia en el mundo occidental en cuanto a número creciente de pacientes afectados, tasa de hospitalización y costes. A pesar de la optimización en el tratamiento médico, la mortalidad permanece elevada. El incremento del volumen ventricular tras un infarto de miocardio (IM) forma parte del proceso de remodelado. la cirugía de restauración ventricular (SVR) se introdujo como una opción terapéutica con el objetivo de reducir los volúmenes ventriculares y restaurar la geometría. Hasta ahora, se ha demostrado que la SVR mejora la función cardíaca, el estadio clínico y la supervivencia en pacientes con miocardiopatía dilatada isquémica e IC. la técnica, desde su descripción inicial, se ha refinado en los últimos 10 años en un esfuerzo para estandarizar el procedimiento y optimizar los resultados. En esta revisión se discuten las razones de revertir quirúrgicamente el remodelado de ventrículo izquierdo (VI) , la técnica, el impacto de la SVR en la función cardíaca y la supervivencia, y una información actualizada sobre los ensayos clínicos actuales y las nuevas guías clínicas.Heart failure is one of the major health care issues in the Western world in terms of increasing number of patients affected, rate of hospitalization, and costs. Despite optimal medical treatment, mortality remains high. The increase in left ventricular volume after a myocardial infarction is a component of the remodeling process. Surgical ventricular restoration (SVR) has been introduced as an optional therapeutic strategy aimed to reduce left ventricular volumes and restore geometry. So far, it has been established that SVR improves cardiac function, clinical status, and survival in patients with ischemic, dilated cardiomyopathy and heart failure. The technique, since its first description, has been refined in the last ten years in an effort to standardize the procedure and to optimize the results. This review will discuss the rationale to surgically reverse lV remodeling, the technique, the impact of SVR on cardiac function and survival, and an up-to-date information regarding the current trials and the new guidelines.

Aims A left ventricular end-systolic volume (LVESV) ≥60 mL/m2 has been shown to be associated with increased cardiac mortality after a reperfused myocardial infarction (MI). The reduction in LVESV following surgical ventricular reconstruction (SVR) is reported to be between 19% and 50% but its impact on prognosis is not well-established. The aim of this study was therefore to assess the impact on survival of a residual LVESV index (LVESVI) of ≥ or

Heart failure is one of the major health care issues in the Western world. An increasing number of patients are affected, leading to a high rate of hospitalization and high costs. Even with administration of the best available medical treatment, mortality remains high. The increase in left ventricular volume after a myocardial infarction is a component of the remodeling process. Surgical Ventricular Restoration (SVR) has been introduced as an optional therapeutic strategy to reduce left ventricular volume and restore heart geometry. So far, it has been established that SVR improves cardiac function, clinical status, and survival in patients with ischemic, dilated cardiomyopathy and heart failure. Since its first description , SVR has been refined in an effort to standardize the procedure and to optimize the results. This review will discuss the rationale behind surgical reversal of LV remodeling, the SVR technique, its impact on cardiac function and survival, and future expectations.

Background This is a clinical investigation of the mid- to long-term follow-up of the Ross procedure in adult patients. The primary end point is to explore the incidence and risk factors for a reoperation on the pulmonary autograft. The secondary end points are to explore the incidence of neoaortic root dilation and valve regurgitation, and the echocardiographic profile leading to a reoperation. Methods Ross operations were done in 110 adults who received at least two echocardiographic examinations for a mean follow-up time of 82 months (range, 5 to 155 months). Kaplan-Meier and Cox regression analyses were applied to assess freedom from events and risk factors for events. Results Freedom from reoperation on the pulmonary autograft, neoaortic root dilation, and moderate-severe neoaortic valve regurgitation were, respectively, 91.4%, 50%, and 70% at 12 years. The main risk factor for a reoperation was the degree of neoaortic valve regurgitation within the first 2 years of follow-up. Patients requiring an early (≤4 years) reoperation had early and severe pulmonary autograft valve regurgitation, and no neoaortic root dilation. Patients needing a late (>4 years) reoperation had severe neoaortic root dilation and severe neoaortic valve regurgitation. The left ventricular end-diastolic diameter at the third year of follow-up was a risk factor for late reoperation. Conclusions The Ross operation in adults is a safe procedure with good clinical results in mid- to long-term follow-up. Early reoperations are due to early neoaortic valve regurgitation, wheras late reoperations are due to progressive neoaortic root dilation.

Objective Any grade of ischemic mitral regurgitation is associated with excess mortality. Whether mild ischemic mitral regurgitation should be repaired at the time of either coronary artery bypass grafting or surgical ventricular restoration is controversial. Surgical ventricular restoration is a treatment option for dilated post-infarction cardiomyopathy and has the potential to improve mitral functioning. The present study assessed the effectiveness of surgical ventricular restoration and unrepaired mild ischemic mitral regurgitation on left ventricular geometry, cardiac and functional status, and survival. Methods We analyzed 55 patients with previous anterior infarction (age 65 ± 10 years) and mild chronic functional mitral regurgitation who underwent surgical ventricular restoration and coronary artery bypass grafting without mitral repair at our center. Left ventricular volumes, ejection fraction, and geometric parameters were measured before and after surgery. Results Even mild ischemic mitral regurgitation is characterized by abnormal left ventricular geometry when compared with that of patients without mitral regurgitation at comparable ventricular volumes and ejection fraction. Surgical ventricular restoration induces a significant decrease in left ventricular volumes, left ventricular diameters, and papillary muscle distance; and an improvement in ejection fraction and New York Heart Association class. Ischemic mitral regurgitation significantly decreases in the majority of patients. Survival is 93% at 1 year and 88% at 3 years. Conclusion Surgical ventricular restoration improves mitral functioning by improving geometry abnormalities. Survival is optimal and greater than would be expected in patients with post-infarction dilated ventricles and depressed left ventricular function. Our data indicate that mitral repair in conjunction with surgical ventricular restoration is unnecessary in such patients.

If the Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrates that surgical therapy is superior to medical therapy, early aggressive evaluation of coronary artery disease as a potentially correctable cause of new-onset heart failure would be the preferred strategy. This strategy could tremendously change the treatment of ischemic heart disease. Confirming the STICH revascularization hypothesis will dramatically increase the use of coronary artery bypass grafting among the millions of patients now being medically treated without evaluation for an ischemic cause.

Background We sought to analyze the characteristics of local left ventricular deformation related to functional mitral regurgitation (MR) in post–anterior myocardial infarction scar, and to evaluate how local remodeling contributes to late development of MR after surgical ventricular reconstruction by endoventricular circular patch plasty repair. Methods Two hundred twenty-one consecutive patients (aged 60 ± 9 years; 193 males) with previous transmural anterior infarction underwent heart catheterization both before and 1 year after endoventricular circular patch plasty repair. Preoperative global left ventricular shape determinents (eccentricity and circularity indexes), regional curvature and wall motion (centerline), and both preoperative and 1-year postoperative hemodynamic parameters (volumes, ejection fraction, capillary wedge and pulmonary artery pressures) were calculated. Results Forty-eight patients had (MR patients), and 173 did not have (NoMR patients) angiographic MR grade 2 or more preoperatively; at follow-up, 30 NoMR patients had MR (late MR [LMR]). Before surgery, MR patients had larger left ventricular volumes, higher capillary wedge and mean pulmonary artery pressures, and lower ejection fraction and cardiac index. The LMR patients had similarly high capillary wedge and pulmonary artery pressures as MR patients; otherwise, they did not differ from NoMR patients. Mitral regurgitation patients had wider lateral wall akinesia and greater inferior wall asynergy; the inferobasal region was hypokinetic in LMR patients. In MR patients, inferior wall systolic curvature was less negative; the inferobasal region had a more positive curvature in LMR patients. Conclusions Local deformation of the inferior wall with loss of systolic inward bending is associated with functional MR, while asynergy and systolic deformation of the inferobasal region and high capillary wedge pressure are prognostic signs of MR development late after endoventricular circular patch plasty repair.

Objective: Pulmonary regurgitation may cause progressiveright ventricular dilatation and dysfunction in adult patients previously repaired for right ventricular outflow tract obstruction (RVOTO), and who require subsequent valve implantation for relief of these symptoms. Right ventricular recovery after pulmonary valve implantation (PVI) may be closely linked to the functional importance of the structural presence of an aneurysm or akinetic segment in the RVOT area. To test this concept, the impact of the right ventricular restoration with a new surgical ventriculoplasty technique is evaluated following pulmonary valve implantation in patients with severe pulmonary regurgitation and right ventricular dilatation. Methods: Sixteen patients with severe pulmonary valve regurgitation (PVR) and right ventricular dilatation with RVOT aneurysm underwent right ventricular remodelling since January 2002. Each underwent preoperative evaluation by Doppler echocardiography, magnetic resonance imaging (MRI), and right ventricular myocardial acceleration during isovolumic contraction (IVC). The surgical procedure included pulmonary valve implantation and RVOT restoration achieved by removal of the aneurysm tissue, coupled with a ventriculoplasty to reduce volume, accomplished by creating a satisfactory RVOT dimension by placing with 2-0 Gortex suture to allow acceptance of a 26 Hegar dilator to avoid restriction. Thirteen associate surgical procedures were added in nine patients. Results: All patients survived the operative procedure and underwent a 16-month follow-up interval. A reduction of cardio thoracic index and a clinical improvement occurred in each patient. Significant reduction of RVEDV and RVESV and increased right ventricular ejection fraction was observed, and IVC changed from 0.7 0.5 m/s 2 to 1.3 0.6 m/s 2 in the 13 patients that underwent MRI and IVC during the preoperative control interval and 6 months after the procedure. Conclusions: This preliminary database implies that the right ventricular restoration is a simple and effective procedure, and introduces a structural component that should be added during pulmonary valve implantation in patients with severe right ventricular dilatation and underlying aneurysm or akinesia of the right ventricular outflow tract.

Background Anterior myocardial infarction leads a sequence of structural changes that alter the size and the shape of the left ventricle. Efforts to assess shape have been made by global left ventricular (LV) chamber analysis (sphericity index, SI) but this analysis does not detect regional shape abnormalities like those at the apical level, which precede global ventricular dilatation. Objective The present study will introduce a new analysis of regional apical changes in 52 normal subjects and in 92 patients with previous anterior myocardial infarction. Methods All patients had transthoracic echocardiogram and multiple views were obtained (long axis, 4CH, 2CH and short axis view). From the 4CH view the long and the short axes were measured and their ratio was calculated (sphericity index). In the same view, the apical axis length was also measured and the ratio between apical and short axis length was calculated (apical conicity index, ACI). Results Patients had all the measured parameters significantly worse than normal, except the sphericity index which remained unchanged. Ventricular length and width increased following anterior MI but the ratio between the two measurements did not change. Conversely, apical conicity index is significantly different following anterior MI, thereby indicating anterior infarction produces a less conical shape. SI and ACI differed when correlations were made in the relationship of mitral valve function; SI correlates with the degree of mitral regurgitation (MR) and with the distance of papillary muscles, conversely ACI shows an inverse correlation with the determinants of mitral regurgitation. These observations reflect differences between apical versus global dilatation in ischemic cardiomyopathy, so that mitral function is better (lower tenting area and lower coaptation height) when the apex is markedly dilated in respect to the short axis (high conicity index). In contrast, mitral function is impaired (bigger distance between papillary muscles and higher degree of mitral regurgitation), when sphericity index is high. Conclusions Sphericity index fails to detect regional apical shape abnormalities. To address this focal change, we introduce a simple new measure termed apical conicity index, which is abnormal in patients with myocardial infarction, and can be useful to evaluate changes induced by the subsequent surgical approach of ventricular re-shaping.

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 EFor = 30%, LVESVIo = 80 ml/m(2), advanced NYHA functional class, and ageor =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.

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

See related article on page 863. H eart failure is a major health problem with increasing prevalence due partly to an aged population and more effective treatment of acute myocardial infarction. Postinfarction left ventricular remodeling is characterized by chamber dilatation and abnormal shape leading to systolic and diastolic dysfunction. In advanced form, it leads to the heart failure syndrome and is progressive. Intensive medical management reduces symptoms and improves survival. However, patients who are in functional class III or IV have a poor 3-year prognosis.1-3 Recently, surgical approaches have been designed to abort and reverse remodeling, diminish heart failure, and improve survival. With minor modifications, this surgical approach uses the Dor procedure. Surgical therapy achieves the following: 1. Relieves ischemia by coronary revascularization. 2. Diminishes ventricular volume. 3. Restores the ventricle to more normal geometry. 4. Further diminishes volume overload by mitral valve repair when appropriate.

The first experience with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular (LV) geometry made more spheric after myocardial infarction. The consequence is dilated ischemic cardiomyopathy. In anterior infarction, the free LV wall and septum are scarred and become dyskinetic or akinetic. The fundamental approach excludes the noncontractile (asynergy) and nonresectable regions to restore more normal size and shape. The current experience of our group in 2001, includes 1,011 patients, and confirmation of our results by others, including an international team. The basic components are LV reconstruction, revascularization, and mitral repair (when needed), which form an integrated method of surgical management. Endocardiectomy and cryoablation are used with spontaneous and inducible ventricular arrhythmias. This article reviews these results and summarizes 10 important points concerning the surgical treatment of ischemic dilated cardiomyopathy that may provide guidelines for the future. These data indicate EVCPP, and its variations, form the central theme in surgical treatment of congestive heart failure.

Objectives: In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation. Methods: Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation. Results: Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. Conclusions: Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively. (J Thorac Cardiovasc Surg 2001;121:91-6)

h doi:10.1016/j.jtcvs.2006.08.088 recent article from O’Neill and coworkers published in the Journal in November 2005 reports that after left ventricular reconstruction (LVR) for ischemic cardiomyopathy, either akinetic or dyskinetic, patients might emain at risk for malignant ventricular arrhythmias and hence might benefit from prophylactic implantable cardioverter defibrillator (ICD). There are no clear uidelines regarding the necessity of early ICD implantation in patients undergoing VR because the most important trials addressing this issue excluded patients ithin 3 months (Madit II) after coronary artery bypass grafting surgery. The authors report a high residual incidence of inducible ventricular tachycardia VT) after surgical intervention (42%), and they conclude that either early ICD mplantation or predischarge electrophysiologic (EP) study for risk stratification is ndicated in patients submitted to LVR for ischemic dilated cardiomyopathy. Major limitations of that study are that (1) ventricular volumes are not measured efore and after, and (2) the EP study is performed only after surgical intervention, nd this negates the possibility of evaluating the effects of LVR on arrhythmias. The authors look at 217 patients who had LVR and divide them into 3 groups. roups 1 and 2 had an ICD implanted either before or after surgical intervention. hirty patients had ICDs in situ before the operation (group 1), and 74 patients had CD implantation after LVR (group 2); indications for postoperative ICD implanation were secondary prevention in 28 and primary prevention in 48 (positive EP tudy result). The authors then compare these 2 groups with another group of 116 atients who did not receive an ICD. Of these, 67 had EP studies (negative results n 65), and 46 did not undergo EP studies for some reason. Patients in group 1 are the sickest because they have the largest volumes, more requent need of concomitant mitral valve surgery, and the lowest proportion of oncomitant revascularization. Group 1 had the highest rate of events (progressive eart failure was the most frequent cause of death). Overall, the incidence of sudden eath was extremely low, with only 1 sudden death of 20 deaths, which occurred in patient who had ICD implantation before the operation. They compare mortality n the 3 groups and show that annualized mortality is significantly lower in groups (with an ICD implanted for primary or secondary prevention) and 3 (without CDs) with respect to group 1 (ICDs implanted before the operation). These groups re not comparable preoperatively, and we can presume that they are not comparable lso after surgical intervention, but the authors do not provide postoperative data. e know that 15 patients with ICDs, 6 in group 1 (20%) and 9 in group 2 (12%), ad appropriate ICD therapies, which saved their lives, according to the O’Neill nterpretation. Independent predictors of ICD firings were preoperative volumes and jection fraction (EF), and we can hypothesize that patients who received ICD herapy and those who had positive EP study results early after surgical intervention id not have an improvement in volumes and EF after LVR. Ventricular volume before and after surgical intervention is crucial for arrhythia development based on the following considerations. A large ventricular volume rings high wall stress and high stretch, and stretch is arrhythmogenic. In previous rticles we have clearly demonstrated that patients with ventricular arrhythmias spontaneous or inducible) have end-diastolic and end-systolic volumes significantly arger than those seen in noninducible patients and that patients who die at follow-up ave the largest ventricular volumes. The antiarrhythmic effect of LVR has been

Surgical ventricular restoration (SVR) is an emerging technique aiming to restore left ventricular geometry and function in dilated ischemic cardiomyopathy. It applies not only to the classic aneurysm (Type 1) but also to the true ischemic dilated cardiomyopathy (Type 3) and to the intermediate type (Type 2). This type classification based on systolic morphology allows patient selection. SVR is performed under total cardiac arrest with antegrade crystalloid cardioplegia, following complete coronary revascularization, almost always on the left anterior descending artery and mitral repair through ventriculotomy, when needed. Results on more than 1000 patients show that SVR is safe and effective in improving pump function, clinical status and survival in patients with post-infarction ischemic cardiomyopathy.

Analyzing 16 recent (1993 to 1997) references devoted to left ventricular aneurysm or wall motion abnormality after myocardial infarct, it appears that 1) cardiologists are on their way to detecting earlier the bad evolution of left ventricular geometry after myocardial infarct, 2) a great number of cardiac surgeons are using the technique of left ventricular reconstruction with circular reorganization of the left ventricular cavity, very often by endoventricular patch; and 3) this advance leads to a modification in the indications for surgery for left ventricular aneurysms or akinesia, either to prevent progressive dilatation, or to improve some apparently hopeless old and large akinesias.

Objectives. This retrospective study attempted to relate surgical outcome with the extent and type of preoperative wall motion asynergy in patients with postinfarction myocardial scar who underwent endoventricular circular patch plasty repair and associated coronary grafting. Background. Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic scar, and previous studies have reported that the absence of paradoxic systolic motion correlates with higher operative mortality and no improvement in pump function. Methods. Two hundred forty-five patients who underwent endoventricular circular patch plasty repair and associated coronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation. All had right and left cardiac catheterization. The centerline method was applied to preoperative right anterior oblique LV angiography to assess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening Results. The overall perioperative mortality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all the clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a higher perioperative mortality rate (12%) than patients with a small scar (2.2%). After the operation, the ejection fraction (EF) increased from 36 ± 13% to 50 ± 13% (mean ± SD), and pulmonary pressures significantly decreased. End-diastolic volume decreased from 199 ± 75 to 89 ± 36 ml/m2. Patients with a large akinetic scar had the most severely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressive improvement in function (EF from 25 ± 9% to 41 ± 12%), not different from that observed with large dyskinetic scarring (EF from 26 ± 7% to 46 ± 11%). Conclusions. Surgical outcome of endoventricular circular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence of dyskinesia. Patients with a large akinetic scar and severely depressed pump function benefit from a relatively simple surgical procedure previously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, and the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function. (J Am Coll Cardiol 1997;29:1569–75)

The present chapter addresses the management of ischemic heart failure (HF) patients after the release of the Surgical Treatment for Ischemic Heart Failure (STICH) trial results. The STICH trial is a multicenter, international, randomized, non-blinded trial that started in 2002.

Increased morbidity and mortality associated with ischemic heart failure (HF) in type 2 diabetic patients requires a deeper understanding of the underpinning pathogenetic mechanisms. Given the implication of microRNAs (miRNAs) in HF, we investigated their regulation and potential role. miRNA expression profiles were measured in left ventricle biopsies from 10 diabetic HF (D-HF) and 19 nondiabetic HF (ND-HF) patients affected by non–end stage dilated ischemic cardiomyopathy. The HF groups were compared with each other and with 16 matched nondiabetic, non-HF control subjects. A total of 17 miRNAs were modulated in D-HF and/or ND-HF patients when compared with control subjects. miR-216a, strongly increased in both D-HF and ND-HF patients, negatively correlated with left ventricular ejection fraction. Six miRNAs were differently expressed when comparing D-HF and ND-HF patients: miR-34b, miR-34c, miR-199b, miR-210, miR-650, and miR-223. Bioinformatic analysis of their modulated targets showed the enrichment of cardiac dysfunctions and HF categories. Moreover, the hypoxia-inducible factor pathway was activated in the noninfarcted, vital myocardium of D-HF compared with ND-HF patients, indicating a dysregulation of the hypoxia response mechanisms. Accordingly, miR-199a, miR-199b, and miR-210 were modulated by hypoxia and high glucose in cardiomyocytes and endothelial cells cultured in vitro. In conclusion, these findings show a dysregulation of miRNAs in HF, shedding light on the specific disease mechanisms differentiating diabetic patients.

Background Early postoperative data show that surgical ventricular reconstruction (SVR) induces reverse remodelling (RR) in dilated ischemic cardiomyopathy. The stability of these results at follow-up is debated. This retrospective study determined whether RR was stable at follow-up and the role, if any, of preoperative left ventricle volume and shape on SVR-induced changes. Methods The study group comprised 220 patients (age, 64 ± 9 years) with an echocardiography study at baseline, discharge, and at follow-up. RR was defined as a reduction of left ventricular end-systolic volume index (ESVI) at follow-up exceeding 15% vs baseline. Results Reverse remodelling occurred in 162 patients (74%); the ESVI at follow-up in the remaining 58 (26%) was equal to or greater than at baseline (no-RR). At baseline, the no-RR patients had lower volumes and higher ejection fraction; at the 1-week post-SVR evaluation, all patients reached significant ESV reduction, but at follow-up, the no-RR patients had dilated and showed significantly higher volumes and lower ejection fraction vs patients with RR. New York Heart Association class improved in both groups (2.6 ± 0.6 to 1.6 ± 0.5 and 2.5 ± 0.8 to 1.8 ± 0.7, respectively, p = 0.0001). Baseline ESVI less than 73 mL/m 2 , apical axis less than 4.35 cm, and conicity index less than 0.759 were predictors of no-RR. Conclusions A relatively small ESVI and a more physiologic apical shape (conical) are predictors of no-RR after SVR. Despite lack of RR, the ESV at follow-up is not severely enlarged, which explains the good survival rate in these patients.

Objectives To investigate the time-course of late gadolinium enhancement of infarcted myocardium using gadobenate dimeglumine at different dosages and administration regimens. Materials and methods After institutional review board approval and informed consent, we studied 13 patients (aged 63 ± 11 years) with chronic myocardial infarction. They underwent two gadobenate dimeglumine-enhanced MR examinations (interval 24–48 h) using short-axis inversion-recovery gradient-echo sequences, with the following two different protocols, in randomized order: 0.05 mmol/kg and imaging at the 2.5th, 5th, 7.5th and 10th minute plus 0.05 mmol/kg and imaging at the 12.5th, 15th, 17.5th and 20th minute; the same as before but using 0.1 mmol/kg for both contrast injections. Contrast-to-noise ratios (CNRs) between infarcted myocardium, non-infarcted myocardium and left ventricle cavity were calculated for each time-point (2.5-min steps). Friedman ANOVA was used for comparing the CNR time-course; Wilcoxon test for comparing CNR at the 10th and the 20th minute. Results The CNR between infarcted and non-infarcted myocardium obtained at the 20th minute with 0.05 plus 0.05 mmol/kg resulted significantly higher than that obtained at the 10th minute with 0.05 mmol/kg ( P = 0.033) while not significantly different from that obtained at the 10th (0.1 mm/kg) or at the 20th minute with 0.1 plus 0.1 mmol/kg. The CNR between infarcted myocardium and the left ventricle cavity obtained at the 20th minute with 0.05 plus 0.05 mmol/kg resulted significantly higher than all other measured values ( P ≤ 0.017). Conclusion Using gadobenate dimeglumine, 0.05 plus 0.05 mmol/kg allows for a higher CNR between infarcted myocardium and the left ventricle cavity allowing for reliable assessment of the sub-endocardial infarctions.

The aim of this study is to compare outcomes of patients undergoing surgical ventricular reconstruction (SVR) with normothermic cardiopulmonary bypass (CPB) and beating heart or hypothermic CPB and cardioplegic arrest. Between 2001 and 2008, 588 patients underwent SVR. A propensity score matching was performed and 91 matched pairs were created: group 1 (G1) operated with normothermic CPB and beating-heart technique, and group 2 (G2) operated with hypothermic CPB and cardioplegic arrest. Mean age was 62+/-9 years in G1 and 63+/-10 years in G2 [not significant (NS)]. Average follow-up was 42.7+/-26 months (range 1-72). Major cardiac and cerebro-vascular events (MACCE) were assessed. Thirty-day mortality was 4% in G1 and 5% in G2 (NS). Kaplan-Meier survival at six years was 79+/-4% and 72+/-9% (NS) and freedom from MACCE was 82+/-4% and 83+/-7% in G1 and G2, respectively (NS). Left ventricular volume reduction, ejection fraction and New York Heart Association (NYHA) class improvement were significant in the overall population; no significant differences were found between groups. The following independent risk factors for cardiac death were identified: mitral valve regurgitation, surgery

N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels have been shown to be increased at baseline in patients undergoing surgical ventricular restoration (SVR) of the left ventricle. However, changes in the values of this marker in the early postoperative period and its prognostic significance remain less known in these patients. We evaluated 31 consecutive patients undergoing SVR who had NT-pro-BNP determined a day before SVR and from postoperative days 0 to 4. Major morbidity was defined asor =1 of the following: ventilation48 hours, stroke, acute renal failure, low cardiac output, reoperation, or mediastinitis. The association of preoperative NT-pro-BNP with perioperative outcomes was assessed using multivariable logistic regression analysis. Receiver operating characteristic curve was used to test its discrimination power. Major morbidity occurred in 16 patients (52%) with only 1 death within 30 days of SVR. Mean preoperative NT-pro-BNP was 4.5-fold higher in patients with postoperative major morbidity than in those without it (3,022 +/- 2,981 vs 676 +/- 533 pg/ml, p = 0.007). On multivariate analysis, preoperative NT-pro-BNP was independently associated with major morbidity after adjusting for baseline confounding, particularly age, ejection fraction, and European System for Cardiac Operative Risk Evaluation (odds ratio 1.002, 95% confidence interval 1.001 to 1.003, p = 0.032). Preoperative NT-pro-BNP had a high discrimination power on receiver operating characteristic analysis for major morbidity (area under the curve 0.84, sensitivity 68%, and specificity 88% for 1,304 pg/ml). Although NT-pro-BNP levels decreased after SVR in patients without major morbidity, their levels remained persistently increased in those with it. In conclusion, preoperative NT-pro-BNP determination may be of value in stratifying the risk for major morbidity after SVR.

The effects on left ventricular function of postextrasystolic potentiation and the dihydropyridinic calcium antagonist diperdipine, alone or in combination, were studied in 14 patients with coronary heart disease by means of two consecutive left ventricular angiographies. To ensure the reproducibility of coupling intervals of the extrasystolic and postextrasystolic beats, the heart was paced during both angiographies. Results showed that postextrasystolic potentiation and diperdipine improved left ventricular ejection fraction to the same degree, but the mechanisms of such an improvement were different and consisted, respectively, of a positive inotropic effect associated with an increase in preload and a slight increase in preload coupled with a marked decrease in afterload. Diperdipine did not abolish the inotropic component of postextrasystolic potentiation, and a combination of the two interventions had additive effects on the improvements in left ventricular ejection fraction and regional wall motion analyzed by the centerline method. Ventricular segments that were normokinetic or hypokinetic during the control basal cycle responded equally to postextrasystolic potentiation and to diperdipine, whereas the former intervention alone had no significant effect on akinetic segments. Diperdipine restored the responsiveness of akinetic segments to postextrasystolic potentiation, a finding that, although it remains to be confirmed by independent techniques, may be interpreted as a possible consequence of improved calcium metabolism or coronary flow in ischemic but still viable myocardium. However, it is concluded that the calcium antagonist revealed a contractile reserve in most of the severely asynergic areas, which would have otherwise been judged to be irreversibly damaged on the basis of the unresponsiveness to postextrasystolic potentiation alone.

ObjectiveLeft ventricular end-diastolic volume is decreased and ejection fraction is increased after surgical ventricular reconstruction; however, the impact on left ventricular stroke volume is not well established.MethodsWe analyzed 248 consecutive patients who underwent surgical ventricular reconstruction at a single center. There were 14 perioperative deaths (5.6%). The 234 surviving patients had pre- and postsurgical ventricular reconstruction echocardiographic measurement of end-diastolic volume, end-systolic volume, and stroke volume, each indexed to body size and ejection fraction. A total of 120 patients had echocardiography data at follow-up (median 8 months).ResultsOverall, surgical ventricular reconstruction resulted in reductions in end-diastolic volume index (–30% ± 18%) and end-systolic volume index (–37% ± 20%), and increases in ejection fraction (21% ± 18% relative increase). However, stroke volume index decreased from 35 ± 8 mL/m2 preoperatively to 28 ± 7 mL/m2 early postoperatively (a 17% ± 24% relative reduction, P

Background This study aimed to identify the impact of diabetes mellitus and related comorbidities on long-term survival of heart failure patients who had undergone surgical ventricular restoration. Surgical ventricular restoration is an optional therapeutic strategy for patients with ischemic dilated cardiomyopathy. Reported prognostic predictors for late morbidity and mortality are predominantly related to cardiac conditions, whereas the prognostic impact of comorbidities still needs to be defined. Methods A total of 329 patients (234 nondiabetic and 95 diabetic) who survived the surgical ventricular restoration operation were admitted to this study. Cardiac mortality follow-up data were collected. Actuarial survival curves were calculated for the two groups; differences between groups and the impact of other comorbidities were established using a log-rank test and a Cox regression analysis. Results The mean follow-up time was 44 months. Diabetic patients had a significantly worse survival rate: at 5 years, their survival rate was 81%, versus 89% for nondiabetic patients (p = 0.019). Other comorbidities significantly associated with the survival rate were chronic renal failure, New York Heart Association class, and liver dysfunction. Diabetic patients without comorbidities had a survival rate similar to that of nondiabetic patients. Diabetic patients with at least one comorbidity had a significantly worse outcome. Diabetic patients with chronic renal failure had a 5-year survival rate of 40%, versus 85% for nondiabetic patients (p = 0.002). Conclusions Noncomplicated diabetes has no negative impact on long-term survival after surgical ventricular restoration. Conversely, complicated diabetes, namely the presence of chronic renal failure, carries a long-term cardiac mortality risk that is four times higher than the risk for nondiabetic patients.

Background Myocardial infarction can result in a spectrum of left ventricular (LV) shape abnormalities. Surgical ventricular restoration (SVR) can be applied to any, but there are no data that relate its effectiveness to LV shape. Moreover, there is no consensus on the benefit of SVR in patients with a markedly dilated ventricle, without clear demarcation between scarred and normal tissue. This study describes postmyocardial infarction shape abnormalities and cardiac function, clinical status, and survival in patients undergoing SVR. Methods Echo studies of 178 patients were retrospectively reviewed. Three types of LV shape abnormalities were identified: type 1 (true aneurysm), type 2 (nonaneurysmal lesions defined as intermediate cardiomyopathy), and type 3 (ischemic dilated cardiomyopathy). Results SVR induced significant improvement in cardiac and clinical status in all patients, regardless LV shape types. Although not significant, mortality was higher in types 2 and 3. Conclusions Ischemic dilated cardiomyopathy and not just the true aneurysm can be successfully treated with SVR. Shape classification may be useful to improve patient selection and compare results from different institutions that are otherwise impossible to compare.

Background. Limited data are available on left ventricle (LV) diastolic function in patients with ischemic dilated cardiomyopathy submitted to surgical ventricular restoration (SVR). The purpose of this study was to assess postoperative diastolic function changes and identify potential predictors of its worsening. Methods. One hundred and forty-six patients (65 9 years) with previous anterior myocardial infarction were evaluated before and after SVR. Hemodynamic and geometric parameters including the sphericity index and conicity index were measured. Diastolic function was explored using the transmitral flow velocity pattern, and four classes were defined: normal, abnormal relaxation, pseudonormal, and restrictive pattern. Diastolic function was defined as unchanged (no difference in diastolic pattern), improved (at least one class less), or worsened (at least one class more or, in the case of preoperative restrictive pattern, an early transmitral flow velocity to atrial flow velocity [E/A] ratio increase of at least 20%). Results. The filling pattern before SVR was normal in 7 patients (4.8%), abnormal relaxation in 99 (68%), pseudonormal in 28 (19%), and restrictive in 12 (8.2%). After SVR, the filling pattern was unchanged in 105 patients (72%), improved in 14 (9.6%), and worsened in 27 (18.4%). Based on the univariate analysis, the preoperative conicity index and the end-diastolic volume difference (the result of surgical volume reduction) were associated with a diastolic pattern worsening. Conclusions. Diastolic function did not change or improve in the majority of patients. In the minority of patients who experienced worsening, this was associated with the preoperative LV shape and residual volume. (Ann Thorac Surg 2008;86:1849‐55) © 2008 by The Society of Thoracic Surgeons

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

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

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

Background This study analyzed morbidity, mortality, and quality of life after aortic valve replacement with mechanical and biologic prostheses in octogenarian patients. Methods A retrospective analysis was performed in 345 consecutive patients, mean age of 82 ± 2 years (range, 80 to 92), who had aortic valve replacement from May 1991 to April 2005. A bioprosthesis (group I) was used in 200 patients (58%), and 145 (42%) received a mechanical prosthesis (group II). Associated cardiac procedures were done in 211 patients (61%), of which 71% were coronary artery bypass grafting. Patients had symptomatic aortic stenosis (84.3%) or associated aortic insufficiency; 88% were in New York Heart Association (NYHA) class III or IV. The mean preoperative aortic valve gradient was 62 ± 16 mm Hg (range, 25 to 122 mm Hg). The mean left ventricular ejection fraction was good (0.52 ± 0.12); 30 patients (8.7%) had an ejection fraction of less than 0.30. Results The in-hospital mortality rate was 7.5% (26 patients); 17 (8.5%) in group I and 9 (6.2%) in group II ( p = 0.536) Significant predictors of operative mortality were preoperative renal insufficiency (blood creatinine > 2.00 mg/mL) and need for urgent operation. Mean follow-up, complete at 100%, was 40 ± 33 months (range, 1 to 176 months). Long-term follow-up, using Kaplan-Meier analysis, showed an overall survival of 61% at 5 years and 21% at 10 years; survival by type of prosthesis was significantly higher with mechanical prostheses (log-rank p = 0.03). Freedom from cerebrovascular events (thromboembolic/hemorrhagic) at 5 and 10 years was 89% and 62% in the mechanical group and 92% and 77% in the biologic group ( p = 0.76). Postoperative NYHA functional class was I or II in 96% of patients. Quality-of-life scores were excellent considering the age of the patients. No differences were found between the two groups. Conclusions Surgical treatment for symptomatic aortic stenosis in octogenarians has an acceptable operative risk with excellent long-term results and good quality of life. In this cohort, survival rate is slightly but significantly higher with mechanical prostheses.

Post-infarction ischemic cardiomyopathy is the most frequent cause of clinical heart failure in the western society. Despite aggressive early revascularization, myocardial infarction leaves shape and function abnormalities in a consistent number of patients with increased risk of death and ischemic events. Alternative treatment strategies are therefore advisable in these high-risk patients. Surgical ventricular restoration (SVR) is a safe and effective surgical option for post-infarction ischemic cardiomyopathy resulting in improvement of pump function, functional class and survival. Observational data now need to be confirmed by randomized data and the multicenter international randomized surgical treatment of ischemic heart failure (STICH) trial will definitely assess if SVR adds benefit to coronary bypass alone in patients with left ventricular dysfunction and dilated ventricle.

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

We report the case of a 41-year-old woman with severe mitral regurgitation due to infective endocarditis caused by a rare zoonotic microorganism (Capnocytophaga canimorsus). She had had a rheumatic mitral endocarditis successfully treated with antibiotics when she was 13 years old. She arrived to our attention for a fever of unknown origin. She had been bitten by her dog and medicated the wound herself. About 2 weeks later she developed a fever with values up to 39.5 degrees C. Blood cultures were initially negative but in view of her particular history (dog bite), the samples were sent to a specialized center where a Capnocytophaga canimorsus (a commensal bacterium contained in the saliva of dogs and cats) infection sensitive to ceftriaxone was detected. The antibiotic therapy was consequently modified and the patient's fever resolved. At echocardiography a mild mitral stenosis with severe regurgitation (3-4+/4+) was detected. We planned surgical mitral repair but the operative findings clearly showed the need for mitral replacement and a 29 mm size bileaflet mechanical prosthesis was implanted. The postoperative course was regular and the patient was discharged on the fifth day. We highlight the importance of a careful history and correct work-up for the diagnosis and treatment of false negative blood culture endocarditis.

We describe the cases of 2 infants aged 6 and 2 1/2 months, respectively, affected by mitral valve dysplasia that caused severe valvular insufficiency and heart failure in which a surgical correction was indicated because of critical general conditions. In both patients the anatomic characteristics of the valves were not suitable for repair, and an implant of a mechanical prosthesis was excluded because of the very young age of the infants and the impossibility of maintaining an adequate anticoagulant therapy. Therefore a Ross-Kabbani intervention was performed with an implant of a pulmonary autograft (in the mitral position) and an insertion of a pulmonary homograft. The postoperative course was free of major complications and good function of the autograft was present at short-term follow-up in both cases.

Defective baroreflex function has been suggested as a potential mechanism accounting for the development of syncopal episodes. The present study was therefore aimed at assessing the non-invasive, indirect hemodynamic profile and baroreflex function by means of tilting, which is a natural stimulation crucial to physiological baroreflex activity, in syncopal patients and healthy controls.Seventeen consecutive patients with a positive response to head-up tilting and fourteen healthy subjects as controls underwent continuous and non-invasive beat-to-beat heart rate and arterial pressure measurements in order to evaluate systolic, diastolic, and dicrotic pressures, as well as heart rate. Baroreflex function was calculated as the slope of the linear regression line relating systolic arterial pressure to RR interval changes during upward and downward phases of tilting, respectively.When compared to healthy subjects, vasodepressive patients showed a significantly weaker correlation between systolic pressure and RR interval changes both in upward tilting, (r = 0.68 vs r = 0.91, p0.05) and downward tilting (r = 0.48 vs r = 0.93, p0.01).Our results show that an impairment in baroreflex-mediated adjustment to postural challenge can be detected in syncopal patients also during upward tilting, that is, in the early phase of the test. Moreover, our investigation emphases the utility of a noninvasive, complete hemodynamic evaluation of the early phase of tilting in order to detect peculiar behaviours of pulse wave contour and related parameters.

The aim of this study was to assess whether a non-invasive automatic evaluation of the pulse wave characteristics could provide clinical clues when monitoring the hemodynamic adjustments to head-up tilting.A continuous assessment of the peripheral pulse wave characteristics (systolic, diastolic, dicrotic and pulse pressures) in 8 control subjects with a negative response to head-up tilting (60 degrees for 45 min) compared to 13 syncopal patients with a vasodepressive one was performed.Controls exhibited, when up-tilted, an increase in blood pressure as well as in the dicrotic and pulse pressures and no changes in heart rate. On the contrary, syncopal patients showed a progressive increase in heart rate associated with a progressive decrease in dicrotic pressure and a trend towards lower values of pulse pressure, but no changes in systolic pressure. Thereafter and until the pre-syncopal symptoms supervened, the systolic, diastolic and dicrotic pressures progressively declined. A decrease in dicrotic pressure mainly characterized the early vasodepressive response while its increase identified the negative one.Our data, even though preliminary, strongly suggest that automatic hemodynamic evaluation is to be used in the clinical setting as a monitor of the sudden changes in blood pressure induced by head-up tilting. Furthermore, the dicrotic and pulse pressures, even those measured during the early phases of the test, should be considered as non-invasive parameters characterizing the vasodepressive response to head-up tilting.

Anterior infarction changes ventricular shape and volume. Akinesia is most commonly observed after early reperfusion. Dyskinesia develops in the absence of reperfusion. Both produce heart failure by dysfunction of the remote muscle. Traditional surgery deals with dyskinesia. This study evaluates surgical anterior ventricular endocardial restoration (SAVER), an operation that excludes the apical and septal scar in both akinesia and dyskinesia. A new international group of cardiologists and surgeons from 13 centers, the RESTORE Group) investigated SAVER in ischemic cardiomyopathy following anterior infarction. From January 1998 to July 2000, 662 patients underwent surgery. Early and 3-year outcomes were investigated. Concomitant procedures included coronary artery bypass grafting (CABG) in 92%, mitral repair in 22%, and mitral replacement in 3%. Hospital mortality was 7.7%. Mortality among 606 patients with SAVER and CABG alone was 4.9%. It was 8.1% among 147 patients who underwent concomitant mitral valve repair. Few patients required IABPs (8.4%), LVADs (0.4%), or ECMO (0.6%). Postoperatively, ejection fraction increased from 29.7% +/- 11.3% to 40.0% +/- 12.3% and left ventricular end systolic volume decreased from 96 +/- 63 to 62 +/- 39 mL/m(2) (P. 05). At 3 years, the survival rate was 89.4% +/- 1.3%. Survival was lower among those with preoperative volume80 mL/m(2) compared with volumeor = 80 mL/m(2) (83.5% +/- 3.3% v 94.5% +/- 2.0%). Freedom from readmission to hospital for heart failure was at 88.7% at 3 years and was not related to preoperative volume. SAVER is a safe and effective procedure for treating the remodeled dilated anterior ventricle following anterior myocardial infarction.