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Partial left ventriculectomy: which patients can be expected to benefit?
O H Frazier1, S Gradinac, A M Segura
1Department of Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston 77225-0345, USA. mmallia@heart.thi.tmc.edu
Insights
Patients with idiopathic cardiomyopathy and severe heart failure may benefit from partial left ventriculectomy. Increased myocyte hypertrophy and fibrosis were associated with poorer outcomes in Texas Heart Institute patients, suggesting potential criteria for patient selection.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pathology
Background:
- Partial left ventriculectomy (PLV) is a surgical option for end-stage heart disease, but preoperative criteria for patient selection are lacking.
- A comparative study between two institutions revealed differences in PLV outcomes, with higher survival and better myocardial function observed in Yugoslavian patients.
Purpose of the Study:
- To identify preoperative criteria for selecting patients who would benefit from partial left ventriculectomy (PLV).
- To investigate the correlation between myocardial histology and clinical outcomes after PLV.
Main Methods:
- A retrospective review of 42 patients (21 per center) with idiopathic cardiomyopathy undergoing PLV.
- Analysis of preoperative data, including left ventricular dimensions and New York Heart Association (NYHA) functional class.
- Histopathological examination of myocardial tissue, including myocyte hypertrophy, vacuolation, fibrosis, and morphometry.
Main Results:
- No immediate postoperative differences in cardiac dimension reduction or mitral regurgitation correction between the two groups.
- Six-month follow-up revealed significantly lower cardiac index and ejection fraction in Texas Heart Institute patients compared to Dedinje Cardiovascular Institute patients.
- Texas Heart Institute patients exhibited significantly higher degrees of myocyte hypertrophy, fibrosis, myocyte diameter, and nuclear size.
Conclusions:
- Increased myocyte hypertrophy and fibrosis in Texas Heart Institute patients may be linked to poorer clinical outcomes after PLV.
- These histological findings suggest potential criteria for selecting suitable candidates for partial left ventriculectomy.
- Further research is warranted to validate these criteria for improved patient selection in PLV procedures.
Background:
Although some patients with end-stage heart disease will benefit from a partial left ventriculectomy, no criteria have been found for identifying this group preoperatively. Our experience with partial left ventriculectomy at two institutions-the Texas Heart Institute in Houston, TX, USA, and Dedinje Cardiovascular Institute in Belgrade, Yugoslavia-showed a higher survival rate and better postoperative myocardial function in the Yugoslavian patients.
Methods:
We reviewed data from 42 patients (21 at each center) who had idiopathic cardiomyopathy, a left ventricular end-diastolic dimension of more than 70 mm, wall thickness of 1 cm or greater, and New York Heart Association class III or IV symptoms. The only significant difference in preoperative status between the two groups was duration of symptoms. Histologic specimens, blinded as to origin, were graded with regard to myocyte hypertrophy, cytoplasmic vacuolation, and fibrosis. Computer-assisted myocyte and nuclear morphometry was also performed.
Results:
Immediately postoperatively, there were no significant intergroup differences in the reduction in cardiac dimension or in corrections of mitral regurgitation. During 6-month follow-up, however, the Texas Heart Institute patients had a lower cardiac index (1.8 versus 3.0 L x min(-1) x m(-2); p = 0.001) and left ventricular ejection fraction (24% versus 34%; p = 0.006) than the Dedinje Cardiovascular Institute patients. The Texas Heart Institute patients differed from the Dedinje Cardiovascular Institute patients in the degree of severe or moderate changes in myocyte hypertrophy (90% versus 29%; p = 0.0003) and fibrosis (71% versus 29%; p = 0.006), as well as in the measurements of median myocyte diameter (35 +/- 7 microm versus 27 +/- 4 microm; p = 0.0002) and median nuclear size (15 +/- 4 microm versus 12 +/- 2 microm; p = 0.0029).
Conclusions:
In the Texas Heart Institute patients, the significant intergroup difference in clinical outcome may have been related to increased myocyte hypertrophy and fibrosis. Further studies should be performed to determine the usefulness of these criteria in selecting patients for partial left ventriculectomy.
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