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Left ventricular reduction for idiopathic dilated cardiomyopathy as alternative to transplant--truth or dare?
T Doenst1, L Ahn-Veelken, C Schlensak
1Department of Cardiovascular Surgery, University of Freiburg, Freiburg i. Br., Germany. doenst@ch11.ukl.uni-freiburg.de
Insights
Left ventricular reduction surgery offers immediate cardiac function improvement in dilated cardiomyopathy (DCM) patients. However, long-term benefits remain uncertain, making it an option only for those unsuitable for heart transplantation.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- The efficacy of left ventricular reduction surgery for advanced heart failure, specifically idiopathic dilated cardiomyopathy (DCM), remains debated due to conflicting clinical data.
- While surgery aims to reduce wall tension, the underlying causes of dilation and contractile dysfunction in DCM may limit its long-term benefits.
- The natural progression of dilated cardiomyopathy can potentially overshadow the advantages gained from surgical interventions.
Purpose of the Study:
- To evaluate the outcomes of a modified Dor's endoventricular patch plasty for restoring physiological geometry in patients with dilated cardiomyopathy.
- To assess the immediate and long-term effects of left ventricular reduction surgery on cardiac function in DCM patients.
Main Methods:
- A series of five patients with dilated cardiomyopathy underwent left ventricular reduction surgery using a modified endoventricular patch plasty.
- Cardiac function was assessed immediately post-operation and monitored during follow-up periods up to 18 months.
Main Results:
- All five patients experienced immediate improvement in cardiac function following the procedure.
- One patient maintained improved function at 18 months, while another required heart transplantation due to ventricular arrhythmias.
- Two patients experienced recurrence of left ventricular dilation and were listed for transplantation; one patient died from sepsis.
Conclusions:
- The modified endoventricular patch plasty is generally well-tolerated in DCM patients, providing initial contractile function improvement.
- The long-term efficacy of this surgical technique for dilated cardiomyopathy is uncertain, and it is not currently a substitute for heart transplantation.
- This procedure may be a viable option for select DCM patients who have contraindications for heart transplantation.
Background:
Although the concept of reducing wall tension a treatment for advanced heart failure is convincing, clinical data from the Batista operation are conflicting. Despite a number of publications, it is not clear whether left ventricular reduction surgery truly benefits patients with idiopathic, dilated cardiomyopathy (DCM). Surgery may reduce wall tension, but the reason for dilation and contractile dysfunction remains. Thus, the potential benefit of the operation may be overshadowed by the natural course of the underlying disease.
Cases:
We report a series of five cases where left ventricular reduction was performed and physiological geometry was restored in patients with DCM by a modification of Dor's endoventricular patch plasty. All patients demonstrated an improvement in cardiac function immediately after the operation. This improvement was sustained in one of the patients after 18 months of follow-up. Another patient developed severe heart failure due to therapy-resistant ventricular arrhythmia (Lown IV b), and underwent successful transplantation 4 months after ventricular reduction surgery. Left ventricular dilation reoccurred in two patients 9 and 12 months after reduction surgery, and they were listed for transplant. One patient died after 9 weeks due to sepsis and respiratory dysfunction.
Conclusions:
Although the endoventricular patch plasty, as used in this study, is well tolerated by most patients with dilated cardiomyopathy, and results in immediate improvement of contractile function, the long-term benefits of this technique for DCM are uncertain. Thus, the technique is currently not an alternative for heart transplantation. However, the procedure may be an option in patients with contraindications for transplantation.