Volume reduction surgery for end-stage heart failure: experience in Korea

Partial left ventriculectomy (PLV) is regarded as one of the alternatives to heart transplantation for idiopathic dilated cardiomyopathy (d-CMP). Between June 1996 and March 2000, 20 patients underwent left ventricular volume reduction surgery at five major cardiac centers in Korea. PLV was performed in 16 patients with d-CMP and in 1 patient with ischemic CMP. The modified Dor procedure was performed in three patients; two patients with d-CMP and one patient with ischemic CMP. Median age was 35 years (range 3-64 years). There were 13 male and 7 female patients; there were 4 patients in Class III and 16 patients in Class IV. Among the 16 patients in Class IV, 5 patients were inotropic dependent, 2 patients were resuscitated from cardiac arrest or shock in hospital, and 1 patient was treated with intra-aortic balloon pumping. Operative technique for PLV was the same as described by Batista and colleagues. For the modified Dor procedures, the apical left ventricle was opened and a circumferential pursestring suture was placed at the base of both papillary muscles to reduce the diameter of the left ventricle concomitant with mitral annuloplasty. Mitral valve repair was performed in 15 patients and mitral valve replacement was performed in 1 patient. Moderate-to-severe tricuspid regurgitation was noted in 12 patients (with tricuspid annuloplasty in 11 of these patients and replacement in 1 patient). Postoperatively, there were seven operative deaths after PLV and one death after the modified Dor procedure. Cause of death after PLV was right heart failure in four of the seven cases, sepsis in one case, and ventricular tachyarrhythmia in the remaining two cases. After the modified Dor procedure, there was one operative death with left ventricular failure. Postoperatively, mean ventricular end-diastolic dimension markedly decreased from 75.3 mm to 50.9 mm. However, this dimension had increased slightly to 58.2 mm, an average observed 22 months later. Mean left ventricular ejection fraction (LVEF) improved significantly from 20.6% to 33.5% (p < 0.0001), but decreased to 28.5% on average 22 months later (p = 0.058). Eleven patients were discharged from the hospital and followed-up for a mean of 20.2 months (range 1-41 months). During the early postoperative period, most were in good condition. However, heart failure progressed with mitral regurgitation in four patients, two of whom underwent heart transplantation. In conclusion, PLV for d-CMP seems to be an effective alternative surgical procedure to heart transplantation in Korea. The modified Dor procedure may be another alternative to transplantation for left ventricular volume reduction. However, in patients showing progression of heart failure, early intervention with ventricular assist or heart transplantation will be necessary. Also, further studies will be necessary for selection criteria and for prevention of ventricular tachyarrhythmia.