A new concept of ventricular restoration for nonischemic dilated cardiomyopathy

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.

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.

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.

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).