Dynamic aortomyoplasty: clinical experience and thoracoscopic surgery feasibility study

Surgical procedures using the latissimus dorsi (LD) muscle to assist chronic heart failure inflict major trauma on severely sick patients. A less invasive approach may prove beneficial. The aim of this article is to review our clinical and experimental approaches of dynamic aortomyoplasty (AMP) and emphasize the necessity to reorient surgical technique towards new directions and a less invasive thoracoscopic approach.

A clinical pilot study on dynamic descending AMP started in June 1995 and included four patients. Two of them could benefit from LD counterpulsation, surviving 6 months and 18 months. Following this clinical experience, we investigated, on an animal model, minimally invasive thoracoscopic surgery for this procedure. Twelve goats underwent endoscopic LD harvest and video-assisted aortic wrap, and were studied after surgical recovery from an anatomical and functional standpoint.

Clinical AMP using open techniques provided extraaortic counterpulsation in NYHA Class IV patients contraindicated for other surgical therapies. However, surgical technique and strategy needed improvements for optimal cardiac assistance and better patient outcome. Minimally invasive thoracoscopic surgery was feasible and reproducible in goats, achieving improved anatomy and physiology as compared to the open technique in humans. When appropriate the wrapping technique and stimulation protocol were used, an optimal counterpulsation was demonstrated. We concluded that thoracoscopic AMP may provide a minimally invasive approach to cardiac assistance and thus, a new surgical option for patients presenting with chronic heart failure.