Skip Navigation

European Journal of Heart Failure 1999 1(4):313-317; doi:10.1016/S1388-9842(99)00056-2
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (6)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Starling, R. C.
Right arrow Articles by McCarthy, P. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Starling, R. C.
Right arrow Articles by McCarthy, P. M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© 1999 European Society of Cardiology

Partial left ventriculectomy: sunrise or sunset?

Randall C. Starling* and Patrick M. McCarthy

Departments of Cardiology and Cardiothoracic Surgery, Kaufman Center for Heart Failure, Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, OH 44195, USA

* Corresponding author. Tel.: +1-216-444-2268; fax: +1-216-44-7155 E-mail address: starlir{at}ccf.org (R. C. Starling)


   Abstract
Top
 Abstract
1. Introduction
 2. Patient description, methods,...
 3. Other centers experience...
 4. Discussion and summary
 References
 
Partial left ventriculectomy (PLV) was proposed as an alternative to cardiac transplantation for patients with advanced heart failure. Patients with dilated cardiomyopathy that were considered eligible candidates for cardiac transplantation were offered the option of surgical ventriculectomy or to continue waiting for a donor organ. Sixty-two patients underwent PLV between May 1996 and December 1998, mean age 54 years, 47 males, mean ejection fraction 13.5%, mean peak oxygen consumption 10.8 ml/kg/min, 39% NYHA class III and 61% NYHA IV. Perioperative mortality 3.2%, 10/62 (16%) required implant of a left ventricular assist device (LVAD) due to shock, most in the early post-operative period. Survival at 1 and 2 years was 78% and 68%. Event free survival (freedom from death, LVAD, or return of NYHA class IV failure) was 50% and 37% at 1 and 2 years. Event free survivors experienced improvement in NYHA class (3.7 to 2.2) and increased oxygen consumption (11.7 to 16.0 ml/kg/min). Based on these data PLV has a significant early failure rate and a 2 year event free survival rate of only 37%. PLV does not yield outcomes equivalent to cardiac transplantation based on current selection criteria and requires further investigation to determine its role in the treatment of advanced heart failure.

Key Words: Cardiomyopathy • Congestive heart failure • Ventricular remodeling

Received July 13, 1999; Revised August 12, 1999; Accepted September 13, 1999


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patient description, methods,...
 3. Other centers experience...
 4. Discussion and summary
 References
 
It is well recognized that patients with severe ventricular dilatation from either ischemic or idiopathic cardiomyopathy have a poor prognosis [1,2]. Increased left ventricular chamber dimensions (LVEDD cm) and ventricular volumes (ESVI ml/m2) have been shown to have an adverse impact on survival [3,4]. Until recently patients with idiopathic dilated cardiomyopathy, refractory heart failure, and extreme ventricular dilatation were deemed inoperable, and were referred for cardiac transplantation. However, cardiac surgeon Randas Batista [5,6] from Brazil introduced the novel technique of ‘partial left ventriculectomy’ to remove part of the ventricular wall and restore the dilated ventricle to a near-normal size and shape. The concept was based on the Law of LaPlace, and Batista hypothesized a smaller ventricle should have reduced wall stress and be more efficient. Batista had operated upon hundreds of patients before the procedure became popularized through the media in the USA and abroad. However, his experience was largely unpublished, follow-up appeared incomplete, and clinicians visiting Brazil were unable to determine the patient selection criteria and post-operative outcomes. Therefore, at the Cleveland Clinic we prospectively sought to evaluate this operation for patients with advanced heart failure due to idiopathic dilated cardiomyopathy.


   2. Patient description, methods, and results
Top
 Abstract
 1. Introduction
 2. Patient description, methods,...
3. Other centers experience...
 4. Discussion and summary
 References
 
This report includes patients from May 1996 to December 1998 that underwent a partial left ventriculectomy. The results have been reported previously and the following summarizes our experience [7,8]. All but three of the 62 patients accepted for this operation were candidates for cardiac transplantation. Three patients were not transplant candidates because of older age and associated co-morbidities. The characteristics of the patient population are listed in Table 1. In general this was a very ill group of patients with several markers predictive of high mortality with conventional medical therapy. These include reduced peak oxygen consumption (mean 10.8 ml/kg/min), increased LV end-diastolic diameter (mean 8.17 cm), requirement for inotropic therapy (37% were hospitalized on intropes waiting for heart transplant), and abnormal neurohormones and cytokines (Table 2) compatible with advanced heart failure (elevated levels of norepinephrine, ANP and TNF).


View this table:
[in this window]
[in a new window]

  		Table 1 Patient characteristics (pre-operative)

 


View this table:
[in this window]
[in a new window]

  		Table 2 Pre-operative neurohormonal results mean±S.E.M.

 
Our group [7] has described the technique of partial left ventriculectomy with mitral valve repair. Briefly, the lateral left ventricle was removed between the two papillary muscles. In approximately half of the patients one or both papillary muscles had to be removed in order to extend the resection. The papillary muscles were then resuspended through the ventriculotomy The operation was combined with mitral valve repair using a posterior annuloplasty ring, and edge-to-edge approximation of the mitral valve (Alfieri repair). In our experience this repair is very effective and durable with few early or late inadequate results. Only two of 62 patients required mitral valve replacement when the valve could not be repaired.

There were two (3.2%) perioperative deaths, both during attempted LVAD bridge to transplantation and with death secondary to multiple organ failure. In total, 10 patients had implantable LVADs placed intraoperatively or in the early perioperative period because of progressive heart failure. One LVAD patient had improvement of cardiac function so that the device was explanted after 86 days (the patient is still alive 2 years later in Class III heart failure), and the other LVAD patients were all successfully transplanted and discharged. At a 12-month follow-up, peak oxygen consumption had improved from 11.7±4.1 ml/kg/min to 16.0±3.8 ml/kg/min, P<0.0001 in the survivors, subjective NYHA functional class had improved from 3.7 to 2.2. Survival at 1 and 2 years was 78% and 68%, respectively. However, freedom from failure for any reason (death, relisting for transplant, insertion of an LVAD, or return to Class IV heart failure) was 50% and 37% at 1 and 2 years, respectively. The causes of late death included four patients (24%) from sudden cardiac death, 12 patients (70%) from progressive heart failure and one patient (6%) from sequelae of a cerebrovascular accident.

In our earliest experience, by multivariant analysis, only young age was found to be a risk factor for failure [8]. In our more recent analysis, preoperative diastolic function (poor ventricular compliance) was included in the model, and was found to be a risk factor for failure [9].

Mathematical modeling and finite element analysis have predicted that following resection, the ventricle should show improved contractility but decreased diastolic function [10,11]. The net effect, however, would be a more efficient ventricle. Using derived single-beat pressure volume loops, these findings were confirmed in our patients with improved contractility, decreased compliance, and improved myocardial efficiency documented (manuscript in review).

In summary, these initial results were encouraging in that many patients with Class IV heart failure, some even inotrope-dependent, were able to be returned to functional class II and removed from the transplant list. However, the results of the surgery were very unpredictable in our early experience, and failures requiring LVAD implantation, or relisting for transplantation were unacceptably high compared to other conventional operations, including infarct exclusion, high risk bypass and valve operations. Several projects are ongoing to further investigate appropriate patient selection, and determinants of poor outcome. We have attempted to characterize the myocardium by using techniques including MRI, PET scanning with rubidium/FDG, and dobutamine echocardiography. Although we expect that myocardial histology may correlate with outcomes, endomyocardial biopsy provides a very limited perspective of global ventricular anatomy. Cardiac MRI may provide the best assessment of the quality of the myocardium (e.g. degree of fibrosis, viability) and correlate with surgical outcomes, but our data is inconclusive at this time.


   3. Other centers experience with partial left ventriculectomy
Top
 Abstract
 1. Introduction
 2. Patient description, methods,...
 3. Other centers experience...
4. Discussion and summary
 References
 
Results in other centers are mixed, but in general are poor and continue to evolve as the follow-up time has increased. One must be careful in comparing results from different centers. Many programs began with non-transplant candidates that have been described in the literature as almost exclusively NYHA class IV, found a high mortality (the patients that would have been re-listed for transplant or bridged to transplant at the Cleveland Clinic) and abandoned the procedure. Many centers that introduced this operation were non-transplant centers, with little experience in the care of end-stage cardiomyopathy patients. There have been different surgical approaches including mitral valve repair vs. replacement, papillary muscle transection and resuspension at some centers, and divergent opinions regarding the extent of myocardium that should be resected. In some instances partial left ventriculectomy was performed without concomitant mitral valve surgery. There was no consistent approach to the post-operative management including medical therapy and implantable defibrillators. The types of heart disease amongst reported series are very heterogeneous and include a mixture of dilated and ischemic cardiomyopathy, Chagas' disease, and valvular heart disease. There is little published information describing these poor results; it is evident in the decreased enthusiasm for the operation that many surgeons have abandoned the procedure from their repertoire.

In the combined series of 120 patients from Buffalo and Brazil (Batista) operative mortality was 22% and 1 year survival was 66% [12]. They reported that all patients were NYHA class IV before surgery and 90% of the survivors were NYHA class 1 or II after surgery. Eight patients in Brazil were studied intraoperatively by a team from the University of Pittsburgh with pressure area loops, and found to have reductions in LV volumes, increases in LV ejection fraction, and RV ejection (fractional area of change), but increase in LV stiffness [13]. Furthermore, these estimates of LV performance were variable, but associated with the semiquantitative degree of myocardial fibrosis observed histologically.

Other reports from Brazil [14–16] include the reports from the Sao Paulo Heart Institute. Their most recent report [16] includes 37 patients with dilated cardiomyopathy, with an operative mortality of 18.9% and actuarial survival of 56.7% at 6 and 24 months. For the survivors, functional class improved from 3.5±0.5 to 1.8±0.9 (P=0.001) and left ventricular ejection fraction increased from 17.1±4.6% to 23±80% (P<0.001). The only factor they found that influenced mid-term survival was significantly different mean diameter of left ventricular myocytes [16]. Angelini's series from England [17] reported 22.5% perioperative mortality, but only one late death of 14 patients. This group included both idiopathic and ischemic cardiomyopathy patients. Results from Yugoslavia [18,19] included 22 patients with three early deaths (13.6%) and four late deaths with 1-year survival of 68±10%. Ejection fraction increased from 23.9±6.8% to 40.7±12.5% (P<0.001) [18]. Further study showed a decrease in LV circumferential end-systolic and end-diastolic wall stresses (P=0.0014) [19]. Another important observation reported by these investigators was that the degree of mitral regurgitation preoperatively did not correlate with benefit. This addresses the hypothesis by some that mitral valve repair alone can provide the same result as partial left ventriculectomy with mitral valve repair. Investigators from Belgrade and Houston (Texas Heart Institute) have observed significant differences in clinical outcome related to degree of myocyte hypertrophy and fibrosis (Frazier, MD personal communication) in patients undergoing partial left ventriculectomy.

A report from Suma in Japan included 30 patients with non-ischemic cardiomyopathy, seven required emergency surgery due to shock and 23 cases were elective [20]. Two deaths of 23 patients (8.7%) who underwent elective operation, and three late deaths (13%) were observed. However, of patients undergoing emergency operations, six of seven patients (85.7%) died in hospital. All patients were weaned from cardiopulmonary bypass, IABP was used in six patients but no LVAD was used [20]. Mean ejection fraction increased from 18±6% to 31±5%. Since transplantation is very limited in Japan, these results for elective operations seem acceptable.


   4. Discussion and summary
Top
 Abstract
 1. Introduction
 2. Patient description, methods,...
 3. Other centers experience...
 4. Discussion and summary
References
 
Partial left ventriculectomy has been considered an investigational procedure since its introduction in the USA. Third party payers have demanded peer reviewed publications and results of randomized clinical trials before considering reimbursement. Medicare has categorized it as ‘investigational’ and has never provided reimbursement. In other parts of the world where technology is limited and cardiac transplantation is not available, partial left ventriculectomy has initially thrived because there were no other options. We have learned via systematic follow-up at the Cleveland Clinic that this procedure offers palliative treatment with improved clinical status, however, initial mortality and/or LVAD support if (when available) occurs in 15–20%, and heart failure progresses with time, after the procedure. Our low operative mortality was achieved only because 15% of the patients survived with LVAD support; without the availability of LVAD support our mortality would be similar to other centers results. Many enthusiastic, ambitious, often desperate clinicians embraced the procedure based on Dr Batista's lectures and very ill patients underwent operation. We now believe patients with advanced heart failure that are dependent on inotropes and mechanical support, are not candidates for this procedure. Data from a variety of sources suggests that histologic changes (myocyte hypertropy and fibrosis) may help to predict outcome. We do not know if random endomyocardial biopsies taken preoperatively will provide adequate histologic information to predict outcome. Newer techniques recently described using molecular techniques to quantify mRNA expression and subtypes of collagen may be useful [21]. We have also learned that arrhythmias are problematic after this procedure and we advocate the routine implantation of cardiac defibrillators [22]. This approach is not feasible in many countries. We believe that one of the keys to success is an excellent and durable mitral valve repair. Clearly, worse outcomes have been reported in patients with recurrent, significant mitral insufficiency. Partial left ventriculectomy should always be performed in conjunction with mitral valve repair and the ventriculectomy alone will disrupt the mitral valve apparatus and ultimately lead to mitral insufficiency. It is not known what is ‘ideal’ with respect to extent of tissue that should be resected and the final geometry of the left ventricle. We have tried without success to retrospectively validate predictive software programs designed to determine postoperative outcomes based on the extent of myocardial resection (e.g. SoftHeart®).

The future of partial left ventriculectomy as has been practiced seems dismal based on the dwindling percentage of patients with good outcomes as follow-up increases. We remain intrigued, however, by the group of patients with 2–3 years of follow-up and excellent clinical outcomes. Clearly these patients still have structural heart disease but their quality of life has significantly improved and they have avoided transplantation for the medium term. Many clinicians remain leery of the efficacy of partial left ventriculectomy as the published reports describe small single center studies and randomized prospective trials have not been performed [23]. The frustration is that we can not reliably predict outcomes preoperatively. As our understanding has improved, our case load has diminished as we cannot obtain reimbursement for the procedure. In the USA it is hard to justify and advise partial left ventriculectomy when one must quote a patient a 15% chance of upfront failure requiring LVAD support, and only a 30% event free survival at 3 years. Certainly, cardiac transplantation, where available, appears a better option. Without the advent of better predictive criteria for successful outcomes the procedure will likely be abandoned. This is unfortunate, as we have observed significant clinical benefit from partial left ventriculectomy in some patients.

Randas Batista has spawned renewed interest for therapeutic strategies that will decrease wall stress. Despite the disappointments with partial left ventriculectomy there is growing interest in other procedures that appear to have lower perioperative mortality and may engender long-term benefits by reducing wall stress and leading to beneficial remodeling. Mitral valve repair in dilated cardiomyopathy and endoventricular circular patch plasty (the Dor procedure) in post myocardial infarction are two examples [24–26]. Investigative techniques designed to reduce wall stress and ventricular chamber dimensions (e.g. struts and restraining wraps) are currently undergoing animal and phase I clinical trials. The lasting effect of partial left ventriculectomy may prove to be a step along the way.


   References
Top
 Abstract
 1. Introduction
 2. Patient description, methods,...
 3. Other centers experience...
 4. Discussion and summary
 References
 

  1. Koelling T.M., Semigran M.J., Mijller-Ehmsen J., et al. Left ventricular end-diastolic volume index, age, and maximum heart rate at peak exercise predict survival in patients referred for heart transplantation. J Heart Lung Transplant (1998) 17:278–287.[Web of Science][Medline]
  2. Dec G.W., Fuster V. Idiopathic dilated cardiomyopathy. N Eng J Med (1994) 331(23):1564–1575.[Free Full Text]
  3. Lee T.H., Hamilton M.A., Stevenson L.W., et al. Impact of left ventricular cavity size on survival in advanced heart failure. Am J Cardiol (1993) 72:672–676.[CrossRef][Web of Science][Medline]
  4. Migrino R.Q., Young J.B., Ellis S.G., et al. End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I Angiographic Investigators. Circulation (1997) 96(1):116–121.[Abstract/Free Full Text]
  5. Batista R.J.V., Santos J.L.V., Takeshita N., et al. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Cardiovasc Surg (1996) 11:96–97.
  6. Batista R.J.V., Nery P., Bocchino L., et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg (1997) 64:634–638.[Abstract/Free Full Text]
  7. McCarthy P.M., Starling R.C., Wong J., et al. Early results with partial left ventriculectomy. J Thorac Cardiovasc Surg (1997) 114:755–765.[Abstract/Free Full Text]
  8. McCarthy J.M., McCarthy P.M., Starling R.C., et al. Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure. Eur J Cardiothorac Surg (1998) 13:334–343.
  9. Fukamachi K., McCarthy P.M., Smedira N.G., et al. Effects of partial left ventriculectomy on left ventricular performance: one year follow-up. Circulation (1998) 68:I1201.
  10. Dickstein M.L., Spotnitz H.M., Rose E.A., Burkhoff D. Heart reduction surgery: an analysis of the impact on cardiac function. J Thorac Cardiovasc Surg (1997) 113:1032–1040.[Abstract/Free Full Text]
  11. Ratcliffe M.B., Jong J., Salahieh A., Ruch S., Wallace A.W. The effect of ventricular volume reduction surgery in the dilated, poorly contractile left ventricle: a simple finite element analysis. J Thorac Cardiovasc Surg (1998) 116:566–577.[Abstract/Free Full Text]
  12. Batista R.J.V., Nery P., Bocchino L., et al. Partial left ventriculectomy to treat end-stage heart disease. Annu Thorac Surg (1997) 64:634–638.[CrossRef]
  13. Gorcsan I.I.I.J., Feldman A.M., Kormos R.L., et al. Heterogeneous immediate effects of partial left ventriculectomy on cardiac performance. Circulation (1998) 97:839–842.[Abstract/Free Full Text]
  14. Bocchi E.A., Bellotti G., de Morales A.V., et al. Clinical outcome after left ventricular surgical remodeling in patients with idiopathic dilated cardiomyopathy referred for heart transplantation. Circulation (1997) 96(Suppl_II):165–172.
  15. Moreira L.E.P., Stolf N.A.G., Bocchi E.A., et al. Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy. J Thorac Cardiovasc Surg (1998) 115:800–807.[Abstract/Free Full Text]
  16. Stolf N.A.G., Moreira L.E.P., Bocchi E.A., et al. Determinants of midterm outcome of partial left ventriculectomy in dilated cardiomyopathy. Annu Thorac Surg (1998) 66:1585–1591.[CrossRef]
  17. Angelini G.D., Pryn S., Izzat M.B., et al. Left ventricular volume reduction for end-stage heart failure. Lancet (1997) 350:489.[CrossRef][Web of Science][Medline]
  18. Gradinac S., Miric M., Popovic Z., et al. Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up. Annu Thorac Surg (1998) 66:1963–1968.[CrossRef]
  19. Popovic Z., Miric M., Gradinac S., et al. Effects of partial left ventriculectomy on left ventricular performance in patients with nonischemic dilated cardiomyopathy. J Am Coll Cardiol (1998) 32:1801–1808.[Abstract/Free Full Text]
  20. Suma J., Isomura T., Horii T., et al. Two-year experience of the Batista operation for non-ischaemic cardiomyopathy. J Cardiol (1998) 32:269–276.[Medline]
  21. Pauschinger M., Knopf D., Petschauer S., et al. Dilated cardiomyopathy is associated with significant changes in collagen type I/III ratio. Circulation (1999) 99:2750–2756.[Abstract/Free Full Text]
  22. Chung M.K., Starling R.C., Buda T.M., et al. Inducibility of ventricular tachycardia after left ventricular remodeling surgery. Circulation (1998) 68:1164.
  23. Laks H., Marelli D. The current role of the left ventricular reduction for treatment of heart failure. J Am Coll Cardiol (1998) 32(7):1809–1810.[Free Full Text]
  24. Bolling S.F., Pagani F.D., Deeb G.M., Bach D.S. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg (1998) 115:381–388.[Abstract/Free Full Text]
  25. DiDonato M., Sabatier M., Toso A., et al. Regional myocardial performance of non-ischaemic zones remote from anterior wall left ventricular aneursym. Eur Heart J (1995) 16:1285–1292.[Abstract/Free Full Text]
  26. Dor V. Reconstructive left ventricular surgery for post-ischemic akinetic dilatation. Semin Thorac Cardiovasc Surg (1997) 9(2):139–145.[Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (6)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Starling, R. C.
Right arrow Articles by McCarthy, P. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Starling, R. C.
Right arrow Articles by McCarthy, P. M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?