Surgical ventricular restoration by means of a new technique to preserve left ventricular compliance: the horseshoe repair.

The STICH trial will elucidate the results of surgical ventricular restoration (SVR) associated with coronary artery bypass grafting in patients with ischemic dilated cardiomyopathy but, while awaiting these findings, the current literature shows that left ventricular (LV) sphericalization, continued LV remodeling, and recurrent mitral valve (MV) regurgitation may occur after SVR.1Di Donato M. Sabatier M. Dor V. Gensini G.F. Toso A. Maioli M. Stanley A.W. et al.Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery.J Thorac Cardiovasc Surg. 2001; 121: 91-96Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar One possible explanation for these events is the worsening or occurrence of diastolic dysfunction.2Tulner S.A.F. Steendijk P. Klautz R.J.M. Bax J.J. Schalij M.J. van der Wall E.E. et al.Surgical ventricular restoration in patients with ischemic dilated cardiomyopathy: evaluation of systolic and diastolic ventricular function, wall stress, dyssynchrony, and mechanical efficiency by pressure-volume loops.J Thorac Cardiovasc Surg. 2006; 132: 610-620Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Until March 2005, we performed SVR by an endoventricular circular patch plasty (Dor procedure),3Dor V. Left ventricular aneurysms: the endoventricular circular patch plasty.Semin Thorac Cardiovasc Surg. 1997; 9: 123-130PubMed Google Scholar which consists of 2 circular purse-string sutures (Fontan stitch) and a polyester fiber patch that is much stiffer than the infarcted myocardium. In the Dor procedure, the amount of foreign material used and lateral wall involvement by the Fontan stitch may be responsible for worsening LV diastolic function, as is shown by the increased slope of the end-diastolic pressure/volume relationship (EDPVR).2Tulner S.A.F. Steendijk P. Klautz R.J.M. Bax J.J. Schalij M.J. van der Wall E.E. et al.Surgical ventricular restoration in patients with ischemic dilated cardiomyopathy: evaluation of systolic and diastolic ventricular function, wall stress, dyssynchrony, and mechanical efficiency by pressure-volume loops.J Thorac Cardiovasc Surg. 2006; 132: 610-620Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar A number of authors have described modifications of the Dor technique based on the limited use of foreign material in an attempt to prevent the untoward effect of increased LV stiffness, but none of these has gained wide acceptance. We describe a new no-patch SVR technique that, by avoiding the use of a circular Fontan stitch, should preserve LV compliance while being as effective as the Dor procedure in reducing LV volumes and diameters. The ideal SVR technique should reduce the equatorial diameter without shortening the longitudinal one. Our technique consists of 2 horseshoe-shaped, semicircular, parallel purse-string sutures (polypropylene 2-0) positioned in the scarred interventricular septum, acting on the LV circumference: one at equatorial level (which is located at the middle of the insertion of the anterior papillary muscle)4Ferrazzi P. Matteucci M.L.S. Merlo M. Iacovoni A. Rescigno G. Bottai M. et al.Surgical ventricular reverse remodeling in severe ischemic dilated cardiomyopathy: the relevance of the left ventricular equator as a prognostic factor.J Thorac Cardiovasc Surg. 2006; 131: 357-363Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar and one displaced 1 cm toward the apex (Figure 1, Figure 2). The equatorial purse string is tied first to obtain an elliptic shape, and then the second purse string is tied to reshape the new apex. In case of very enlarged LV cavity, 3 (or 4) horseshoe purse-string sutures can be necessary. The ventriculotomy is closed without interposition of a patch or reinforcing felt strips. To avoid shortening the long axis, if the LV longitudinal diameter is <90 mm, we perform a linear mattress suture reinforced by a running suture (more usual in akinetic LV). If the LV longitudinal diameter is ≥90 mm, we use an “overcoat” suture, described by Guilmet in 19845Guilmet D. Popoff G. Dubois C. Tawil N. Bachet J. et al.A new surgical technique for the left ventricular aneurysm: the overcoat aneurysmoplasty. Preliminary results. 11 cases.Arch Mal Coeur Vaiss. 1984; 77: 953-958PubMed Google Scholar (more usual in dyskinetic LV). We apply this technique in all patients with anteroseptal myocardial infarction, regardless of LV dimensions.Figure 2Drawing of the surgeon's view of the 2 semicircular purse-string sutures as they appear through the ventriculotomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Between April 2005 and November 2006, 15 severely symptomatic (5/15 New York Heart Association class IV, 2/5 under inotropic support) consecutive male patients, aged 61.7 ± 6.7 years, with a history of a previous large anteroseptal myocardial infarction underwent the horseshoe repair (Table 1). The surgical protocol consisted of the insertion of a prophylactic intra-aortic balloon pump, induction of normothermic blood cardioplegia, complete myocardial revascularization, MV repair (for grade ≥ 2 regurgitation), and the placement of a permanent LV epicardial lead (in case of dyssynchrony).Table 1Preoperative and follow-up dataPreoperativeFollow-up (mean 6.9 mo)P valueNYHA class2.7 ± 0.81.3 ± 0.5.002LVEF (%)25 ± 4.945.1 ± 10.1.001LVEDV (mL)242.4 ± 60.3140.9 ± 32.2