ORIGINAL ARTICLE – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 19 (2014) 398–405 doi:10.1093/icvts/ivu173 Advance Access publication 4 June 2014
Restoration of optimal left ventricular apical geometry and rotation following surgical ventricular restoration using rectangular patch plasty technique: a pilot study using cardiac magnetic resonance Srilakshmi M. Adhyapaka,†*, Prahlad G. Menonb,c,d,†, V. Rao Parachurie, Karthik Gadabanahallie, Venkat Ramana Bhate, Varun Shettye and Devi Shettye a b c d e
Department of Cardiology, St John’s Medical College Hospital, Bangalore, India Department of Electrical and Computer Engineering, SYSU-CMU Joint Institute of Engineering, Pittsburgh, USA Shunde International Research Institute, Guangdong, China QuantMD LLC, Pittsburgh, USA Department of Cardiac Surgery, Narayana Hrudayalya Institute of Medical Sciences, Bangalore, India
* Corresponding author. Narayana Hrudayalaya Institute of Medical Sciences, 258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore 560099, India. Tel: +91-80-27835000; fax: +91-80-27832648; e-mail:
[email protected] (S.M. Adhyapak). Received 13 December 2013; received in revised form 24 April 2014; accepted 2 May 2014
Abstract OBJECTIVES: Clinical outcomes of surgical ventricular restoration (SVR) have been confirmed by Registry data. Accurate assessment of left ventricular (LV) morphology and function can help optimize these outcomes. METHODS: LV remodelling in 7 patients (NYHA class 3 ± 1.2) with post-myocardial infarction LV aneurysms was characterized by the regional LV volume (RLVV) computed by dividing the LV in cine steady-state free precession cardiac magnetic resonance imaging (CMR) at each slice level into six radial segments. Rotation of the LV apex and base was analysed using tagged CMR. The apical conicity ratio was used to characterize the restored apical geometry. RESULTS: The mean end-diastolic volume (EDV) was 174.8 ± 100.3 ml and the mean ejection fraction (EF) was 18.8 ± 7.8%. Following SVR, all patients had significant clinical improvements (NYHA Class I), and significant increases in the left ventricular ejection fraction (LVEF) to 38.8 ± 4.4%. The LV volumes and regional volumes at the base and apex decreased with a trend towards significance. The mean preoperative apical conicity ratio (ACR) was 1.90 ± 0.43 and, following SVR by endoventricular linear patch plasty (EVLPP), was 1.35 ± 0.3 (P = 0.02). The percent decrease in the ACR following SVR from baseline was 28.68 ± 10.98%. The apical EF increased from 1.19 ± 13.9 to 15.8 ± 8.2% (P = 0.028). The basal rotations improved from 3.13 ± 2.1 to 4.69 ± 2.94° (P = 0.04). The apical rotations also improved significantly from 2.48 ± 1.23 to 3.93 ± 2.45° (P = 0.05) and reversed to the normal anticlockwise direction. CONCLUSIONS: SVR by geometric repair using a rectangular intracavitary patch helps restoration of a physiological apex with normalization of apical rotation reflecting a near-physiological LV function. Keywords: Aneurysm • Cardiac volume • Ventricles • Imaging
INTRODUCTION Heart failure of ischaemic origin has become increasingly common over the past decade because of improved survival of patients with acute myocardial infarction (AMI) [1]. This underscores the fact that the burden of heart failure following AMI has significant implications for advances in cardiac imaging to guide selection of specific therapy [2]. The development of new methods for accurate quantification of regional myocardial function is predicated by the clinical need to tailor appropriate therapy when contractile recovery is not possible because of large areas of scarred myocardium [3]. In ischaemic cardiomyopathy, evaluation of ventricular shape, function †
The first two authors contributed equally to this work.
and mechanical dyssynchrony (MD) forms the basis of decisionmaking in non-transplant therapies. For patients with large areas of dyskinesia or left ventricular (LV) aneurysms, registry data have clearly documented significant improvements in quality of life with LV restoration surgery combined with revascularization with or without mitral valve repair [4]. Recent data from the STICH trial have demonstrated that surgical ventricular restoration (SVR) in addition to coronary artery bypass grafting (CABG) has a definite mortality benefit in post-myocardial infarction LV aneurysms when compared with CABG alone when the postoperative restored ventricle has an end-systolic volume (ESV)
