Search

Background: The level of sympathetic nervous activity is a major determinant of prognosis in patients with heart failure., Objective: The purpose of this investigation was to perform a proof-of-principle trial of therapeutic endoscopic left thoracic sympathetic blockade in heart failure patients to assess safety and immediate effects., Methods: Fifteen patients with dilated cardiomyopathy and left ventricular ejection fraction (LVEF) < 40%, New York Heart Association functional class II or III, and heart rate > 65 bpm, despite either adequate betablocker use or intolerant to it, were enrolled. Ten patients underwent left infra-stellate ganglion plus T3-T4 interspinal space clipping through videothoracoscopy, while the other five patients were randomized to a control group., Results: None of the treated patients had any procedure-related adverse cardiovascular events at the perioperative period. Two patients from the surgical group died due to pulmonary thromboembolism or myocardial infarction within 6 months of the initial follow-up, while three patients from the control group had heart failure progression and died or developed cardiogenic shock during the same period. Treated patients presented improvement in quality of life, level of physical activity and LVEF (from 25 ± 9% to 32 ± 8%, p=0.024) at 6 months of follow-up, whereas these parameters did not change in control patients., Conclusion: Endoscopic left thoracic sympathetic blockade is feasible and appears to be safe in severe heart failure patients. This initial study suggests that this procedure might be an effective alternative approach to sympathetic blockade in the treatment of dilated cardiomyopathies.

Background: Cardiac transplantation faces the serious problem of lack of donors and it is estimated that 20 to 40% of the patients die while waiting for heart transplantation. For these patients, the use of mechanical circulatory assist devices is the only choice of survival while waiting for a donor. In Brazil, the experience with mechanical circulatory support is limited and there is no regular program regarding the use of these devices as a bridge to heart transplantation., Objective: To evaluate the hemodynamic performance and the systemic inflammatory response during the clinical use of the InCor-type ventricular assist device (VAD-InCor) as a bridge to heart transplantation., Methods: Between October 2003 and April 2006, 11 patients in the waiting list for heart transplantation presented hemodynamic deterioration due to refractory cardiogenic shock. Seven of these patients were submitted to VAD-InCor implantation for left ventricular assistance. The etiologic diagnosis was Chagas' disease in 5 patients and idiopathic dilated cardiomyopathy in 2., Results: The duration of left ventricular assistance ranged from 14 to 42 days (mean 26.2 days). During this period, the hemodynamic performance of the DAV-InCor was adequate to support a normal hemodynamic state. There was normalization of central venous oxygen saturation and serum lactate. Two patients were submitted to heart transplantation, while the other 5 patients died under assistance due to infection and multiple organ failure., Conclusion: The performance of the VAD-InCor, in the hemodynamic behavior of the studied patients, was adequate for the maintenance of a satisfactory circulatory state during the studied period. There was improvement in the tissue perfusion parameters and maintenance of systemic inflammatory response signs. There was a high incidence of complications; however, complications related to the device, which could compromise the safety of its use, were not demonstrated.

Background: Peak oxygen consumption and resting left ventricular ejection fraction (LVEF) are independent predictors of survival in adult heart failure (HF) patients., Aim: To evaluate these factors in children., Methods: We prospectively studied 31 children with NYHA class I to III HF (mean LVEF 26+/-10%; mean age 8.6+/-1.9 years). All had dilated cardiomyopathy and were awaiting heart transplantation. A cardiopulmonary treadmill exercise test was performed and LVEF determined by radionuclide ventriculography., Results: During a median follow-up of 1282 days, 20 children reached at least one end-point (death or heart transplantation). Clinical data from the 11 children without events and the 20 children with events are as follows: NYHA class 1+/-0 vs. 2+/-0.9 (p<0.01); SBP 118+/-17 vs. 102+/-16 (p=0.01); DBP 70+/-10 vs. 61+/-10 (p=0.02); heart rate 165+/-22 vs. 148+/-22 (NS); double-product 19+/-4 vs. 15+/-4 (p=0.01); end-tidal carbon dioxide tension (PetCO2) 35+/-5 vs. 30+/-6 (NS); oxygen consumption (VO2) 22+/-5.4 vs. 18.3+/-5.7 (NS); exercise time 19+/-4 vs. 13+/-6 (p<0.003), and LVEF 31+/-8 vs. 22+/-10 (p=0.02). These variables all correlated with prognosis on univariate analysis. In multivariate analysis, only decreasing exercise time and LVEF were predictive of events during follow-up (p<0.001 and 0.04)., Conclusion: These findings suggest that reduction in LVEF and exercise tolerance in children with heart failure is predictive of functional status.

Background: Palliative procedures have been proposed for treatment of dilated cardiomyopathies. This study analyzes long-term outcomes of 43 patients who underwent dynamic cardiomyoplasty., Methods: Patients were in New York Heart Association class III (n = 35) or IV (n = 8) before the procedure. Hospital mortality was 2.2%, and patients were followed for 44 +/- 33 months. Thirty-nine patients completed the skeletal muscle adaptation period, and the muscle flaps were stimulated to contract in concert with every cardiac beat (n = 27) or with every other beat (n = 12)., Results: One-year event-free survival was 81.3% +/- 5.9%; 2-year, 65.1% +/- 7.2%; 5-year, 34.7% +/- 7.2%; and 9-year, 10.8% +/- 5.3%. Causes of late deaths were equally divided between progressive heart failure and arrhythmia-related events. Multivariable Cox proportional hazard regression identified that functional class IV, high pulmonary vascular resistance, and muscle flap stimulation synchronized to every cardiac beat were independent predictors of poor event-free survival. The same factors were associated with the occurrence of progressive heart failure, but none was a predictor of arrhythmia-related deaths. Five-year survival of patients maintained with the muscle flap stimulated at every other cardiac beat was 58.3% +/- 14.2%. Skeletal muscle stimulation protocols also influenced the long-term behavior of left ventricular ejection fraction., Conclusions: Long-term results of dynamic cardiomyoplasty are limited by the patient's preoperative condition and by a high incidence of sudden cardiac death. These results may be improved using modified skeletal muscle stimulation protocols and cardioverter-defibrillator implantation, while maintaining dynamic cardiomyoplasty as an option for selected patients.

Objective: Dynamic cardiomyoplasty and partial left ventriculectomy have shown limited and controversial results in the treatment of dilated cardiomyopathies. This study investigates causes and determinants of long-term mortality after these procedures., Methods: Forty-three patients submitted to dynamic cardiomyoplasty and 43 who underwent partial ventriculectomy were studied. Patients were in New York Heart Association (NYHA) class III or IV before the procedures. In dynamic cardiomyoplasty group, hospital mortality was 2.2% and patients were followed for 48+/-31 months. Nine hospital deaths occurred after partial ventriculectomy and the remaining patients were followed for 38+/-29 months., Results: For patients submitted to dynamic cardiomyoplasty, 1-year event-free survival was 81.3+/-5.9%; 2-year, 65.1+/-7.2%; and 6-year, 23.1+/-6.7%. Partial left ventriculectomy patients presented event-free survival rates of 58.1+/-7.5%, 46.6+/-7.6% and 21.6+/-6.4% at the same periods, respectively. Late deaths were equally related to heart failure progression and arrhythmia events in both groups. Preoperative NYHA class IV, pulmonary hypertension and absence of left ventricular (LV) function improvement at the time of the final event were identified as independent predictors of poor long-term event-free survival and heart failure progression in cardiomyoplasty patients, while NYHA class IV, elevated serum nor-epinephrine and absence of LV function improvement were associated with these events after partial left ventriculectomy. Arrhythmia related deaths were only predicted by previous events of sustained ventricular tachycardia in partial left ventriculectomy group., Conclusions: Long-term results of dynamic cardiomyoplasty and partial left ventriculectomy are limited by patients' preoperative condition, by the loss of LV function benefits and by high incidence of sudden cardiac death. Palliative surgical treatment of dilated cardiomyopathies needs to be indicated earlier and may achieve better efficiency with the combination of different procedures to provide sustained improvement of LV function, to interrupt the progressive remodeling process and to prevent sudden cardiac death.

Background: The Batista operation, or partial ventriculectomy, has been designed by the Brazilian surgeon Dr. Randas Batista as an alternative method for treating patients with idiopathic dilated cardiomyopathy., Hypothesis: This study aimed to analyze electro- and vectorcardiographic data obtained from patients who underwent such surgery, and to evaluate its electrical repercussions on the heart., Methods: Pre- and postoperative electrocardiography (ECG) and vectorcardiography (VCG) were performed 45 days apart in 15 patients undergoing reductive ventriculectomy., Results: All ECGs showed sinus rhythm, with unchanged QRS duration. Left atrial enlargement (86.6%) and left ventricular hypertrophy (100%) were the most common findings. Bundle-branch blocks (BBBs) were often demonstrated on preoperative studies, predominantly (46.7%) left BBBs. Left anterior fascicular blocks were seen in four patients (26.6%), one associated with right BBB. Electrocardiographic changes suggestive of myocardial infarction (MI) were seen in four patients preoperatively; postoperatively, all had extended to or within the lateral wall. Five additional patients developed lateral MIs postoperatively, for a total of 9 patients (60%) with postoperative signs of infarction (p < 0.05). Electro- and vectorcardiography also showed significant postoperative lowering of QRS voltages (mean 40.74%) in all patients and a consequent difficulty to diagnose left ventricular hypertrophy, although the morphologic features did not change., Conclusions: These important ECG and VCG alterations are reflections of both the surgical technique and its clinical consequences.

Objective: The purpose of this study was to analyze the behavior of the mitral valve ring and the left ventricle in dilated cardiomyopathy., Methods: We analyzed 68 fixed adult human hearts, divided into 48 hearts with dilated cardiomyopathy of ischemic or idiopathic origin and 20 hearts free of pathologic heart conditions. Digital images of the mitral ring perimeter, attachment of the anterior and posterior leaflets, and fibrous and muscular portions were collected. We also measured the internal perimeter of the left ventricle, the distance from the septum to the anterior and posterior papillary muscles, the distance between the papillary muscles, and the extension of interventricular septum., Results: The analysis of the results showed proportional distribution of the ring's fibrous portion (r2 = 0.98) and muscular portion (r2 = 0.99) according to the degree of mitral valve dilation. Linear regression revealed that the perimeters of anterior and posterior leaflet attachments (r2 = 0.96 and r2 = 0.98, respectively) also had a proportional relation. We did not observe proportionality between the degree of dilation of the mitral ring and the left ventricle. It was observed that dilation of the left ventricle takes place globally in its segments., Conclusion: Differently from what was thought, in ischemic or idiopathic dilated cardiomyopathy, dilation of mitral ring is proportional and does not exclusively affect the posterior portion. The degree of left ventricular dilation does not determine the degree of dilation of the mitral ring because they are independent processes. These observations shed new light on the techniques used to correct mitral valve insufficiency in dilated cardiomyopathy.

Background: Cardiomyocyte apoptosis as well as proliferation have been described in congestive heart failure, but their clinical relevance remains unclear. In order to clarify whether apoptosis and cell proliferation occur in patients with idiopathic dilated cardiomyopathy and whether their degree in left ventricle fragments resected during partial left ventriculectomy has any influence on the outcome after this surgery, we compared their occurrence in four groups of patients: group A, short-term survivors (n = 18); group B, deaths within 6 months of the surgery (n = 13); group C, long-term survivors (n = 12); and Group D, deaths within 60 months (n = 19)., Design: Apoptotic cardiomyocytes and interstitial cells were quantified in left ventricle fragments from 31 patients with idiopathic-dilated cardiomyopathy using the TUNEL assay. Cell proliferation was quantified in parallel sections by KI-67 immunohistochemistry., Results: Apoptotic cells were present in the majority of cases (n = 24) and proliferative cells in all cases. Whereas there was no significant difference regarding all parameters examined between Groups A and B, there was a highly significant difference between Groups C and D in the number of apoptotic cardiomyocytes (P = 0.012) and apoptotic interstitial cells (P = 0.006). There was no significant relationship between apoptotic cardiomyocytes and KI-67-positive cardiomyocytes, but a negative correlation between apoptotic interstitial cells and KI-67-positive interstitial cells (r = -0.383; P = 0.028)., Conclusion: Cardiomyocyte apoptosis and proliferation occur in the majority of patients with idiopathic-dilated cardiomyopathy. High numbers of apoptotic cardiomyocytes and apoptotic interstitial cells are significantly related to a bad late outcome after partial left ventriculectomy.

We evaluated short-term effects of partial ventriculectomy on left ventricular (LV) parameters and its impact on late survival by magnetic resonance imaging (MRI). Twenty patients and 10 normal volunteers were studied, and LV volumes (EDV, ESV), ejection fraction (EF), short- and long-axis dimensions (SA, LA), wall thickness (Wth), shape (LA/SA), geometry (Wth/SA), a geometry index (Phi), and wall-motion score index (WMSI) were evaluated pre- and postoperatively. Also, we compared results and survival of patients with preoperative EF 17%. Short-term results showed significant changes (P < 0.001) in: EF (17.3 +/- 7.3% vs. 30.4 +/- 9.5%), EDV (391.9 +/- 118 vs. 272.7 +/- 90 mL); ESV (308.2 +/- 102.8 vs. 190.3 +/- 68.4 mL); SA (80.5 +/- 10.4 vs. 71.7 +/- 7.8 mm); LA/SA (1.13 +/- 0.1 vs. 1.34 +/- 0.1); Wth (8.35 +/- 0.99 vs. 9.75 +/- 1.41 mm); Wth/SA (0.10 +/- 0.01 vs. 0.14 +/- 0.02), diastolic( 0.80 +/- 0.16 vs. 0.58 +/- 0.13) and systolic (0.78 +/- 0.18 vs. 0.55 +/- 0.12) Phi; and WMSI (-2 vs. -1) (P = 0.032). The EF division showed differences in: LA/SA (1.26 +/- 0.10 vs. 1.49 +/- 0.12) (P < 0.001); Wth/SA (0.13 +/- 0.02 vs. 0.15 +/- 0.02) (P = 0.023); diastolic (0.65 +/- 0.11 vs. 0.48 +/- 0.11) and systolic (0.63 +/- 0.09 vs. 0.46 +/- 0.09) Phi (P < 0.001); and WMSI (-2 vs. -1) (P = 0.033). Finally, correlation between pre/postoperative EF showed for EF < 17%, r = 0.32 and for EF >17%, r = 0.83, which had different late survival. Our study showed significant changes on LV parameters after ventriculectomy. Patients with EF >17% showed better EF correlation between pre/postoperative values and higher survival rate. J. Magn. Reson. Imaging 2001;13:781-786., (Copyright 2001 Wiley-Liss, Inc.)

Objectives: Partial left ventriculectomy has been performed as an alternative to heart transplantation in the treatment of severe cardiomyopathies. This investigation documents the clinical and left ventricular (LV) function effects of this procedure, associated, when necessary, with mitral insufficiency correction, in 43 patients with idiopathic dilated cardiomyopathy., Methods: Eighteen patients were in New York Heart Association class III and 25 in class IV. Seven of them were operated in cardiogenic shock. The procedure was associated with mitral annuloplasty in 32 patients and mitral replacement in three., Results: Nine patients (20.9%) died during the hospital period and the cause of death was associated with ventricular failure in seven patients. The other patients were followed up from 2 to 57 months (mean, 28.3 months). At 6 months of follow-up, eight patients were in functional class I, 13 in class II, three in class III and one patient was in class IV (P<0.001). On the other hand, nine patients died during the first 6 months and another six in the later postoperative period. The cause of late death was progressive heart failure in eight patients, and seven patients died because of arrhythmia related events. The actuarial survival was 58.1+/-7.5% at 1 year and 43.9+/-8.1% at 4 years of follow-up. Regarding ventricular function modifications, the LV diastolic volume decreased by around 25% and the LV ejection fraction increased from 17.8+/-4.7 to 22.3+/-7.9% (P<0.001), whereas significant changes in the cardiac index, stroke index and pulmonary pressures were also found 1 month after the operation. In the later follow-up, despite the maintenance of hemodynamic improvement, the LV diastolic volume tended to increase and returned to preoperative levels at 4 years, while a concomitant decrease in the LV ejection fraction was also observed., Conclusion: Partial left ventriculectomy associated with mitral insufficiency correction improves LV function and ameliorates congestive heart failure in patients with idiopathic cardiomyopathy. Otherwise, the LV function benefits seem to be restricted by the possibility of progressive LV redilatation. Furthermore, the clinical application of this procedure is limited by the high mortality observed in the first postoperative months and by the possibility of heart failure progression and arrhythmia related events at late follow-up.

Objective: Left partial ventriculectomy has been proposed for treatment of heart failure. We investigated the effects of isolated left partial ventriculectomy and left partial ventriculectomy associated with mitral annuloplasty on refractory heart failure due to idiopathic dilated cardiomyopathy., Methods: Nineteen patients underwent partial left partial ventriculectomy associated with mitral annuloplasty and six patients isolated left partial ventriculectomy. In two patients the left partial ventriculectomy associated with mitral annuloplasty was combined with tricuspid annuloplasty. We evaluated before and after the surgery (24+/-14 days): the functional class, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (EF), regional wall motion, hemodynamics, mitral regurgitation, left ventricular geometry and coronary angiography., Results: For the overall group LVEF improved from 14.5+/-8.0 to 30.3+/-12.2% (P<0.0002) and right ventricular EF from 21.2+/-7.1 to 28.4+/-8.3% (P<0.002). In patients who underwent left partial ventriculectomy associated with mitral annuloplasty LVEF increased from 14.5+/-8.6 to 29.5+/-12.2% (P<0. 002). Isolated left partial ventriculectomy increased LVEF from 13. 5+/-7.5 to 31.5+/-11.1% (P<0.04). Distal segments of marginal branches of the circumflex artery were not visualized by coronary angiography. Left partial ventriculectomy associated with mitral annuloplasty reduced the wedge pressure from 25.0+/-12.1 to 18.0+/-7. 0 mmHg (P<0.03) and increased cardiac output from 3.8+/-0.8 to 4. 6+/-1.1 l/min (P<0.004), while isolated left partial ventriculectomy increased cardiac output from 3.7+/-1.0 to 4.8+/-1.3 l/min (P<0.03). Regional wall motion increment was more evident in anterolateral region from 4.2+/-6.8 to 14+/-8.3% (P<0.002) except in two patients. Left ventricular geometry changed in most patients, but a homogeneous pattern was not identified. Seven patients died during a mean follow-up of 546+/-276 days. Survivors had improvement in functional class. Augmentation of LVEF >5% was associated with a favorable clinical outcome with improvement in clinical status without death., Conclusions: Effects of left partial ventriculectomy are not necessarily dependent upon reduction of mitral regurgitation or changes in left ventricular geometry. However, risk of death after the surgery must be reduced for a clinical application.

Background: Partial left ventriculectomy (PLV) is an alternative to heart transplantation for patients with severe heart failure. However, this procedure is accompanied by high morbidity and mortality. Therefore, we studied the hearts of 12 patients who underwent this procedure to increase our understanding of the causes of bad outcome., Methods: We analyzed the autopsy hearts of 11 of 16 patients who died after PLV, and one heart from a patient who underwent heart transplantation., Results: Six patients died less than 30 days postoperatively, 4 of cardiogenic shock, 1 of arrhythmia, and 1 of coagulopathy. Five patients died from 36 to 120 days after the procedure, 4 of cardiogenic shock and 1 of arrhythmia. The patient who underwent heart transplantation had a cardiogenic shock 230 days after PLV. Ten hearts weighed more than 500 g and nine had myocardial infarction that extended to the papillary muscles. Four patients had infarction of both papillary muscles and 3 of them had episodes of arrhythmia, suggesting some relation between these events., Conclusions: We found several important morphologic clues for bad outcome: infarction of both papillary muscles, which may be associated with the development of arrhythmia, and myocardial infarction and pericardial hemorrhage, which may contribute to the outcome of heart failure.

Background: Despite the initial promissory results of partial left ventriculectomy, or Batista's operation, the postoperative mortality associated with the procedure has been too high. We described a histopathologic study performed to identify histological parameters that could help to determine outcomes of patients undergoing this procedure., Methods and Results: Myocardial fiber diameter, myocardial fibrosis, thickness of the compact wall, and number of cells presenting from the endocardium to epicardium were analyzed in 32 patients with idiopathic dilated cardiomyopathy who underwent Batista's operation. Data were grouped by patients who died < or = 6 months and patients who survived for > 6 months after the surgical procedure. Additional analyses were performed to compare results according the causes of death and to test the application of these results to biopsy., Results: Myocardial fiber diameter was the only index that could distinguish the two groups. Myocardial fiber diameter < 22 microm distinguished the group of patients who survived the 6-month postoperative period from patients who died during that time with sensitivity of 85.7 and specificity of 72.2. The subendocardial region of the compact wall and the trabecular portion of the wall exhibited comparable results., Conclusion: Our results indicate that the myocardial fiber diameter of samples from the trabecular or subendocardial compact wall regions may help predict the outcome of left ventriculectomy. Samples from the trabecular or subendocardial compact wall regions were used for analysis. Further prospective studies involving left ventricular endomyocardial biopsies are necessary to confirm if the use of myocardial fiber diameter in the selection of patients for surgery improves the index of success of Batista's operation. Other factors that are involved remain unclear.

Background: Partial left ventriculectomy has been proposed for treatment of severe cardiomyopathies. This study reports midterm results of this procedure in 37 patients with dilated cardiomyopathy., Methods: All patients were in New York Heart Association class III (16) or IV (21). Partial ventriculectomy was associated with mitral annuloplasty in 27 patients and with mitral replacement in 2., Results: There were seven operative deaths (18.9%). During a mean follow-up of 18.2+/-9.3 months, 9 more patients died. Actuarial survival was 56.7%+/-8.1% at 6 and 24 months. Analysis of factors influencing outcome showed that midterm survival was significantly affected only by myocardial cell diameter. Otherwise, functional class improved from 3.5+/-0.5 to 1.8+/-0.9 in the survivors (p < 0.001). Furthermore, left ventricular diastolic volume decreased from 523+/-207 to 380+/-148 mL (p < 0.001), and left ventricular ejection fraction increased from 17.1%+/-4.6% to 23%+/-8% (p < 0.001), whereas significant changes in cardiac index, stroke index, and pulmonary pressures were found at 1 month of follow-up. Although left ventricular diastolic volume tended to increase in the late postoperative period, left ventricular ejection fraction and hemodynamic variables did not change significantly., Conclusions: Partial ventriculectomy improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy for up to 24 months of follow-up. Nevertheless, this procedure's clinical application is limited by the high mortality observed in the first postoperative months. Otherwise, new perspectives may be advised by the identification that partial ventriculectomy results seem to be influenced by compromised myocardial cells.

Objective: This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy., Methods: Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months., Results: Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up., Conclusions: Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.

Background: Left ventricular partial ventriculectomy (LVPV), an unconventional operation to reverse some aspects of the cardiac remodeling, has been proposed for treatment of congestive heart failure., Methods and Results: Twenty-four patients (age 46+/-9 years) referred to heart transplantation underwent isolated LVPV or LVPV associated to valve annuloplasty. Patients were in New York Heart Association functional class IV (15) or III (9) due to idiopathic dilated cardiomyopathy. Functional class, left and right ventricular ejection fraction (radionuclide), left ventricular end-diastolic and end-systolic diameter, and fractional shortening (by echocardiography), and hemodynamic variables were determined. The mean follow-up was 474+/-174 days. Survival at 30, 180, and 365 days was 92+/-6%, 67+/-10%, and 63+/-10%, respectively. Nine patients died, and the cause was associated with arrhythmias in 4 patients. The left ventricular end-diastolic diameters before and at 23+/-14 days, 188+/-27, and 365+/-14.8 days of follow-up were 82.6+/-9.8, 68.9+/-7.8, 69.9+/-6.9, and 70+/-5.3 mm, respectively (P=0.0001). The left ventricular end-systolic diameters were 73.5+/-7.4, 55.9+/-7.5, 57.4+/-7.8, and 55+/-5.5 mm (P=.0001). Fractional shortenings were 13+/-3, 19+/-4, 18+/-5, and 22+/-2%, respectively (P=.0001). The left ventricular ejection fractions before and 18+/-14, 188+/-26, and 369+/-3.6 days after the surgery were 17.2+/-4.7, 24.5+/-8.3, 24.5+/-7.4, and 23.7+/-6.1%, respectively (P=.004). The right ventricular ejection fractions were 20.5+/-6.2, 27.9+/-8.4, 28.2+/-10.1, and 27.4+/-7.3% (P=0.02). Pressures were unchanged. There was improvement in cardiac index from 2.11+/-0.52 to 2.53+/-0.64 L/min (P=.0037). Norepinephrine blood levels reduced from 702+/-258 to 439+/-307 pg/mL (P=.001). Most surviving patients presented improvement in functional class. Sustained ventricular tachycardias were observed in 9 patients (38%)., Conclusions: The left ventricular partial ventriculectomy may improve the left and right ventricular function, functional class, and cardiac output. These initial results were associated to high prevalence of sustained ventricular tachycardia. The ventriculectomy introduces the concept that reduction of left ventricular chamber diameter may improve cardiac function in heart failure. Further progress is necessary to improve the results and evaluate its proper role in the management of heart failure.

Background: Heart transplantation is the surgical procedure of choice for treatment of refractory heart failure. However, it benefits a small number of patients because of the limited number of donors and selection criteria of recipients. Cardiomyoplasty is an alternative surgical procedure for heart failure. The aim of this investigation was to report our experience with heart transplantation, cardiomyoplasty, and clinical treatment of heart failure caused by idiopathic dilated cardiomyopathy., Methods: Ninety patients with refractory heart failure caused by idiopathic dilated cardiomyopathy were observed from May 1988 to March 1993. The patients had New York Heart Association functional class III or IV symptoms. The patients were divided in three groups according to the treatment received: heart transplantation (33 patients), cardiomyoplasty (25 patients), or medical treatment (32 patients). We studied the event-free curve, the New York Heart Association functional class, the left ventricular ejection fraction, and the morbidity of the groups in the follow-up of 19 +/- 16 months. We considered as an event death or crossover to another group because of severe symptoms., Results: The event-free rate in the cardiomyoplasty group was 92%, 88%, 79%, 74%, and 62% at 3, 9, 12, 18, and 24 months of follow-up, respectively. The event-free rate after heart transplantation was 82%, 78%, 82%, 75%, and 69% at 3, 9, 12, 18, and 24 months, respectively. The event-free rate in the medical treatment group was 78%, 65%, 61%, 48%, and 48% at 3, 9, 12, 18, and 24 months, respectively. All surviving patients in the heart transplantation group had functional class I symptoms. After cardiomyoplasty 90% of surviving patients had class I or II symptoms and 10% had class III symptoms. However, in the medical treatment group 27% of surviving patients had class I or II symptoms and 67% had class III or IV symptoms. In the cardiomyoplasty group left ventricular ejection fraction increased from 20% +/- 3% to 24.4% +/- 6.3% at 6 months (p < 0.05). In the heart transplantation group the left ventricular ejection fraction normalized, and the mean value of the left ventricular ejection fraction did not change in the medical treatment group. The need for endomyocardial biopsy and the incidence of rejection and infection were characteristics of the heart transplantation group., Conclusions: In properly selected patients, cardiomyoplasty and heart transplantation seem to be associated with improvement in survival and functional class at mid-term follow-up. Heart transplantation was more effective than cardiomyoplasty for functional class improvement.

Background: The purpose of this article is to provide an overview of the current indications, results, and perspectives of dynamic cardiomyoplasty in the treatment of patients with dilated cardiomyopathy. Particular emphasis is placed on the clinical experience with 36 patients operated at the São Paulo Heart Institute between 1988 and 1995., Methods: Based on several clinical reports, the mechanisms of action of dynamic cardiomyoplasty in these patients include the enhancement of left ventricular systolic function, by the direct action of synchronized skeletal muscle flap contraction and the reversion of chamber remodeling. Moreover, both mechanisms seem to be responsible for improved diastolic function properties and for the decrease of ventricular wall stress. Besides the acceptable hospital mortality observed for patients with dilated cardiomyopathy ranging from 0% to 8% with this surgical procedure, clinical improvement after dynamic cardiomyoplasty has been demonstrated as a prevailing and significant outcome., Results: Nevertheless, the 1-year survival for these patients ranges from 82% to 86% and the 5-year survival on the order of 41% to 49%. In addition, the analysis of factors influencing the outcome showed that cardiomyoplasty long-term survival was significantly affected by the severity of preoperative clinical compromise and cardiac function impairment. On the other hand, patients with dilated cardiomyopathy who were operated in functional Class III or intermittent Class IV and with pulmonary vascular resistance below 4 Wood units, present survival rates on the order of 79% at 2 years and of 64% at 5 years of follow-up, which are similar to those reported after cardiac transplantation., Conclusions: Furthermore, technological advances incorporated in the new cardiomyostimulators may ameliorate skeletal muscle flap performance at long term. Other developments are also discussed in this field.

Improvement in congestive heart failure and left ventricular function after dynamic cardiomyoplasty has been reported in patients with severe cardiomyopathies, but the long-term effects of this procedure remain unclear. In this investigation 31 patients undergoing cardiomyoplasty for treatment of idiopathic dilated cardiomyopathy were annually investigated with radionuclide scintigraphy, Doppler echocardiography, and right-sided heart catheterization. They were in New York Heart Association functional class III or IV before the operation. No hospital deaths occurred, but one patient with progressive heart failure required urgent heart transplantation 42 days after cardiomyoplasty. The other patients were followed up from 6 to 70 months (mean 25.6 months) and 12 patients died at late follow-up. Actuarial survivals were 86% at 1 year, 61.4% at 2 years, and 42.5% at 3 to 5 years of follow-up. Multivariate analysis of factors influencing outcome showed that long-term survival was significantly affected by preoperative functional class and pulmonary vascular resistance. Functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.7 in the surviving patients (p < 0.01). Furthermore, left ventricular ejection fraction improved from 19.8% +/- 3% to 23.9% +/- 7.2% (p < 0.01), and significant changes in stroke index, arterial pressure, pulmonary wedge pressure, and left ventricular stroke work index were also found at 6 months of follow-up. In the late postoperative period, the left ventricular ejection fraction tended to decrease and returned to preoperative levels at 5 years, whereas hemodynamic variables did not change significantly. Thus, despite the tendency of the left ventricular ejection fraction to decrease at late follow-up, the long-term course of these patients seems to be characterized by the maintenance of hemodynamic improvement. However, long-term survival after cardiomyoplasty is limited by the severity of the patient's condition before the operation.

Background: Long-term clinical and hemodynamic benefits of dynamic cardiomyoplasty (DC) have been reported. However, no information is available about long-term morphological changes in the wrapped latissimus dorsi (LD) muscle in humans., Methods and Results: The LD muscle flap was evaluated by magnetic resonance imaging (MRI) in 13 patients submitted to dynamic cardiomyoplasty for treatment of severe dilated cardiomyopathy. Eight patients were studied 15 days after the surgery (group 1) and 5 patients were studied from 24 to 52 months after the surgical procedure at the time of the cardiomyostimulator replacement (group 2). In the interim, LD was stimulated with burst of 6 pulses (duration, 185 milliseconds; burst frequency, 30 Hz) synchronized to every cardiac contraction, with a maximum of 100 LD contractions per minute. Images were acquired on a GE Sigma 1.5-T system (echo time, 25 milliseconds; repetition time, R-R x 2; slice thickness, 8 mm). The thickness of the LD decreased from 19.6 +/- 7.3 mm for group 1 to 7.6 +/- 0.8 mm for group 2 (P < .01). In addition, the signal intensity of the LD was compared with that of thoracic skeletal muscle and was found to be significantly increased in group 2 (2.19 +/- 0.42) compared with group 1 (1.04 +/- 0.07, P < .001). The signal intensity for group 2 on the T1-weighted images was similar to that of subcutaneous fat in those images., Conclusions: Morphological changes in the wrapped LD muscle consistent with fatty degeneration occur after DC and can be detected by MRI. Further studies will be necessary to demonstrate the clinical significance of such LD muscle flap changes.

Background: The main causes of death in patients with severe cardiomyopathy are progressive heart failure and sudden death. The influence of cardiomyoplasty on the incidence of sudden death and arrhythmias in patients with cardiomyopathy remains unclear. The aim of this study was to investigate the occurrence of arrhythmias and sudden death after cardiomyoplasty., Methods and Results: We studied 32 patients (26 male, 6 female; mean age, 48 +/- 12 years) who submitted to cardiomyoplasty for treatment of heart failure in New York Heart Association (NYHA) class III (n = 24) or class IV (n = 8). The etiology was idiopathic dilated cardiomyopathy in 27 patients, ischemic heart disease in 3 patients, and Chagas' heart disease in 2 patients. Patients were routinely studied before and every 6 months after cardiomyoplasty by means of radioisotopic angiography and 24-hour Holter monitor recordings. There were no operative or immediate postoperative deaths. During the postoperative period, 5 patients presented with acute atrial fibrillation and 1 had an episode of sustained ventricular tachycardia. All episodes were successfully treated with intravenous antiarrhythmic drugs or cardioversion. During follow-up (from 2 to 66 months), 15 patients died from sudden death (n = 5) or progressive heart failure (n = 10). Survival rates at 1, 2, and 4 years were 79.9 +/- 7%, 62.5 +/- 9.7% and 35 +/- 12.1%, respectively. At 6-month follow-up, NYHA functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.6 (P = .001) and left ventricular ejection fraction increased from 19.8 +/- 3.3% to 24 +/- 8.2% (P = .004). The mean values per day of premature ventricular complexes (PVCs) and episodes of nonsustained ventricular tachycardia (NSVT) did not change statistically. The mean number of PVCs per 24 hours before and at 6, 12, 24, 36, and 48 months after surgery were 126 +/- 44, 96 +/- 33, 90 +/- 29, 81 +/- 35, 71 +/- 35, and 59 +/- 48. The mean number of episodes of NSVT per 24 hours before and at 6, 12, 24, 36, and 48 months after surgery were 3.3 +/- 1.3, 1.9 +/- 0.5, 1.3 +/- 0.5, 1 +/- 0.5, 1.5 +/- 1.1, and 0.6 +/- 0.5, respectively. With respect to analysis of the idiopathic dilated cardiomyopathy subgroup, there also were no significant differences in the incidences of pre- and postoperative arrhythmias., Conclusions: Despite NYHA functional class and left ventricular function improvements observed after cardiomyoplasty, the incidence of arrhythmias did not change, and sudden death was an important finding mainly in late follow-up. The problem of sudden death after cardiomyoplasty, the mechanism that produces it, and the means to prevent it remain critical areas for future research.

Background: Dynamic cardiomyoplasty is a relatively new surgical procedure proposed for treatment of severe myocardial failure. Limited clinical experience suggests that this procedure reverses congestive heart failure, improving the long-term survival., Methods and Results: In this investigation, the late effects (16.5 +/- 4.8 months after surgery) of cardiomyoplasty on left ventricular mechanics and diastolic filling were studied in eight male patients (mean age, 45 +/- 7 years). The investigation was performed with the myostimulator on and off (24 +/- 1 hours off) using a microtip catheter to obtain the left ventricular pressures simultaneously with Doppler (inflow velocities) and M-mode and two-dimensional echocardiographic recordings. Statistical comparisons were made with Student's t test for paired data. Dynamic cardiomyoplasty increased the maximal elastance (17 +/- 1 versus 21 +/- 1 mm Hg/cm, P = .006) and decreased the systolic wall stress (253 +/- 17 versus 190 +/- 12 g/cm2, P = .029). Left ventricular end-diastolic pressure decreased (27.1 +/- 2.8 versus 17.6 +/- 1.7 mm Hg, P = .019), as did end-diastolic circumferential wall stress (69 +/- 8 versus 37 +/- 5 g/cm2, P = .002). The chamber and muscle stiffnesses decreased (120 +/- 31 versus 52 +/- 11 mm Hg/cm, P = .017; 994 +/- 185 versus 426 +/- 76 g/cm2, P = .002, respectively). The pattern of left ventricular diastolic filling changed, with a decrease of early peak flow (231 +/- 20 versus 217 +/- 21 mL/s, P = .022), of deceleration time (163 +/- 28 versus 116 +/- 26 seconds, P = .001), and of flow area during rapid filling (105 +/- 15 versus 75 +/- 12 mL, P = .004) and an increase of flow area during atrial contraction (39 +/- 4 versus 88 +/- 9 mL, P = .001)., Conclusions: Our detailed evaluation of left ventricular mechanics demonstrates that cardiomyoplasty has significant multiple beneficial effects on dilated myopathic heart.

Background: Dynamic cardiomyoplasty may provide functional and hemodynamic improvement in patients with heart failure. The purpose of this study was to investigate the effects of cardiomyoplasty on global ejection fraction, regional wall motion, and geometry of the left ventricle., Methods and Results: These parameters were determined in 10 patients submitted to cardiomyoplasty for treatment of refractory heart failure by left ventricular (LV) angiography. The studies were performed before and 16.5 +/- 4.8 months after cardiomyoplasty with the myostimulator turned on. They were repeated 24 +/- 1 hours with the myostimulator turned off in eight patients. LV ejection fractions were determined by the area-length method, and the centerline method was used for assessment of regional wall motion. LV geometry was studied by LV major-to-minor axis ratio and sphericity index. A LV ejection fraction improvement from 15 +/- 8% to 30.9 +/- 8.3% (p < 0.01) was demonstrated with the myostimulator turned on after cardiomyoplasty. The values with the myostimulator turned off were 23 +/- 13%, remaining higher than the values observed before surgery (p < 0.05). Regional wall motion analysis showed an improvement in all studied regions. Regarding the LV shape, the left ventricle became markedly more spheric in the diastole., Conclusions: Dynamic cardiomyoplasty may improve LV function in selected patients. The analysis of LV wall motion corroborated these results, and these changes were associated with modifications in the LV geometry.

Surgical support to the failing heart has been investigated in the treatment of severe myocardial failure. Dynamic cardiomyoplasty was indicated in 32 patients with dilated or chagasic cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximum medical therapy. Fifteen patients were operated on, and 17 refused the surgical treatment and were maintained by clinical means. With an average follow-up period of 12.3 months, actuarial survival rates for cardiomyoplasty patients were 86.6% at 6 months, 78.7% at 1 year, and 65.6% at 2 years of follow-up, whereas patients under medical therapy presented survival rates of 58.8%, 41.1%, and 27.4% at the same periods, respectively (p = 0.03). Furthermore, five of the 11 surviving patients of the cardiomyoplasty group are in NYHA class I, five in class II, and one in class III. At 6 months of cardiomyoplasty follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.1 +/- 3.9% to 26.8 +/- 7.5% (p less than 0.01). Cardiopulmonary exercise testing showed that maximum oxygen consumption during treadmill testing improved from 14.7 +/- 3.9 to 18.3 +/- 3.9 ml/kg/min (p = 0.01). At 1 year of follow-up, these data remained essentially unchanged. In conclusion, dynamic cardiomyoplasty reverses congestive heart failure and improves the long-term survival of patients with severe cardiomyopathies.

Dynamic cardiomyoplasty has been reported in the treatment of severe myocardial failure. In this investigation significant improvement of left ventricular function with dynamic cardiomyoplasty was demonstrated in patients with dilated cardiomyopathy or Chagas' disease for more than 1 year of follow-up. Thirteen patients with advanced heart failure who were in New York Heart Association class III or IV were operated on. There were no operative deaths. Patients were followed up for a mean of 11.5 months, and two patients died during the late follow-up period. Five of nine patients observed long term are in New York Heart Association class I, three in class II, and one in class III. At 3 months of follow-up, Doppler echocardiography demonstrated that left ventricular segmental wall shortening increased from 11.4% +/- 2.3% to 16.4% +/- 3.9% (p less than 0.01), and left ventricular stroke volume from 23.9 +/- 5.7 to 34.4 +/- 10 ml (p less than 0.01). Radioisotopic left ventricular ejection fraction improved from 20.9% +/- 3.3% to 25.4% +/- 7.7% (p = 0.06), and its better increases occurred in patients with lesser left ventricular end-diastolic dimensions. Cardiac catheterization showed that left ventricular stroke work index increased from 14.6 +/- 3.8 to 23.7 +/- 6.7 gm.m/m2 (p less than 0.01), whereas pulmonary wedge pressure decreased from 24.8 +/- 3.7 to 17.2 +/- 5.8 mm Hg (p less than 0.01). At 6 and 12 months of follow-up, all the preceding values remained essentially unchanged. Thus cardiomyoplasty improves left ventricular function and may halt the steady evolution of severe cardiomyopathies.

Stimulated skeletal muscle grafts have been proposed as a means to reinforce ventricular wall in the treatment of severe myocardial failure. Latissimus dorsi cardiomyoplasty was performed in 11 patients with advanced heart failure due to cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximal medical therapy. There were no operative deaths. Eight patients were followed for a mean of 10.8 months. Two patients remain in muscle conditioning protocol. One patient died with latissimus dorsi ischemia and congestive heart failure. Four of the eight patients in long-term follow-up are in NYHA class I, three in class II, and one in class III. At 3 months of follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.5 +/- 3.6% to 26.8 +/- 8.1% (p less than 0.01). Doppler-echocardiography demonstrated that left ventricular segmental wall shortening improved from 11.3 +/- 2.5% to 16.5 +/- 3.9% (p less than 0.01) and left ventricular stroke volume from 22.9 +/- 4.6 to 33.1 +/- 10 ml (p less than 0.01). Cardiopulmonary exercise test showed that maximal oxygen consumption during treadmill test increased from 14.8 +/- 3.7 to 18.2 +/- 3.3 ml/kg.min (p less than 0.05). At 6 months of follow-up, all the above values remained essentially unchanged. Furthermore, nonsustained ventricular tachycardia was abolished without specific medical therapy in four patients. Thus, cardiomyoplasty improves left ventricular function, reverses congestive heart failure, and may improve long-term survival in severe cardiomyopathies.