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Objective: We sought to examine the hemodynamic effects at 1 month and 1 year of left ventricular reconstruction by means of endoventricular patch plasty for patients with acute or chronic, very severe post-myocardial infarction heart failure who would have been systematically excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial., Methods: From 2002 to May 2008, 274 patients underwent left ventricular reconstruction for post-myocardial infarction scarring; 117 of these patients would not have been eligible for the STICH trial. The pertinent criteria for exclusion included 12 patients with no coronary vessel suitable for coronary artery bypass grafting; 17 patients within a month of myocardial infarction, including 11 with acute heart failure (8 septal ruptures and 3 cases of ventricular tachycardia); 48 patients receiving intravenous inotropes, intra-aortic balloon pumping, or both; 15 patients with bifocal or posterior scarring; 4 patients scheduled for heart transplantation; and 21 patients meeting 5 other exclusion criteria. These patients (mean age, 64 years; age range, 34-83 years) preoperatively had a mean 49% (range, 35%-75%) scarred left ventricular circumference, as determined by means of magnetic resonance imaging assessment. In the patients with chronic heart failure, the preoperative ejection fraction was 26% ± 4% (range, 9%-34%), the end-diastolic volume index was 130 ± 43 mL/m(2) (range, 62-343 mL/m(2)), and the end-systolic volume index was 95 ± 37 mL/m(2) (range, 45-289 mL/m(2)). Mitral regurgitation was mild to severe in 56 patients and associated with annular dilatation (≥35 mm) in 51 patients. A strategy of left ventricular reconstruction by means of endoventricular circular suturing and patching excluded the scarred left ventricular wall and was balloon sized to provide a diastolic volume of 50 mL/m(2). Circular patches were used for anteroseptoapical lesions, and triangular patches were used for posterior lesions. The mitral valve was repaired in 51 patients, and coronary revascularization was performed in 105 patients (arterial grafts in 95 and mixed in 12). Seventy-eight patients had endocardectomy, and cryotherapy was used in 39 patients for ventricular tachycardia., Results: Four in-hospital and 2 delayed deaths occurred during the first year. In 101 patients with chronic heart failure, magnetic resonance imaging revealed that ejection fraction improved from 26% ± 4% preoperatively to 40% ± 8% at 1 month and 44% ± 11% at 1 year postoperatively. At these same time points, the end-diastolic volume index was reduced from 130 ± 43 mL/m(2) to 81 ± 27 and 82 ± 25 mL/m(2), respectively, and the end-systolic volume index was reduced from 96 ± 45 mL/m(2) to 50 ± 21 and 47 ± 20 mL/m(2), respectively., Conclusions: With minimal associated mortality, left ventricular reconstruction produces durable improvement in left ventricular function in patients with a large scarred ventricular wall. Considering that this patient cohort would have been systematically excluded from the STICH trial, care should be taken not to extrapolate that study's results too widely so as to inappropriately deny selected patients an effective treatment for ischemic cardiomyopathies with an injured ventricle., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

The first experience with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular (LV) geometry made more spheric after myocardial infarction. The consequence is dilated ischemic cardiomyopathy. In anterior infarction, the free LV wall and septum are scarred and become dyskinetic or akinetic. The fundamental approach excludes the noncontractile (asynergy) and nonresectable regions to restore more normal size and shape. The current experience of our group in 2001, includes 1,011 patients, and confirmation of our results by others, including an international team. The basic components are LV reconstruction, revascularization, and mitral repair (when needed), which form an integrated method of surgical management. Endocardiectomy and cryoablation are used with spontaneous and inducible ventricular arrhythmias. This article reviews these results and summarizes 10 important points concerning the surgical treatment of ischemic dilated cardiomyopathy that may provide guidelines for the future. These data indicate EVCPP, and its variations, form the central theme in surgical treatment of congestive heart failure.

Most cases of left ventricular aneurysms undergo operation through resection of the exteriorized dyskinetic area with longitudinal suturing of the opening and this technique has been considered by cardiologists (Froehlich et al) to bring no improvement to the morphology and performance of the left ventricle. Some technical modifications have been adopted, such as the septal plicature (Cooley) or circular suturing of the opening (Jatene). Since 1984 our team has used an endoventricular patch, sutured over the contractile area and excluding the akinetic non-resectable scars, bringing a significant and calculable improvement to the left ventricular function. This technique of left ventricular reconstruction (LVR), called endoventricular circular patch plasty (EVCPP) has been already used on more than 750 patients (May 97). Clinical and echographic data for each case are completed by right catheterisation with measurement of the cardiac output, pulmonary arterial pressures (PAP) and programmed ventricular stimulation (PVS), in order to detect eventual ventricular tachycardia (IVT). During left heart catheterisation, the morphology of the left ventricle (LV) is studied on right and left anterior oblique incidences and the LV ejection fraction (EF) is checked globally (GEF) and especially in its contractile portion (CEF). After surgery, a hemodynamic study associated with a PVS, is carried out during the first post-operative month, and again after one year. Results were clinically satisfactory in more than 90% of cases (8.9% of NYHA III-IV), and in more than 90% of cases with ventricular arrhythmia with the hemodynamic persistent EF at one year, superior to the pre-operative CEF. Thus we have to propose the following indications: Elective: This ventricular reconstruction can be recommended for ventricular aneurysms or akinesias with angina, arrhythmias or attacks of cardiac insufficiency, when GEF > 30% and CEF > 40%. The operative mortality rate varies from 1,5 to 3%, which is better than allowing natural evolution. Mandatory: In emergency, when safe immediate circulatory assistance or a cardiac transplant is unavailable, LVR can give hope for survival to more than 80% of patients, whereas natural evolution is without hope. Finally the operative indication is uncertain in two contrasting circumstances: In asymptomatic patients when hemodynamic and angiographic examinations after myocardial infarction show left ventricular dyskinesia. If GEF is below 40% and CEF below 50%, it seems wise to propose LVR in order to prevent unfavourable evolution. In end-stage ischemic cardiomyopathies, if the EF is below 20%, CEF is below 30%, cardiac output is below 1.5 l, and the mean pulmonary pressure is above 25, then a cardiac transplant should be considered. EVCPP with septal exclusion is a safe technique and easily reproduced when associated with coronary revascularization as far as practicable, then EVCPP improves the ventricular function. When associated with sub-total endocardectomy, then EVCPP allows excellent control of VA.

Since 1968, following Cooley's and Zubiate's group presentation, our team has been using extracorporeal circulation (ECC) with hemodilution without use of blood for priming of the circuit. Progressively this technique, that was only reserved to the Jehovah's Witnesses, became routine. Whereas in 1980, 30% of the patients operated by our group had not received any blood products during their stay in hospital, in the last few years, 1987-95, more than 80% of the patients could benefit from this technique. So, out of 15,573 cardiac surgeries under ECC performed between 1972 and 97, 14,798 (95%) were done in auto-perfusion, and 314 to Jehovah's Witnesses. The results of this routine technique, not using blood, was analysed in the adult as well as the child. More precisely, 100 adults operated on consecutively in 1995 and 50 children of less than 15 kilos operated on in 1994 were closely examined clinically and biologically. In adults, biology was studied in the 90 patients who did not receive any blood, and showed, as already quoted in previous studies on identical or larger series, the following evolution of the different parameters: Hematocrit went from 41% in a pre-operative mean value to 33% at the 10th day, which is a decrease of 20%. Hemoglobin went from 14 gr to 11 gr, that is a decrease of 21%. Proteinemia which was at 73 gr pre-operatively decreased to 58 gr at the first day to reach 60 gr at the 10th day (decrease of 13%). In children, blood was necessary in 20 among 28 patients below 8 kg (group I), and no blood was used for the 22 patients above 8 kg (group II). Regarding the biological results, in the group I, hematocrit showed a decrease of 18% between the day before surgery and 1 day after. Hemoglobin a decrease of 17%, platelets a decrease of 56% and Protides 3%. Fibrine showed a decrease of 43% the day of surgery, and an increase of 15% at day 1; and the Prothrombine time finally decreased by 24%. The results are very similar in group II. In conclusion, cardiac surgery without any pre or post-operative use of blood is therefore possible, simply, without pre-donation or without any particular treatment in 90% of adults of all ages and pathologies, and in over 50% of children (78% if category is over 7 kg) and has satisfactory results.

To determine the efficacy of left ventricular (LV) aneurysm resection and endoventricular patch repair with septal exclusion in patients with severely depressed pump function, we retrospectively selected 62 patients (mean age 59 +/- 7 years) with preoperative LV ejection fraction < or = 20%, from a series of 322 patients with postinfarction LV aneurysm who underwent this type of surgery at our center during a 5-year period. Mean ejection fraction was 17 +/- 3%; all patients were in New York Heart Association (NYHA) class III/IV, and all had hemodynamic and electrophysiologic studies before and after surgery. We analyzed both operative and long-term survival, and hemodynamic, electrophysiologic, and angiographic variables, as well as the symptomatic state after surgery. Follow-up was available in all patients (mean 23 +/- 14 months). Subtotal endocardiectomy and cryotherapy were associated in patients presenting with spontaneous or inducible ventricular arrhythmias (VA). Hospital mortality rate was 19.3%. Ejection fraction improved from 17 +/- 3% to 37 +/- 10% (p < 0.001); ventricular arrhythmias decreased significantly after surgery. Factors influencing early mortality at multivariate analysis were the presence of critical lesions on the circumflex artery and the duration of cardiopulmonary bypass. At 1-year control, a significant reduction in NYHA class was observed and no patient was in NYHA class IV. The improvement in ejection fraction was maintained (39 +/- 11%), as well as the reduction in inducible and spontaneous ventricular arrhythmias. There were 5 late deaths at follow-up, accounting for a late mortality of 10% at 5 years.

We analyzed the effects of nonguided endocardiectomy in patients with ischemic ventricular arrhythmias who underwent reconstructive operations for postinfarction left ventricular aneurysm. A total of 106 patients among 287 consecutive patients had spontaneous or inducible ventricular tachycardia (49 spontaneous and 57 inducible). Cryotherapy was done in 67 patients and coronary revascularization was done in 98%. Patients underwent complete hemodynamic study including programmed ventricular stimulation before and early after operation. Thirty-seven patients underwent hemodynamic evaluation after 1 year. The hospital mortality rate was 7.5%. At early and late studies the mean ejection fraction was significantly increased. Ventricular tachycardia was no longer inducible in 92% of patients after operation; only two patients had spontaneous ventricular tachycardia early after operation. At late study 10.8% of patients had inducible ventricular tachycardia and no spontaneous ventricular tachycardia was documented. All surviving patients had clinical follow-up (mean 21.3 months, range 2 to 64 months). There were eight late deaths and no episodes of ventricular tachycardia or syncope that necessitated hospitalization. In conclusion, nonguided, extended endocardiectomy associated with left ventricular reconstruction is safe and effective in curing ischemic spontaneous and inducible ventricular tachycardia.

To assess the efficacy of left ventricular (LV) reconstruction after aneurysmectomy, 35 consecutive patients with anterior LV aneurysm were studied before and after surgery. Surgical technique was performed by applying a circular patch after aneurysmectomy to maintain a "more physiological" LV cavity. Myocardial revascularization was performed in all but 1 patient concurrently. Global perioperative mortality was 4.8%. LV filling pressure and volumes and regional wall motion were assessed before and after surgery. The major indication for surgery was angina; 8 patients were in New York Heart Association class III/IV. The results showed a significant decrease in end-diastolic volume index (from 120 +/- 55 ml/m2 to 76 +/- 22 ml/m2, p less than 0.001), end-systolic volume index (from 74 +/- 44 ml/m2 to 40 +/- 18 ml/m2, p less than 0.001) and end-diastolic pressure (from 17 +/- 7 mm Hg to 13 +/- 5 mm Hg, p less than 0.05). Ejection fraction significantly increased (from 39 +/- 13% to 49 +/- 15%, p less than 0.001). LV wall motion significantly improved in all but the anterobasal region; the extent of LV asynergy significantly decreased after surgery. Six of the 35 patients had a deterioration of postintervention ejection fraction (from 44 +/- 14% to 34 +/- 9%). They had no reduction in LV volumes and no improvement in wall kinetics. It is concluded that LV reconstruction after aneurysmectomy induces significant early improvement of global and regional LV function in most patients; postoperative functional improvement is mainly related to the increase in inferior LV wall motion.

Since 1984 the authors have developed a technical modification of left ventricular surgery after myocardial infarction. The principle is to reorganise the contractile muscle in a circumferential manner by excluding the fibrous akinetic parts of the interventricular septum. The operation consists of implanting sutures distally then resecting the exteriorized fibrous zones and finally mobilising the scarred endocardium in the zones inaccessible to resection (septum and the base of the anterior and posterior papillary muscles) up to the limits of the viable myocardium. A patch of septal endocardium or dacron lined with pericardium is sutured in the contractile muscular zone. One hundred and fifty patients have been operated for cardiac failure (37%), angina (40%) or arrhythmias (10%). One third of patients required intra-aortic balloon pumping in the preoperative period. Myocardial revascularisation was associated in 75% of cases. Surgery was performed as an emergency in 33 cases (25% mortality); in the remaining 117 cases the mortality was 5%. Postoperative control assessment (115 immediate postoperative and 60 one year controls) showed the left ventricular geometry to be almost normal and the global ejection fraction to have increased by an average of 17%. This technique of left ventricular remodelling with septal exclusion enables the surgeon to perform a more physiological repair in patients without cardiac failure and to extend the surgical indications in patients with cardiac failure.

Between November 1978 and March 1985, 27 cardiac transplant operations were performed at the Arnault Tzanck Institute; Barnard's heterotopic method was used in 21 cases. In 16 cases, follow-up was prolonged to assess the effects on the assisted receiving heart. In the first postoperative hours the receiving heart is often more effective than the graft. There were no pathological consequences due to the two different rhythms. The increased pressures in the right cavities of the receiving heart decreased but sometimes this look several weeks. The volume of the left atrium decreased. Left ventricular contraction was unchanged in some cases but in others it improved significantly. This was accompanied by an average decrease of 20 mm in echocardiographic left ventricular end diastolic internal dimension. This technique of heterotopic assistance seems particularly suitable for advanced stages of cardiomyopathy with stage IV pulmonary hypertension.

Having employed routinely the monitor of cerebral function in cardiac surgery operations for about a year, the authors now present an analysis of the variations in the traces of a group of 57 patients. They have found, when there is no major haemodynamic consequence associated with the induction of anaesthesia, and when there are no difficulties of a surgical or a technical nature accompanying the artificial extra-corporeal circulation, that the monitor curve stays perfectly stable. On the other hand, all sudden haemodynamic changes result in hypotension (haemorrhage, dysrhythmia, and a fall in flow in the extracorporeal circulation) that is reflected in the level of the monitor curve which also falls. They conclude, using examples of certain variations, that the monitor curve is a supplementary form of surveillance and that the trace recorded simultaneously with the anaesthetic sheet allows retrospective analysis of the haemodynamic events to be performed for each operation.