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Ann Thorac Surg 1999;67:387-391
© 1999 The Society of Thoracic Surgeons

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Original Articles

A survey on partial left ventriculectomy in the Asia–Pacific region

^a Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong

Accepted for publication June 19, 1998.

Address reprint requests to Dr Izzat, P.O. Box 33831, Rawda, Damascus, Syria
e-mail: izzat{at}cyberia.net.lb

	Abstract

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 
Background. There has been increasing interest in partial left ventriculectomy as a new therapy for end-stage heart failure. Because the most significant impact of this development is likely to be in regions where heart transplantation is largely unavailable, we conducted a survey among a group of cardiac surgeons based in the Asia–Pacific region to evaluate their overall views on partial left ventriculectomy procedures.

Methods. A questionnaire was sent to surgeons from 65 major institutions in 17 countries and regions in the Asia–Pacific. Questions examined current demographics and opinions regarding potential application and future prospects of this operation.

Results. Surveyed surgeons were based in equal proportions in academic, government, and private practice institutions. One third of respondents have already performed partial left ventriculectomy operations, largely in small numbers. In total, 86 procedures were performed with 75% hospital survival rate. Failures were thought to be caused by limited knowledge about patient selection criteria and lack of experience with operative technique and perioperative care. The majority of respondents believe that partial left ventriculectomy is potentially a valuable intervention and intend to perform more cases. Nevertheless, most surgeons identified the need to have larger clinical experience, to perform randomized trials against other therapeutic modalities, and to improve perioperative care.

Conclusions. Although all surgeons recognize that more knowledge is needed before partial left ventriculectomy becomes a standard procedure, it is clear from this survey that the procedure has rapidly gained interest, with more surgeons seeking to learn it.

	Introduction

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 
During the past 2 years there has been increasing interest in partial left ventriculectomy (PLV) as a new treatment modality for end-stage heart failure [1–3]. This has been prompted by the significant increase in the incidence of heart failure worldwide [4] and the restriction on wider application of heart transplantation by the limited availability of donated organs.

The most significant impact of the development of the PLV procedure, however, is likely to be in regions like the Asia–Pacific, in which the incidence of heart failure is rapidly approaching 0.4% of the entire population [5] and heart transplantation is largely unavailable. Indeed, only 247 heart transplantation procedures were carried out in 11 countries in Asia between 1991 and 1995 [6, 7].

Surgical Reduction of Ventricular Volume Trial (SURVIVAL) group, an international working group with members from 65 major institutions in 17 countries and regions in the Asia–Pacific, was recently formed to share experience and to improve the understanding of indication, techniques, and outcome of PLV [8]. This survey represents the views of this group.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 
In February 1998, a questionnaire was sent to all members of the SURVIVAL group to examine and poll, in a direct noncomparative fashion, the current demographics and attitudes of surgeons about the PLV procedure (including its potential application), present experience, and their opinion about its future prospects. The questionnaire was completed in full and returned by all members within 2 months of mailing. Responses were tabulated as absolute numbers and percentages without statistical analysis. This article presents the results of the most pertinent questions.

	Results

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 
Demographics
Seventy-six percent of respondents practice in academic or government institutions, and 24% in private practice settings. Heart transplantation is available in 36% of participating institutions, and left ventricular assist devices in 50%, whereas 35% of these centers have neither of these capabilities. Surveyed surgeons were quite experienced, with 66% having practiced cardiac surgery for 10 or more years, and more than 86% having at least 5 years of practice experience. Seventy-four percent of respondents perform more than 150 cardiac surgical operations annually (Fig 1).

View larger version (16K): [in this window] [in a new window]   Fig 1. (A) Years in practice of respondents. (B) Annual case load of respondents.

View larger version (12K): [in this window] [in a new window]   Fig 2. Causes of cardiomyopathy in partial left ventriculectomy cases performed in the Asia–Pacific region.

View larger version (13K): [in this window] [in a new window]   Fig 3. Factors believed to contribute to the current high early failure rate of partial left ventriculectomy. (LVAD/Tx = left ventricular assist device/transplantation.)

The availability of left ventricular assist devices and heart transplantation backup was considered necessary by 50% of respondents, the majority of whom have not yet performed PLV operations. Among those with experience in PLV procedures, only surgeons who have access to such backup facilities considered them to be crucial.

Almost all respondents (95%) believed that attending a live demonstration of the technique is necessary before embarking on performing the operation. In addition, the majority (80%) also thought that to start performing PLV operations, the surgeon should be assisted by a colleague with prior experience in this procedure.

The principal present limitations to wider adoption of the PLV procedure were believed to be (1) the unavailability of colleagues with relevant experience to advise early in the learning curve (80%), (2) lack of data about the indications for operation (70%), and (3) the unacceptable high failure rate (70%) (Fig 4). Lack of suitable candidates for the procedure was not believed to be an important factor (12% of respondents).

View larger version (12K): [in this window] [in a new window]   Fig 4. Factors believed to limit wider adoption of partial left ventriculectomy.

View larger version (12K): [in this window] [in a new window]   Fig 5. Factors believed to be critical for the future success of partial left ventriculectomy.

	Comment

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

Although any survey of a population is subjective by nature, surveyed surgeons in this study were based in equal proportions in academic, government, and private practice institutions, with a wide geographic distribution as well. Hence, this survey in our opinion is likely to represent fairly the overall status in the Asia–Pacific region.

The clinical significance of the development of PLV operations for the treatment of heart failure is clearly reflected by the large number of procedures that have already been performed in this region. It is clear, however, that only a small number of procedures are now being performed in each center, and the need to have larger clinical experience has been identified.

The main concern about PLV operations by the majority of surgeons remains the relatively high early procedural failure rate. Overwhelmingly, this was believed to be related to the limited knowledge about patient selection criteria or the lack of experience with perioperative care strategy. It was widely acknowledged that the increased risk associated with PLV procedures reflects in part the poor preoperative health status of candidates and the frequent presence of associated advanced comorbidities. Furthermore, there was a general consensus that lack of left ventricular assist devices and heart transplantation backup was unlikely to be an important contributing factor to current results.

Despite these concerns, the survey appears to indicate that the overall number of PLV procedures performed in the Asia–Pacific region will increase somewhat over the next 2 years. This is likely to encompass an increase in the number of procedures performed in each center and an increase in the total number of centers performing PLV operations. With this in mind, the majority of surgeons realized the significance of the early learning curve for the success of this operation. Hence, almost all surgeons believed that a surgeon should attend a live demonstration of the technique and should be assisted by a colleague with considerable prior experience before embarking on performing the procedure independently.

It is notable that the overwhelming majority of respondents (96%) believed that the PLV procedure is potentially a valuable treatment option for end-stage heart failure. Nevertheless, expectations for future applicability appear to be realistic, and they hinged on acquiring more knowledge about this procedure. Most surgeons, therefore, identified the need to have larger clinical experience, to perform randomized trials against other currently available treatment modalities, and to improve perioperative care protocols.

The possibility of successful PLV operations offers a new hope for patients with end-stage heart failure who, with the current extreme shortage of donor organs in regions such as the Asia–Pacific, have a restricted lifestyle and gloomy prognosis. Although cardiac surgeons recognize that much effort is required before this operation becomes a standard procedure, it is clear from this survey that PLV procedures are rapidly gaining interest, with more surgeons and centers seeking to learn the procedure (Appendix 1).

	Appendix 1. The members of the SURVIVAL Asia–Pacific group

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 

Name Institution City Country Brian Buxton Victorian Heart Center Richmond Australia John L. Knight Flinders Medical Center South Australia Australia Julian A. Smith Alfred Hospital Victoria Australia James Tatoulis Royal Melbourne Hospital Victoria Australia Peter Tesar Prince Charles Hospital Chermside Australia Mohammad Bashar Izzat The Chinese University of Hong Kong Hong Kong China Xu Ping Qingdao University Qingdao China Anthony P. C. Yim The Chinese University of Hong Kong Hong Kong China Chen Zhong Yuan Shanghai Second Medical University Shanghai China Bao-Ren Zhang Changhai Hospital Shanghai China K. K. Cherian Institute of Cardiovascular Diseases Chennai India K. M. Cherian Institute of Cardiovascular Diseases Chennai India Himansu K. Dasmahapatra Peerless Hospital Calcutta India Anil Jain Rajasthan Hospital Ahmedabad India A.G. Jayakrishnan Srge Uthradom Thirunal Hospital Trivandrum India Arkalgud S. Kumar All India Institute of Medical Sciences New Delhi India Pavan Kumar P.D. Hinduja National Hospital Mumbai India Nitu V. Mandke Lilavati Hospital & Research Center Mumbai India S. Muralidharan G. Kuppuswami Naidu Memorial Hospital Coinbatore India Kaushal Pandey P.D. Hinduja National Hospital & Medical Bombay India Dharma Rakshak Nizams Institute of Medical Sciences Hyderabad India D. Prasada Rao Care Hospital Hyderabad India Edwin Ravikumar Christian Medical College Hospital Vellore India Devendra S. Saksena Bombay Hospital & Medical Research Center Bombay India Kole Shrikant Bombay Hospital Mumbai India Solomon Victor The Heart Institute Chennai Chennai India Maizul Anwar National Cardiac Center Jakartra Barat Indonesia Adhiwidjdja Budhi Rajawali Hospital Bandung Indonesia Ito Puruhito Airlangga University Medical School Surabaya Indonesia T. Isomura Shounann Kamakura General Hospital Kamakura Japan Yasushi Kawaue Hiroshima General Hospital Hiroshima Japan Takashi Kunihara Hokkaido University Sapporo Japan Hikaru Matsuda Osaka University Medical School Osaka Japan Kiyofumi Morishita Sapporo Medical University Sapporo Japan Katsushi Oda Kochi Medical School Kochi Japan Shinji Sano Okayama University Medical School Okayama Japan Akira Seki Okazaki Municipal Hospital Aichi Japan Hisayoshi Suma Shounann Kamakura General Hospital Kamakura Japan Juro Wada Yudou Clinic Medical Center Tokyo Japan Hyuk Ahn Seoul National University Hospital Seoul Korea Bong Hyun Chang Kyungpook National University Hospital Taegu Korea Byung-Chul Chang Yonsei University Seoul Korea Kwang-Hyun Cho Inje University Pusan Paik Hospital Pusan Korea Dong-Hyup Lee Yeungnam University Hospital Taegu Korea Weonyong Lee Kangdong Sacred Heart Hospital Seoul Korea Sang Joon Oh Inje University Seoul Paik Hospital Seoul Korea Sin Keat Khoo National Heart Institute Kuala Lumpur Malaysia Poo Sing Wong Sultanah Aminah Hospital Johor Bahru Malaysia N. Baasanjav National Institute of Health Ulaanbaatar Mongolia David Haydock Green Lane Hospital Auckland New Zealand Peter Raudkivi Green Lane Hospital Auckland New Zealand Masud ur-Rehman Kiani Armed Forces Institute of Cardiology Rawalpindi Pakistan Parvez Mannan Postgraduate Medical Institute Hayatabad Pakistan J. Garcia Makati Medical Center Makati Philippines Adrian E. Manapat Makati Medical Center Makati Philippines Seong Huat Saw Gleneagles Medical Center Singapore Singapore Eugene Sim National University Hospital Singapore Singapore Tan Yong Seng Singapore General Hospital Singapore Singapore Ming Chuan Tong Singapore National Heart Center Singapore Singapore Sami S. Kabbani Damascus University Damascus Syria Chung-I Chang National Taiwan University Hospital Taipei Taiwan Yu-Sheng Chang Chang Gung Memorial Hospital Taipei Taiwan Hou Shou Hsien Mackay Memorial Hospital Taipei Taiwan Tarng-Jenn Yu Veterans General Hospital—Taipei Taipei Taiwan Chalit Cheanvechai Chulalongkorn Hospital Bangkok Thailand Weerachai Nawarawong Chiangmai University Chiangmai Thailand Pinya Sakiyalak Siriraj Hospital Bangkok Thailand Yoosuph Abdul-Nazer Al-Mafraq Hospital Abu-Dhabi Unite Arab Emirates

SURVIVAL = Surgical Reduction of Ventricular Volume Trial.

	References

Top Abstract Introduction Material and methods Results Comment Appendix 1. The members... References

 

1. Batista R.J.V., Santos J.L.V., Takeshita N., Bocchino L., Lima P.N., Cunha M.A. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Card Surg 1996;11:96-97.[Medline]
2. 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]
3. Angelini G.D., Pryn S., Mehta D., et al. Left-ventricular-volume reduction for end-stage heart failure. Lancet 1997;350:489.[Medline]
4. Tavazzi L. Epidemiology of dilated cardiomyopathy: a still undetermined entity. Eur Heart J 1997;18:4-6.[Free Full Text]
5. Sanderson J., Chan S.K.W., Chan W.W.M., Hung Y.T., Woo K.S. The aetiology of heart failure in the Chinese population of Hong Kong—a prospective study of 730 consecuive patients. Int J Cardiol 1995;51:29-35.[Medline]
6. Takagi H. Organ transplants still too few in Japan and Asian countries. Transplant Proc 1997;29:1580-1583.[Medline]
7. Ota K., Teraoka S., Kawai T. Donor difficulties in Japan and Asian countries. Transplant Proc 1995;27:83-86.[Medline]
8. Regional news. Asian Cardiovasc Thorac Ann 1998;6:33A.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohammad Bashar Izzat Anthony P.C. Yim Song Wan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Izzat, M. B. Articles by Atassi, W. Search for Related Content PubMed PubMed Citation Articles by Izzat, M. B. Articles by Atassi, W.