Ann Thorac Surg 2004;78:1100-1102
© 2004 The Society of Thoracic Surgeons
How to do it
Surgical anterior ventricular restoration in patients with aortic regurgitation
Pasala S. Ravichandran, MDa,
Bahaaldin Alsoufi, MDa,*,
Constantine L. Athanasuleas, MDb,
Gerald D. Buckberg, MDc
a Oregon Health and Science University, Portland, Oregon, USA
b Norwood Clinic and Kemp-Carraway Heart Institute, Birmingham, Alabama, USA
c David Geffen School of Medicine at the University of California–Los Angeles, Los Angeles, California, USA
Accepted for publication August 7, 2003.
* Address reprint requests to Dr Alsoufi, Department of Cardiothoracic Surgery, Oregon Health and Science University, 8515 SW Apple Way, No Q-201, Portland, OR 97225, USA.
balsoufi{at}hotmail.com
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Abstract
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My colleagues and I describe a novel method of perfusion during surgical anterior ventricular restoration in patients with aortic regurgitation. The modified technique was used in 2 patients with aortic incompetence who required the restoration operation.
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Introduction
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| Drs Athanasuleas and Buckberg disclose that they have a financial relationship with Somanetics.
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Ventricular restoration is an operation that reduces ventricular volume [1]. It is applied in patients with congestive heart failure after anterior myocardial infarction. Its efficacy has been established, and it offers sustained relief from symptoms of congestive heart failure, as evidenced by long-term results [2].
A method of myocardial protection that has been advocated during this procedure is placement of an endoventricular patch in the open beating heart [3, 4]. Concomitant coronary bypass, mitral valve repair, or both are performed in the arrested heart by using antegrade/retrograde blood cardioplegia by the "integrated method" [5]. The beating heart is used for restoration, and the method of protection is modified if there is aortic regurgitation. Without aortic insufficiency, the aortic clamp is removed, and the open beating heart is incised while the left ventricle is vented by the right superior pulmonary vein. After the apical incision is made, a demarcating suture (Fontan suture) is placed to exclude the noncontracting segment. The open beating method facilitates this placement aided by palpation and ensures ongoing perfusion during the restoration procedure in these high-risk patients. The raised edge created by this suture is the platform onto which a patch is constructed. This technique is associated with excellent results even in severely depressed ventricles [3].
The presence of significant aortic regurgitation presents a problem in the unclamped open beating heart, because blood will normally flood the field during patch placement. To circumvent this, a novel method of perfusion is used to combine simultaneous antegrade perfusion through the vein and arterial grafts and retrograde perfusion through the coronary sinus, as described in the following cases that illustrate how to deal with this matter.
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Technique
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Case 1
A 55-year-old hypertensive man sustained anterior myocardial infarction 6 years before admission and presented with worsening symptoms of angina and heart failure. His clinical status was New York Heart Association (NYHA) class III and Canadian Cardiovascular Society class III. His medications included nitroglycerin, angiotensin-converting enzyme inhibitors, ß-blockers, diuretics, digitalis, and aspirin. The exercise tolerance test results were positive. Technetium 99 nuclear study showed ischemia in the anteroseptal wall with fixed defects in the apical, inferoapical, distal anterior, distal septal, and distal anterolateral walls. Echocardiography demonstrated akinesia of the apical and distal septal segments with a global ejection fraction of 26%. A dilated left atrium and ventricle were noted with trace mitral regurgitation and moderate aortic regurgitation. Cardiac catheterization showed total occlusion of the left anterior descending artery (LAD), 50% stenosis of the circumflex artery with significant lesions in several marginal branches, and an 80% stenosis of the right coronary artery. The left ventricular end systolic volume index was 107 mL/m2 (reference range, 25 to 30 mL/m2).
A midline sternotomy was performed, and cardiopulmonary bypass was established through aortic cannulation, dual-stage venous atrial drainage, and placement of antegrade and retrograde cardioplegia cannulas. The left ventricle was vented through the right superior pulmonary vein. The patient was cooled to 32°C. After aortic cross-clamping, induction cardioplegia was administered through the retrograde cannula because of the aortic insufficiency. Distal vein anastomoses to 2 marginals and both branches of the right coronary were constructed by using vein grafts. At the conclusion of each distal anastomosis, cold cardioplegia was given retrograde and antegrade through the vein graft before the suture was tied. During the last distal anastomosis of the internal mammary artery to the LAD, the patient was warmed, and warm retrograde cardioplegia was infused. The internal mammary clamp was removed so that the heart perfused simultaneously through the internal mammary artery graft, the vein grafts, and the retrograde coronary sinus cannula (Fig 1). Coronary sinus pressure averaged 45 mm Hg. The aortic cross-clamp was left in place, and the heart resumed beating. The flow rate through the coronary sinus and perfused vein grafts was approximately 400 mL/min.
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Fig 1. The beating, clamped heart. The aorta was clamped while the myocardium was continuously perfused with warm blood through the internal mammary artery and unattached vein grafts and simultaneously through the coronary sinus.
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The anterior ventricular scar was opened 2 cm lateral to the LAD. The margin separating the contracting myocardium from the akinetic scar was identified by palpation of the open beating heart. An encircling Fontan suture was placed along this margin, excluding the akinetic septum and anterolateral wall. A medium (2 x 3-cm) CorRestore oval patch (bovine pericardium; Somanetics, Troy, MI) was placed at the level of the Fontan suture to reduce the size of the ventricle and restore the elliptical shape. The remaining procedure of left ventricular restoration was performed as previously described. The cross-clamp was released after adequate venting. The proximal anastomoses were performed with a partial aortic occluding clamp. Warm blood was perfused through the venous grafts until completion of all anastomoses. The patient was receiving minimal inotropic agents at the end of the operation and was extubated 5 hours thereafter. He was discharged on the fifth postoperative day. He is currently in NYHA and Canadian Cardiovascular Society class I.
Case 2
A 74-year-old man presented with acute anterior infarction and pulmonary edema after a 6-month history of severe dyspnea and class IV congestive heart failure. Eight years before this admission, he experienced an anterior myocardial infarction with successful reperfusion followed by angioplasty of the LAD. A few years later a circumflex artery was treated by angioplasty. The current admission demonstrated repeat anterior infarction complicated by severe mitral regurgitation. In addition, severe aortic regurgitation was present. Ventriculography confirmed a significant area of anteroapical and septal akinesia. The ejection fraction was 20%, and the left ventricular end-diastolic volume index was 93 mL/m2. Maximal medical therapy, including ß-blockers, angiotensin-converting enzyme inhibitors, and diuretics, failed to control the symptoms of congestive heart failure. Surgical therapy was indicated with special reference to aortic and mitral regurgitation.
The presence of aortic regurgitation necessitated aortic valve replacement. The patient was placed on cardiopulmonary bypass with mild (34°C) systemic hypothermia. Antegrade and retrograde cannulas were positioned. The aorta was cross-clamped, and warm high-potassium amino acid–enriched cardioplegia was administered retrograde and directly into the right coronary ostium for right-sided protection. This was followed by low-potassium cold maintenance cardioplegia. Vein grafts to the posterior descending artery, LAD, and marginal arteries were constructed. After each distal anastomosis, cardioplegia was administered through the unattached vein graft and simultaneously through the coronary sinus cannula. This was repeated every 15 minutes while the mitral valve was repaired with an annuloplasty ring, and the aortic valve was replaced with a pericardial prosthesis. Substrate-enriched warm blood cardioplegia was infused retrograde at 150 mL/min for 4 minutes followed by warm blood infusion, not to exceed a coronary sinus pressure of 40 mm Hg (approximately 400 mL/m), while the heart resumed contractility. The left ventricle was vented and opened. The anterior ventricle was 6 to 7 mm thick, with marbled fibrosis indicative of old infarction. Palpation was used to identify the margins of the contractile and noncontractile ventricle. An encircling suture was placed into this region and tightened. This created a platform onto which a medium CorRestore patch was secured. Proximal grafts were attached to the aorta, and the cross-clamp was then released. The patient was weaned off bypass on minimal inotropic agents.
The patient was extubated on the second postoperative day. Electrophysiologic testing on the seventh day demonstrated inducible ventricular tachycardia. An implantable defibrillator was placed, and the patient was discharged to a rehabilitation facility, where he remained for 10 days. At 6-month follow-up, the patient was NYHA functional class II.
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Comment
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The surgical anterior ventricular endocardial restoration procedure excludes the noncontracting segments in the dilated remodeled ventricle, restores elliptical shape, and improves left ventricular function. The surgery is performed in the beating heart to delineate the contractile myocardium from the akinetic area by palpation. Major contributions to the success of the operative treatment of this difficult condition is adequate myocardial protection during cardioplegic arrest and continuous warm blood perfusion while the heart is beating.
Modification of our standard myocardial perfusion method was needed to perform ventricular restoration in the presence of aortic regurgitation. The aortic cross-clamp was left in place to prevent flooding of the field, which occurs if the clamp is released. The heart was continuously perfused through the unattached vein grafts and the mammary artery and simultaneously through the coronary sinus to maintain myocardial nourishment in the open beating state. The myocardium supplied by coronary arteries with no significant surgical disease was perfused through the coronary sinus. Proximal anastomoses were made after the restoration was completed.
In summary, when significant aortic regurgitation is present, ventricular restoration may safely be accomplished in the open beating heart by retrograde and coronary graft perfusion while aortic clamping is maintained.
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References
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- Dor V, Di Donato M. Ventricular remodeling in coronary artery disease. Curr Opin Cardiol. 1997;12:533–537[Medline]
- Athanasuleas CL, Stanley AW, Buckberg GD, et al. Surgical anterior ventricular endocardial restoration (SAVER) for dilated ischemic cardiomyopathy. Semin Thorac Cardiovasc Surg. 2001;13:448–458[Medline]
- Athanasuleas CL, Stanley AW Jr, Buckberg GD, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV. J Am Coll Cardiol. 2001;37:1199–1209[Abstract/Free Full Text]
- Beyersdorf F, Doenst T, Athanasuleas C, et al. The beating open heart for rebuilding ventricular geometry during surgical anterior restoration. Semin Thorac Cardiovasc Surg. 2001;13:42–51[Medline]
- Buckberg GD, Beyersdorf F, Allen BS, et al. Integrated myocardial management: background and initial application. J Card Surg. 1995;10:68–89[Medline]
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Abstract
Introduction
