Notes: Abstract Background: Effects of partial left ventriculectomy (PLV) remain ill-defined because mitral regurgitation (MR) repair by isolated annuloplasty alone has been reported to improve patients with dilated left ventricle and severe MR. Methods: Among patients undergoing PLV, 120 had paired pre- and postoperative (〈1 week) Doppler echocardiograms. Effects of preoperative MR were studied by comparing 45 patients with no preoperative MR (MR−) and 75 patients with significant MR (MR+; MR = 1.51 when MR is enumerated as none = 0, mild = 1, moderate = 2). Results: MR− patients as compared with the MR+ group were older (53.8 vs. 49.2 years, P = 0.047), had less frequent dilated cardiomyopathy (33.3% vs 49.3%,P 〈0.01), similar ventricular dimension (72.3 mm vs 73.0 mm), septal thickness (9.5 mm vs 9.6 mm), posterior wall, fractional shortening (15.9% vs 16.8%) and ventricular mass (330 g vs 345 g), resulting in comparably reduced functional capacity (NYHA 3.40 vs 3.67). Although the MR− group required significantly less frequent mitral procedure (64.4% vs 84.0%, P 〈 0.01) and shorter cardiac arrest time, they had similar postoperative MR (0.22 vs 0.39), highly significant parallel reduction in ventricular dimension (P 〈 0.001 in either group), and improved %FS (P 〈0.001 in either group), resulting in similar hospital survival (87.1% vs 86.4%) and 90-day survival (71.1% vs 78.7%) with significantly comparable improvement in functional class (P = 0.011 in both groups). Histological severity of interstitial fibrosis (P = 0.80), weight (P = 0.93), and thickness (P = 0.76) of excised myocardium was comparable between the two groups. Conclusion: Patients with no preoperative MR were found to benefit from PLV as did patients with significant MR. Beneficial effects of PLV appeared to derive mainly from volume reduction rather than abolished MR in this study.(J CARD SURG 2003;18 (Suppl 2):S95-S100)

Notes: Objective: To establish the role that coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) may have in improving perioperative outcomes of patients 70 years of age and older. Background: Coronary revascularization in elderly patients is associated with morbidity and mortality rates higher than those observed in younger patients. The impact of CABG without CPB on perioperative outcomes has not been clearly established. Methods: This retrospective, nonrandomized study consisted of 1872 CABG patients. Of these, 1389 underwent CABG with CPB (CPB group) and 483 patients underwent CABG without CPB (off-pump group). Preoperative variables and outcomes were compared between the two groups. Multivariate logistic regression analysis was used to identify independent predictors of mortality, stroke, and adverse outcome. Results: Demographics, Canadian Cardiovascular Society staging, operative priority, and other preoperative variables were comparable between the two groups. The prevalence of previous myocardial infarction was higher in the CPB group (62.6% vs 56.7%; p 〈 0.005), whereas the prevalence of calcified aorta and preoperative renal failure were higher in the off-pump group (5.4% vs 9.5%; p = 0.04 and 1.7% vs 3.3%; p = 0.04, respectively). Although the graft/patient ratio was higher in the CPB group (3.4 vs 1.9), these patients displayed more extensive coronary artery involvement. At univariate analysis, patients in the off-pump group had a higher rate of freedom from complications (88.2% vs 81.3%; p 〈 0.005) and a lower incidence of stroke (2.1% vs 4.2%; p = 0.034) than patients in the CPB group. Although there was a trend for a higher actual mortality in the off-pump group (4.8% vs 3.7%; p = ns), the risk adjusted mortality in this group was lower (1.9% vs 2.1%). Multivariate analysis showed that while the use of CPB correlated independently with an increased risk of overall complications, it was not associated with a higher probability of death or stroke. Conclusions: This investigation suggests that elderly patients undergoing CABG may benefit from off-pump revascularization, as the use of CPB correlated independently with an increased risk of overall complications. However, CPB did not emerge as an independent predictor of death or stroke at multivariate analysis.

Notes: Whereas discouraging clinical results and lack of scientific evidence decreased the initial interest in partial left ventriculectomy (PLV), factors contributing to success and failure have now been identified by clinical observations, theoretical analyses, and data from an international registry, which are herein reviewed to outline the current status and future role of this procedure as a treatment of heart failure.

Notes: Background: It remains unclear whether ventricular redilatation after partial left ventriculectomy (PLV) is due to underlying pathology or to continued volume overload amenable to surgery. Methods: Among patients undergoing PLV, 32 had Doppler echocardiography preoperatively, immediately after surgery (〉 1 week), early after surgery (1–3 months), and late after surgery (8–14 months). Patients were divided into groups with mitral regurgitation (MR; MR+, n = 16) and without postoperative MR (MR-, n = 16) and were compared for ventricular size, performance, and survival. Results: After initial surgical reduction, left ventricular dimension on average gradually increased back to the preoperative level in subgroups of patients with valvular disease and cardiomyopathy and in all patients combined. Most patients showed drastically reduced left ventricular dimension early after PLV. In MR+ patients, dimension increased back to the preoperative level within 3 months after surgery, whereas the MR- group maintained reduced dimension throughout the first year in all patients combined and in a subgroup of patients with cardiomyopathy. Occurrence of significant MR after PLV appeared to be related to severity of fibrosis in excised myocardium but not to severity of preexisting MR, etiology, or performance of mitral valvuloplasty. Conclusions: Early postoperative MR, residual or new, appeared to play an important role in dictating early hemodynamics and late outcome in patients undergoing PLV. Results suggest an aggressive simultaneous approach to abolish MR. Causative role of myocardial fibrosis remains unclear and needs further study.

Notes: Bleeding after aortic root replacement with a valved conduit may be problematic and difficult to control. A few technical details that may facilitate hemostasis in aortic root surgery are described.

Notes: Doppler-based techniques of coronary graft flow measurement are frequently used, especially during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), to exclude graft dysfunction resulting from technical errors. Nevertheless, early graft failure in the immediate postoperative period continues to affect a small percentage of patients who may require emergent reoperation as a result of severe hemodynamic deterioration. In this setting, in which coronary angiography is infrequently an option, expeditious intraoperative assessment of previously constructed coronary grafts may be performed by using the Doppler-based technique Transit Time Flow Measurement (TTFM). As a result, the hemodynamic values obtained during reoperations may guide the operative strategy. In this study we report on eight patients who underwent “off-pump” CABG and necessitated early reintervention as a result of presumed graft dysfunction. In these patients, graft dysfunction was confirmed or excluded by using intraoperatively the TTFM technique, comparing newly obtained flow hemodynamic variables with those recorded as a baseline during primary operations.

Notes: Background: Since preoperative hemodynamics are not proven to be a predictor of effects of partial left ventriculectomy (PLV), myocardial histopathology may be better correlated with effects and outcome of PLV. Methods: Myocyte size (μ) in the excised myocardium was measured in 338 patients undergoing PLV. Endocardial fibrosis, interstitial fibrosis, and inflammatory cell infiltration were enumerated as none = 0, mild = 1, moderate = 2, and severe = 3. These histopethologic observations were correlated with patients' postoperative survival. Results: Reduced survival was seen in patients with advanced (≥ moderate) interstitial fibrosis in all patients (n = 338, p = 0.064) and in the subgroup with nonischemic etiology (n = 229, p = 0.0039). Although correlation between endocardial and interstitial fibrosis was significant (r = 0.55, p 〈 0.01), endocardial fibrosis failed to correlate with postoperative survival. While Chagas' disease was associated with severe inflammation and poor survival, the presence of inflammatory cell infiltration had no effect on survival in all patients combined (p = 0.943). Although most patients (n = 266, 79%) had myocyte diameter over 30 μ, those with less hypertrophy (〉 30 μ, n = 70, 21%) had a tendency toward increased survival (p = 0.067) regardless of underlying etiology. Conclusion: Interstitial fibrosis may be an important factor in stratification of patients for repair (PLV) or replacement (transplantation). PLV may be more beneficial in patients with less hypertrophy, before development of interstitial fibrosis. Endomyocardial biopsy might not predict the extent or variation in degree of interstitial fibrosis, which may be better evaluated by other metabolic or perfusion studies that measure overall myocardial histopathology and viability.

Notes: Abstract  The “single suture” technique, which consists of placing a suture in the oblique sinus of the posterior pericardium and connecting it to a vaginal tape, is commonly adopted in off-pump coronary artery revascularization to obtain elevation of the heart and coronary artery exposure. This report describes the use of this technique to expose the anterior wall of the heart in the setting of ventricular aneurysm repair.