Indication of posterior restoration and surgical results in patients with dilated cardiomyopathy

Abstract

Objective: Nontransplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. Anterior restoration for anterior akinesis has shown favourable outcome. Posterior restoration and surgical results are also discussed.

Methods: At the Hayama Heart Center in Japan, between 2005 and 2009, posterior restoration for DCM was performed in 36 patients (10 with ischaemic and 26 with nonischaemic, including muscular dystrophy in three). There were 32 men and four women with a mean age of 53 years. The mean preoperative ejection fraction was 23% and the preoperative New York Heart Association (NYHA) classification was class III in 16 patients and class IV in 20 with eight emergent operations. To identify the posterior lesion before operation, speckle-tracking echocardiography was used, with a Vivid 7 ultrasound machine. The short-axis images from the middle level of the left ventricle (LV) were obtained to assess myocardial segmental viability. Based on the results of speckle-tracking echocardiography, posterior restoration was performed in patients with postero-lateral akinesis and septal kinesis. After the cardioplegic arrest, mitral plasty or coronary artery bypass grafting (CABG) was performed and the posterior LV muscle between bilateral papillary muscles was partially resected under beating heart. The LV apex was preserved and cryoablation was applied between the cut edge and the mitral annulus. All the patients were followed with cardiac echocardiography.

Results: In addition to LV restoration, mitral plasty was successfully performed in all the patients. Concomitant CABG was performed in seven, tricuspid surgery in 11 and cardiac resynchronisation therapy (CRT) in eight. Perioperative intra-aortic balloon pumping (IABP) was used in six and there was no hospital mortality, including eight emergent operations. After the operation, 29 patients (80.6%) improved their functional class into class I or II. In the late follow-up, there were two cardiac deaths and one noncardiac death and the 4-year survival rate was 85.8%.

Conclusions: The site selection with speckle-tracking echocardiography demonstrated the accurate akinetic lesion of the posterior LV wall. The posterior restoration with preservation of bilateral papillary muscles and LV apex based on the site selection improved operative and mid-term results in the selected patients with DCM.