**4. Results**

94 Front Lines of Thoracic Surgery

For patients requiring PRP, the bilateral papillary muscles were surgically approximated during closure of the posterior wall of the LV. Thus, the posterior wall was approximated

Although MVP is a standard operation for ICM with functional MR, mitral valve replacement (MVR) is indicated for a few limited cases. In the early period of this series, MVR via the ventriculotomy was performed to reduce aortic crossclamping time. Patients with ICM and MR caused by organic valvular changes were also treated by MVR, although

MVR was performed via the ventriculotomy during SVR in a beating heart. The ascending aorta was declamped after closure of the LV, and the LV was opened in the akinetic region. The mitral leaflets were preserved as much as possible to prevent LV rupture, and 2-0 polyfilament braided vertical mattress sutures were placed on the mitral annulus from the LA toward the LV. These sutures were then anchored to the mitral leaflets. A prosthetic

Under general cardiac anesthesia and monitoring, the chest was entered via median sternotomy. CPB was installed via the ascending aorta with bicaval drainage under generalized heparinization. For patients requiring coronary artery bypass grafting (CABG), all anastomoses were completed prior to opening the LA. An LA vent tube was introduced via the right upper pulmonary vein (PV) to obtain a bloodless surgical field. When the MAZE procedure was required, left PV isolation was performed with a radiofrequency ablation system (AtriCure, Inc, West Chester, OH, USA). Under mild hypothermia, the ascending aorta was crossclamped. Antegrade tepid blood cardioplegia was delivered to obtain cardioplegic cardiac arrest. For maintenance, retrograde tepid blood cardioplegia was

MAP was performed via the right-sided left atriotomy. Details of the technique were

Aortic valve replacement was performed via the aortotomy prior to SVR, when it was required. Tricuspid valve surgery was also performed via the right atriotomy when it was

After completion of MAP, the akinetic scar was opened to perform SVR and other mitral procedures via the LV. Selection of SVR depended on the location of the scar: the anterosepto-apical region for EVCCP, a broad antero-septal region for SAVE, and the posterior region for PRP. First, chordal cutting of both mitral leaflets was performed when it was indicated for patients requiring SAVE. Details of the technique were described above. Secondly, papillary muscle approximation was performed for patients with a severely dilated LV requiring SAVE. The technical details were described above. For patients requiring PRP, the incision of the posterior wall was placed just between both papillary

Finally, SVR was performed after completion of other mitral procedures. The details of the

during the usual PRP procedure.

they were excluded in this series.

**3.6 Overview of the operative procedure**  a. Preparation for SVR and mitral valve surgery

infused every 20 to 30 minutes.

procedure were described above.

necessary.

b. MAP via the right-sided left atriotomy

described above. The LA was closed in two layers.

c. SVR and other mitral procedures via the ventriculotomy

muscles, resulting in papillary muscle approximation by usual LV closure.

mitral valve was seated in the infravalvular position (**Fig. 5E**).

#### 1. Operative procedures

In 88 patients with ICM and MR, SVR was performed with three different procedures: EVCPP in 25 patients (28%), SAVE in 50 patients (57%) and PRP in 13 patients (15%). Two cases with antero-septal scars repaired by an overlapping cardiac volume reduction operation had a SAVE procedure. Mitral valve surgery was performed with MAP in 78 patients (89%) and MVR in 10 patients (11%). Of a total of 78 patients repaired with MAP, an under-sized Carpentier-Edwards Physio Ring was used in 72 patients (92%), and a just-sized Carpentier-McCarthy-Adams IMR ETlogix annuloplasty ring was used in 6 patients (8%). Of a total of 46 cases repaired with SAVE plus MAP, chordal cutting was required in 10 patients (22%), and papillary muscle approximation was required in 16 patients (35%). In the early period of this series, 10 patients were treated by MVR with the Carpentier-Edwards pericardial bioprosthesis (Edwards Life Science Corporation). Detailed combinations of SVR and mitral valve surgery are summarized in **Table 1**.


Table 1. Surgical Ventricular Restoration and Mitral Valve Surgery.

Of the 88 patients with ICM and functional MR, concomitant procedures included CABG in 63 (72%), tricuspid valve surgery in 30 (34%), aortic valve surgery in 4 (5%), and the MAZE procedure in 7 (8%). The number of grafts for patients requiring CABG was 2.0±1.4/patient.

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation 97

Table 3. Hospital Mortality and Morbidity.

Table 4. Geometric and Hemodynamic Parameters.

Tricuspid annuloplasty was performed with the Carpentier-Edwards classic annuloplasty ring (Edwards Life Science Corporation) in 13 patients, the Edwards MC3 annuloplasty ring (Edwards Life Science Corporation) in 9 patients, the Cosgrove-Edwards annuloplasty system (Edwards Life Science Corporation) in 3 patients, the St. Jude Medical Tailor flexible band (St. Jude Medical, Inc. St. Paul, MN, USA) in 2 patients, and the DeVega technique in 3 patients. Aortic valve replacement was performed with the Carpentier-Edwards pericardial bioprosthesis (Edwards Life Science Corporation) in 4 patients (5%). Intra- and postoperative CRT or CRT-D was required in 26 patients (30%).

2. Early surgical results

Aortic crossclamping and CPB times are shown in **Table 2**. IABP was preoperatively introduced in 2 patients (2%) requiring the SAVE procedure, and 20 patients (23%) required postoperative IABP (6 for EVCPP, 10 for SAVE, and 4 for PRP). Two patients repaired by the SAVE procedure required a left ventricular assist system and percutaneous cardiopulmonary support after the operation.


#### Table 2. ACC and CPB Time. (Hirota et al.)

Overall hospital mortality was 13% (11/88), with 9 patients in the SAVE group. Hospital mortalities of elective and emergent operations were 9% and 29%, respectively. The most frequent morbidity was non-sustained and sustained VT/VF (17/88; 19%). Details of hospital mortality and morbidity are shown in **Table 3**.

Geometric and hemodynamic parameters are summarized in **Table 4**. Both diastolic and systolic LV volumes (LVEDVI and LVESVI) were significantly decreased with each procedure (*p*<0.05). LVEDVI and LVESVI were the largest with SAVE (LVEDVI: EVCPP 166±46 ml/m2, SAVE 185±53 ml/m2, PRP 154±48 ml/m2; LVESVI: EVCPP 129±44 ml/m2, SAVE 149±49 ml/m2, PRP 117±50 ml/m2). As an index of the extent of volume reduction, the volume reduction rate (reduction volume by SVR/preoperative LV volume × 100 [%]) was calculated. The volume reduction rates of LVEDV and LVESV were similar (LVEDV: EVCPP 27%, SAVE 22%, PRP 26%; LVEDV: EVCPP 19%, SAVE 21%, PRP 26%). EF and peak pulmonary artery pressure were not significantly improved with any procedure. The severity of functional MR was less after each procedure. The majority of moderate or severe MR was improved to none or trivial MR (**Fig. 6**). NYHA functional class also improved with each procedure, and of all surviving patients in classes III and IV, 78% improved to class I or II (**Fig. 7**).


#### Table 3. Hospital Mortality and Morbidity.

96 Front Lines of Thoracic Surgery

Tricuspid annuloplasty was performed with the Carpentier-Edwards classic annuloplasty ring (Edwards Life Science Corporation) in 13 patients, the Edwards MC3 annuloplasty ring (Edwards Life Science Corporation) in 9 patients, the Cosgrove-Edwards annuloplasty system (Edwards Life Science Corporation) in 3 patients, the St. Jude Medical Tailor flexible band (St. Jude Medical, Inc. St. Paul, MN, USA) in 2 patients, and the DeVega technique in 3 patients. Aortic valve replacement was performed with the Carpentier-Edwards pericardial bioprosthesis (Edwards Life Science Corporation) in 4 patients (5%). Intra- and post-

Aortic crossclamping and CPB times are shown in **Table 2**. IABP was preoperatively introduced in 2 patients (2%) requiring the SAVE procedure, and 20 patients (23%) required postoperative IABP (6 for EVCPP, 10 for SAVE, and 4 for PRP). Two patients repaired by the SAVE procedure required a left ventricular assist system and percutaneous

Overall hospital mortality was 13% (11/88), with 9 patients in the SAVE group. Hospital mortalities of elective and emergent operations were 9% and 29%, respectively. The most frequent morbidity was non-sustained and sustained VT/VF (17/88; 19%). Details of

Geometric and hemodynamic parameters are summarized in **Table 4**. Both diastolic and systolic LV volumes (LVEDVI and LVESVI) were significantly decreased with each procedure (*p*<0.05). LVEDVI and LVESVI were the largest with SAVE (LVEDVI: EVCPP 166±46 ml/m2, SAVE 185±53 ml/m2, PRP 154±48 ml/m2; LVESVI: EVCPP 129±44 ml/m2, SAVE 149±49 ml/m2, PRP 117±50 ml/m2). As an index of the extent of volume reduction, the volume reduction rate (reduction volume by SVR/preoperative LV volume × 100 [%]) was calculated. The volume reduction rates of LVEDV and LVESV were similar (LVEDV: EVCPP 27%, SAVE 22%, PRP 26%; LVEDV: EVCPP 19%, SAVE 21%, PRP 26%). EF and peak pulmonary artery pressure were not significantly improved with any procedure. The severity of functional MR was less after each procedure. The majority of moderate or severe MR was improved to none or trivial MR (**Fig. 6**). NYHA functional class also improved with each procedure, and of all surviving patients in classes III and IV, 78% improved to class I or

operative CRT or CRT-D was required in 26 patients (30%).

cardiopulmonary support after the operation.

Table 2. ACC and CPB Time. (Hirota et al.)

II (**Fig. 7**).

hospital mortality and morbidity are shown in **Table 3**.

2. Early surgical results


#### Table 4. Geometric and Hemodynamic Parameters.

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation 99

Fig. 8. Kaplan-Meier survival curves in patients with ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). **(A)** In a total of 88 patients, overall survival repaired by the three different procedures including endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE), and the posterior restoration procedure (PRP). **(B)** Survival curve in patients repaired by EVCCP. **(C)** Survival curve in patients repaired by

Fig. 9. The surgical effects of papillary muscle approximation on mitral regurgitation (MR) and left ventricular (LV) volume in patients repaired by the SAVE procedure and ring annuloplasty. In a total of 50 patients, the severity of MR was decreased irrespective of papillary muscle approximation. LV volumetric indices including LV end-diastolic diameter (LVDd), LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI) were also decreased irrespective of papillary muscle approximation. However, the volume reduction rate was much smaller in patients repaired by concomitant papillary

SAVE. **(D)** Survival curve in patients repaired by PRP.

muscle approximation.

Fig. 6. The surgical effects on mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM). In a total of 88 patients, the severity of MR was decreased after the operation. The similar effect was detected in three different procedures including endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE), and the posterior restoration procedure (PRP).

Fig. 7. The surgical effects on the New York Heart Association (NYHA) functional class in patients with ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). In a total of 79 survived patients, the functional class was improved after the operation. The similar effect was detected in three different procedures including endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE), and the posterior restoration procedure (PRP).

#### 3. Mid- to long-term surgical results

Mid- to long-term survival rates of elective operations were estimated by Kaplan-Meier analysis (**Fig. 8**). In this series, 1-year and 5-year overall survival rates were 84% (EVCPP 81%; SAVE 79%; PRP 100%) and 66% (EVCPP 50%; SAVE 66%; PRP 67%), respectively.

Fig. 6. The surgical effects on mitral regurgitation (MR) in patients with ischemic

operation. The similar effect was detected in three different procedures including

and the posterior restoration procedure (PRP).

procedure (PRP).

3. Mid- to long-term surgical results

cardiomyopathy (ICM). In a total of 88 patients, the severity of MR was decreased after the

endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE),

Fig. 7. The surgical effects on the New York Heart Association (NYHA) functional class in patients with ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). In a total of 79 survived patients, the functional class was improved after the operation. The similar effect was detected in three different procedures including endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE), and the posterior restoration

Mid- to long-term survival rates of elective operations were estimated by Kaplan-Meier analysis (**Fig. 8**). In this series, 1-year and 5-year overall survival rates were 84% (EVCPP 81%; SAVE 79%; PRP 100%) and 66% (EVCPP 50%; SAVE 66%; PRP 67%), respectively.

Fig. 8. Kaplan-Meier survival curves in patients with ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). **(A)** In a total of 88 patients, overall survival repaired by the three different procedures including endoventricular circular patch plasty (EVCCP), septal anterior ventricular exclusion (SAVE), and the posterior restoration procedure (PRP). **(B)** Survival curve in patients repaired by EVCCP. **(C)** Survival curve in patients repaired by SAVE. **(D)** Survival curve in patients repaired by PRP.

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation 101

disregarded, the cumulative survival rate was assessed by a systematic review of the literature associated with SVR in ischemic heart disease48). According to the review, the weighted average early mortality (defined as in-hospital or 30-day mortality) was 6.9%, and the cumulative 1-year and 5-year survivals were 88.5% and 71.5%, respectively. Although our surgical outcome did not reach the cumulative value, the extent of LV dysfunction with coexisting MR secondary to ischemia was much more severe in our series. More than 50% of patients had a large antero-septal akinetic region of the LV requiring the SAVE procedure, and all of them were classified as NYHA functional class III and IV. In fact, the remodeled hearts presented with severe LV dysfunction (EF <20%) with a dilated LV (LVESVI > 140 ml/m2). Moreover, more than half of the patients had concomitant severe MR (grade III and IV) in the present series. Earlier clinical reports demonstrated that the mortality risk is related to the degree of functional MR in patients with ICM52,53). Thus, our early and late

Although SVR improved cardiac function and functional status for patients with ICM, it was reported that potential determinants of hospital mortality included preoperative advanced heart failure status, postoperative large LV volume (LVESVI > 60 ml/m2, LVESV > 80 ml), coexisting MR, and need for mitral valve surgery53,54). Many potential risks were involved in this series, and baseline LVESV would be much larger in a patient population with ICM and functional MR. In the present series, preoperative LVESVI (140±50 ml/m2) was larger than in other reports, and thus, postoperative LVESVI (104±42 ml/m2) was not included in the smaller LV volume category with low mortality. Although more exclusions to reduce LVESV would result in better surgical results, we believe that excessive exclusions involving contractile myocardium should be avoided for such ICM patients with severely dilated LV accompanying MR. Accordingly, prediction of the exclusion area of non-functional scar or

As one of the additional surgical adjuncts, we performed papillary muscle approximation to reduce LV volume for patients with a severely dilated LV requiring the SAVE procedure. The SAVE procedure effectively excludes a broad akinetic region of the antero-septo-apical wall, and papillary muscle approximation shortens the posterior wall between both papillary muscles. Thus, these combined procedures achieve further reduction of the LVESV. Although the volume reduction rate was increased by papillary muscle approximation, the early surgical effect on functional MR was almost the same, irrespective of papillary muscle approximation. Although the long-term effect on the LV dimension has not been elucidated, it may contribute to prevention of MR due to re-dilation of the LV.

SVR for patients with ICM and functional MR requires various surgical combinations depending on the location of the akinetic region, ventricular size, and subvalvular morphology beneath the MV. The surgical strategy is very important to achieve better

[1] Kwan J, Shiota T, Agler DA, Popovic ZB, Qin JX, Gillinov MA, Stewart WJ, Cosgrove

DM, McCarthy PM, Thomas JD; Realtime three-dimensional echocardiography study. Geometric differences of the mitral apparatus between ischemic and dilated

surgical results would be acceptable in patients with such severe backgrounds.

myocardium is very important to perform effective SVR for these patients.

**6. Conclusion** 

**7. References** 

surgical outcomes for such high-risk patients.

#### 4. Effects of papillary muscle approximation in the SAVE procedure

Of the 50 patients treated with the SAVE procedure, 16 underwent papillary muscle approximation. To illustrate the effects of papillary muscle approximation, dimensional parameters and severity of MR are summarized in **Fig. 9**. Preoperative LVESVI was greater in patients repaired by SAVE and papillary muscle approximation than in patients repaired by SAVE alone (174±56 vs. 141±48 ml/m2), but the difference was not significant. The volume reduction rate was also increased by additional papillary muscle approximation (26% vs. 19%). Irrespective of papillary muscle approximation, the severity of MR was improved after SAVE and mitral ring annuloplasty.
