**Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation**

Masanori Hirota, Shintaro Katahira, Joji Hoshino, Yasuhisa Fukada, Taichi Kondo, Takayuki Gyoten, Yuichi Notomi and Tadashi Isomura *Department of Cardiovascular Surgery, Hayama Heart Center, Kanagawa, Japan* 

#### **1. Introduction**

82 Front Lines of Thoracic Surgery

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Ischemic cardiomyopathy (ICM) is defined as diffuse akinesis of the ventricle after myocardial ischemia1). A subset of patients with ICM develop progressive heart failure as a consequence of adverse left ventricular (LV) remodeling, leading to a depressed ejection fraction, a dilated LV, a large akinetic region of the myocardium, an abnormal globular shape to the ventricular chamber, and functional mitral regurgitation (MR)2-5). Although a dilated LV with poor cardiac function is a risk by itself, coexisting functional MR worsens the prognosis of ICM6,7). Thus, for patients with ICM and functional MR, it is very important to repair the geometric changes of LV remodeling and to decrease the extent of functional MR.

For patients with ICM, surgical ventricular restoration (SVR) is an established treatment to reduce ventricular size and restore the elliptical shape of the LV8-12). Anatomical restoration by SVR may decrease the severity of MR, through various mechanisms, including reduction of ventricular dimensions, lowering of end systolic volumes, and restoration of blood flow to the ischemic region of the mitral subvalvular apparatus13,14). However, concomitant procedures for the mitral valve are required for further reduction of functional MR. In this chapter, our therapeutic strategy for patients with ICM is demonstrated, and we describe the details of the surgical techniques of SVR and mitral valve surgery.

#### **2. Patients**

Between May 2000 and May 2010, SVR was performed in 335 patients with ICM (n=199) and non-ischemic cardiomyopathy (n=136). Of the 199 patients with ICM, 88 had concomitant mitral valve surgery for functional MR.

These patients with ICM and functional MR included 77 males and 11 females, ranging in age from 32 to 83 years (mean, 61±10 years). The preoperative New York Heart Association (NYHA) functional class was class III for 55% (48/88) and class IV for 45% (40/88). Preoperative heart failure was medically controlled with inotropes in 34 patients (39%), and 2 of these patients (2%) required intra-aortic balloon pumping (IABP). Due to uncontrollable

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation 85

short-axis images with circular cross-sections and minimal out-of-plane movement. Shortaxis images were analyzed by the EchoPAC platform (2DS software package, version 7; GE Medical Systems), which uses a speckle-tracking technique to derive rotation and strain for selected regions of the myocardium24). LV torsion is also calculated automatically from the LV basal and apical rotation data in the platform. For assessing segmental myocardial viability, the myocardial region obtained from the short-axis images of the midlevel LV was divided into four segments (septal, anterolateral, posterior, inferoseptal), and the circumferential strain profile was analyzed, which is closely related to myocardial

Fig. 1. Late gadolinium enhancement of cardiac magnetic resonance imaging (in the left panel) and two-dimensional speckle-tracking echocardiographic imaging (in the right panel)

circumferential strain of speckle-tracking echocardiographic imaging detected nearly +20% lengthening at the posterior region only (shown as dark blue). Two-dimensional speckletracking echocardiography could identify such transmurally injured "dyskinetic scars" (a mechanodynamic myocardial property), which is critically important in ventricular

Using these results, the exclusion area of non-functional myocardium for SVR was predicted preoperatively. A representative case with ICM is shown in **Fig. 1**. On the left side, late gadolinium enhancement of cardiac MRI demonstrated regional stains on the endocardium in the lateral, posterior, and infero-septal segments. On the right side, two-dimensional speckle-tracking echocardiography revealed LV torsion at the corresponding short-axis slice level seen on cardiac MRI. Severe ischemic injury and suggestions of fibrotic change (a tissue characteristic) were depicted by cardiac MRI, while end-systolic circumferential strain of speckle-tracking echocardiographic imaging detected nearly +20% lengthening at the posterior region only (shown as dark blue). Thus, two-dimensional speckle-tracking echocardiography could identify such transmurally injured "dyskinetic scars" (a

in a representative case with ischemic cardiomyopathy. Severe ischemic injury and a suggestion of fibrotic change (a tissue characteristic) are depicted in the lateral, posterior,

and inferoseptal segments by late gadolinium enhancement, while end-systolic

d. Prediction of the non-functional akinetic region of the LV

viability25,26).

restoration tactics.

heart failure and worsening multiorgan failure, an emergent operation was performed in 12 patients (14%).
