Abstract
Left ventricular surgical remodeling (LVSR) has been, for long time, the
procedure applied for large dyskinetic, or akinetic, areas as a
consequence of a myocardial infarction, manly located in the left
anterior descending area. Many surgical techniques were developed, aimed
to a pure reduction of the volume of the left ventricular cavity or to
add to volume reduction a more physiologic conical shape. The expansion
of interventional procedures invaded most of the fields before treated
only by cardiac surgeons. In this issue, Pillay describes an hybrid
technique, involving both interventional cardiologists and cardiac
surgeons, aimed to LV volume reduction after an anterior myocardial
infarction. A series of internal (right ventricular septum) and external
(anterior wall) anchors are implanted to approximate the LV free wall to
the anterior septum, consequently excluding the scarred myocardium.
Although some limitations of this study, the Authors have to be
commended for having revitalized a procedure almost eliminated from the
surgical scenario
Key-words: left ventricle; hybrid approach; volume reduction.
Left ventricular surgical remodeling (LVSR) has been, for long time, the
procedure applied for large dyskinetic, or akinetic, areas as a
consequence of a myocardial infarction, manly located in the left
anterior descending area. Many surgical techniques were developed, aimed
to a pure reduction of the volume of the left ventricular
cavity1 or to add to volume reduction a more
physiologic conical shape2-5. Long-term results were
good, even if better outcome was reported with shape-based
techniques6.
Many factors led to a progressive limitation of the surgical indications
to LVSR. The most important was the widespread diffusion of primary
angioplasty, that was able, through early revascularization, to limit
the extension of necrosis and the dilatation of the necrotic area.
Another important event was the publication of the STICH
trial7, that casted shadows on the real benefit of
adding LVSR to coronary artery bypass grafting (CABG). Even if post-hoc
studies demonstrated that, when the procedure was performed correctly
the results were by far better than CABG alone8, this
was not sufficient to reverse the trend and suddenly LVSR became an
obsolete procedure.
On the other side the expansion of interventional procedures invaded
most of the fields before treated only by cardiac surgeons, as
myocardial revascularization, repair of mitral and tricuspid
regurgitation, replacement of aortic and pulmonary valves, repair of
prosthetic leaks, closure of atrial or ventricular septal defects, and
so on. In the same time median sternotomy, and in general cardiac
surgery, were considered the evil and the feeling that every solution
was better than a cardiac surgical procedure diffused slowly but
inexorably.
In this issue Pillay et al9 describe a modification of
a hybrid technique by them previously used10, that
allows interventional cardiologists and cardiac surgeons to work
together to reduce the LV volume after an anterior myocardial
infarction. A series of internal (right ventricular septum) and external
(anterior wall) anchors are implanted to approximate the LV free wall to
the anterior septum, consequently excluding the scarred myocardium. This
technique was first applied by Wechsler et al11 using
a median sternotomy. A pure surgical variant was used by Chiariello et
al12, who performed the volume reduction via a left
thoracotomy, without the aid of an interventional cardiologist. A more
complex hybrid strategy was introduced to replace the median sternotomy.
The internal anchor was deployed after being placed over a wire
introduced through the internal jugular vein10 and the
external anchor was positioned after a small left anterior thoracotomy.
In this study9 this technique was changed (and very
likely improved) starting July 2018. The clinical results were very
good: 47 cases reported (till January 2020), no in-hospital deaths, no
complications, no late mortality, and clinical results reported an
improvement of 1 NYHA class after a mean follow up of 9.8 months.
All these steps suggest that the involvement of the cardiologists was
considered necessary to continue the experience with a different
approach to LVSR. Reading the technique used by Wechsler et
al11 it is evident that some problems can arise from
the manipulation of a large heart without cardiopulmonary bypass. A left
thoracotomy, as used in a case report by Chiariello et
al12, provides a better approach and allows to deploy
the intracardiac anchor through the anterior wall without the
involvement of interventional cardiologists.
The Authors do not compare the clinical outcome of the different hybrid
techniques by them used. Their most recent clinical
study10 reports the results of the first version of
hybrid technique (n=35) which replaced the median sternotomy. Some
mechanical complications, as tricuspid insufficiency increase and
ventricular septal defect, were reported and very likely pushed to
introduce some modifications. Whereas the latest version seems
promising, nothing is said about what happened between March 2016 and
July 2018. This is in line with the apparent reluctance of the Authors
to report their full experience, limited to 12-month follow up and to
more or less one third of the cases in their first
study11, to 12 months (even if the experience, started
in 2010 and reported in 201910 could include a maximum
follow up of at least 8 years) and in this report9,
where the outcome is summarized in a few line. The enthusiasm for the
good outcomes pushed the Authors to compare their series with the
RESTORE registry. But comparing the early mortality of 1,198 patients
with the early mortality of 47 patients is meaningless and does not add
anything to the validity of the technique.
What reported by the Authors is brilliant and can have a future, mainly
because of cardiologists’ involvement. But the evidence of the validity
of this hybrid strategy will go through many steps, first of all the
demonstration a long term benefit and afterward a comparison with more
standardized approaches. However, the Authors have to be commended for
having revitalized a procedure almost eliminated from the surgical
scenario.
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