CONCLUSION
The techniques previously reported are at the basis of all techniques
described thereafter. Many surgeons re-reported a previously described
technique either after limited and irrelevant changes or simply renaming
the procedure. Original techniques depend on the development of new
concepts and changing the position or the shape of a patch or the number
of purse strings is not enough to identify something new. The memory of
the cardiac surgeons is often short!!
The most innovative techniques reported in the literature are surely the
Stoney technique (the first one that addresses the septum in every
patient) and the Jatene technique, that introduced the concept of
geometric repair of the LV anatomy, described the use of a purse string
to reduce obliquely the cavity and addressed the septum that was changed
from dyskinetic to akinetic with a reduced surface by means of
interrupted sutures. However, we must recognize that the concept to
exclude the dyskinetic septum and to reduce its surface was present
since the early times of the LVSR. Cooley and his group reported 421
cases operated on between 1969 and 19799. The Dor
technique was aimed to exclude the scarred septum, but without a purse
string and a shaper the remaining cavity would be more rectangular than
conical. However, Dor’s concept moved ahead in a new direction a complex
surgery.
All the surgical solutions aimed to solve the problem of LVSR tried to
maintain a conical shape (as much as possible) and a reduction of volume
such to improve the contractility without compromising the diastolic
function. This aspect was evaluated by Lee et al25,
who demonstrated that, in patients undergone the Dor technique, the
postsurgical improvement in systolic function was compromised by a
decrease in diastolic distensibility in all investigated patients.
Worsening of the diastolic function was due to increase of sphericity
index, with consequent reduction of stroke volume. By simulating a
restoration of the left ventricle back to its measured baseline
sphericity, the Authors showed that both diastolic and systolic function
improved. The benefit in maintaining a conical shape was demonstrated by
us after a follow up of 15 years in propensity matched
patients26.
These results are consistent with the speculation proposed in the
Surgical Treatment for Ischemic Heart Failure trial27for the neutral outcome, that “the lack of benefit seen with surgical
ventricular reconstruction is that benefits anticipated from surgical
reduction of left ventricular volume (reduced wall stress and
improvement in systolic function) are counter-balanced by a reduction in
diastolic distensibility.” There is no doubt that, independently from
the surgical procedure applied, postoperative diastolic function remains
the Achille’s heel of the left ventricle reshaping.
The anatomical spectrum of LV aneurysms changed over time. Lack of early
reperfusion selected patients who were able to survive with large scars,
that were, in expert hands, easy to resect or exclude. Nowadays, the
increased use of early coronary reperfusion made the infarcted area
become akinetic rather than dyskinetic, making more difficult patients’
selection and less predictable the clinical results. But this aspect is
outside the purpose of this report.