Endoventricular circular patch plasty repair

The effect on longitudinal shortening is most pronounced in the lateral wall. There is an increase at 2 weeks but a return near baseline at 6 weeks after the Dor procedure. Effects of aneurysm plication on selected end-systolic strain tensor components. A, Circumferential strain versus distance from LV base. B, Longitudinal strain versus distance from LV base.

C, Circumferential strain versus quadrant. D, Longitudinal strain versus quadrant. They can be used with our finite element method to determine myocardial contractility and stress in these LV regions after the Dor procedure.

The primary finding of this three-dimensional MRI tagging study is that the Dor procedure significantly increases systolic circumferential shortening in all noninfarcted LV regions in sheep.

The greatest regional changes in circumferential shortening are found in the equatorial region and in the posterior wall. Longitudinal shortening is increased 2 weeks after the Dor procedure but then returns near baseline by 6 weeks. Moreover, the present study together with our previous study 18 of myocyte orientation with MR diffusion tensor imaging provides the most complete set of data to date for creating and validating mathematical models for the mechanics of the infarcted LV before and after aneurysm repair.

Certainly, if regional myocardial systolic and diastolic material properties including the properties of the infarct could be normal after the Dor procedure, then preinfarct normal shape would be optimal. However, the ventricle has remodeled 19 and, as documented in our prior modeling study of border zone contractility, regional systolic and diastolic myocardial material properties are altered after anteroapical MI.

We did not attempt to recreate a normal shape, and it is clear that the shape we obtained is not normal. The Dor procedure probably decreases the force or stress that the ventricular muscle fibers must develop to generate the preoperative end-systolic pressure or afterload. If we were to idealize LV wall geometry as a hemispherical shell that is 10 mm thick at end diastole and is made of an incompressible material, an analysis of our LV pressure—volume data see Table 1 and Figure 3 in Zhang and associates 13 based on statics 22 suggests that the Dor procedure decreases average circumferential wall stress by Furthermore, mathematical modeling of the heart and cardiac operations has developed sufficiently to be of predictive value.

For instance, Dang and colleagues 23 used a finite element model of the LV with an akinetic but contractile anteroapical LV wall to test the hypothesis that the Dor procedure increases stroke volume and reduces mean myofiber stress.

An increase in myocardial strain could be caused by an increase in preload end-diastolic stress , a reduction in afterload end-systolic stress , or an improvement in regional myocardial contractility. An increase in preload is unlikely. However, the reduction in end-systolic stress after the Dor procedure that is predicted by the above studies is probably sufficient by itself to increase strain.

In addition, we suggest that the reduction in stress that occurs after the Dor procedure may also reverse hypertrophy and cause remote and border zone contractility to returnanto normal levels. In addition, although regional myofiber orientation was unchanged after linear repair in 24 the Dor procedure might align myofibers so that they contract more effectively.

There is an improvement in longitudinal strain in some regions of the myocardium 2 weeks after repair, but this improvement is lost at 6 weeks. There are only three possible explanations for this. First, there was a temporary improvement in regional contractility that, because of regional myocyte orientation, manifested itself as an increase in longitudinal strain.

However, it is not clear why an improvement in contractility would reverse. Second, the increase in strain was not due to increased contractility but to a change in load, which could be either an increase in preload or a decrease in afterload. An increase in preload could have been from too much intravascular volume in the early postoperative period, because the animals did not receive furosemide Lasix.

A change in afterload would be related to either shape change or pressure. There was a trend toward an increase in end-systolic pressure at 6 weeks. These two possibilities would require modeling to sort out. The last possibility is that there is some sort of progressive LV restraint caused by fibrosis in the pericardium. Myocyte contractility is probably decreased in both the remote uninfarcted and border zone myocardium of the LV that has remodeled after large anteroapical MI.

For instance, immediately after MI, the infarcted region loses contractile function. The remote uninfarcted myocardium compensates via the Starling relationship, end-diastolic volume is increased, and stroke volume is maintained. Systolic function is initially preserved, but eventually contractility of the remote myocardium is decreased.

However, if the stress is immediately reduced by the operation and then remains unchanged until 6 weeks postoperatively whereas the strain only improves increases in the interval between 2 and 6 weeks, then the most likely cause is an increase in contractility in the remote myocardium that occurs between 2 and 6 weeks. Contractility in the border zone is also decreased. For instance, Jackson and associates 19 described infarct extension after anteroapical MI in sheep that surprisingly occurs in the face of normal border zone blood flow.

This nonischemic infarct extension is associated with an increase in end-systolic stress. It is also unknown whether the reduction in end-systolic stress that occurs with the Dor procedure is sufficient to reverse nonischemic infarct extension and thereby increase regional border zone contractility. The effect of surgical ventricular remodeling on ventricular function is difficult to determine from clinical data given that the operations often include concomitant CABG and mitral valve repair.

Thus, despite the strong clinical trend away from linear repair of LV aneurysm, it is not clear that a choice for patch aneurysmorrhaphy is correct. After having performed fully three-dimensional strain analyses on a very reproducible animal model of LV aneurysm before and after each of these two types of repairs, we now are in a unique position to compare their effects on regional systolic deformation. The greatest regional differences in circumferential shortening between 6 weeks after and before the Dor procedure 5.

Moreover, patch aneurysmorrhaphy is not associated with LV redilation. Patch aneurysmorrhaphy is therefore superior to aneurysm plication. End-systolic radial strain tends to be more variable than does circumferential strain in tagged MRIs. For example, a mm-thick myocardium with a tag spacing of 8 mm yields only one or two tag lines in the radial direction, which makes the resulting measurement of radial strain sensitive to noise in the tag line position measurements and highly influenced by the deformation model.

Another source of variability in both radial and longitudinal strain is the difficulty of defining the radial and longitudinal directions on the curved LV wall, particularly at the apex. Another limitation of the present study is the limited spatial and temporal resolution associated with our MRI acquisition. In several of our experiments, we acquired tagged short-axis images that were separated by 1 cm.

Since the long-axis lengths of repaired LVs were significantly less than those of the other LVs, strain comparisons could be made only in the short-axis slices 1 to 4 cm below the valves. Moreover, the border zone in the anterior LV wall was contained within the latter slice, but the other border zone regions were located below it.

Thus, it is not entirely accurate to label all LV regions in the short-axis slice 4 cm below the valves as border zone regions. We acquired tagged MRIs every 40 ms between end diastole and end systole. This temporal resolution was not sufficient to rigorously study strain during isovolumic systole and thus prevented us from confirming the measurements of Moulton and coworkers. No baseline imaging ie, before infarction was performed during the present study.

This would have allowed comparison of regional differences in contractility to be assessed and would have permitted therapy to be compared to normal. Such analysis would better elucidate the effect of the remodeling procedure. Since the effect of the anteroapical infarct in sheep on regional 2-dimensional circumferential myocardial strain has already been measured, 31 however, we did not think that preinfarct and immediately postinfarct data collection was critical.

Conversely, our present study extends only 6 weeks after the Dor procedure and may miss later remodeling events. The Dor procedure significantly increases systolic circumferential shortening in all noninfarcted LV regions in sheep. This is the first objective evidence other than that suggested by Ribeiro and colleagues 3 and Zhang and colleagues 13 that the Dor procedure does anything.

Moreover, these results support our hypothesis that the effect is on border zone and remote systolic function and is mediated by stress reduction. Ideally, our mathematical modeling that is currently underway will support an improvement in remote and border zone function rather than just a reduction in load. We thank Dr J. Guccione, Sr, for his help in the construction of the plastic container used in this study.

Supplemental material is available online. National Center for Biotechnology Information , U. J Thorac Cardiovasc Surg. Author manuscript; available in PMC Jan Guccione , PhD, a, b Susan I.

Nicholas , MD, a Joseph C. Walker , PhD, c Philip C. Saloner , PhD, b, e Arthur W. This article reviews these results and summarizes 10 important points concerning the surgical treatment of ischemic dilated cardiomyopathy that may provide guidelines for the future.

These data indicate EVCPP, and its variations, form the central theme in surgical treatment of congestive heart failure. Abstract The first experience with endoventricular circular patch plasty EVCPP was reported in as a surgical method to rebuild left ventricular LV geometry made more spheric after myocardial infarction.

The difference between the Dor and Komeda-David operations is in the use of the purse-string suture Fontan stitch in the healthy myocardium surrounding the infarcted area to reduce the base of infarcted area. The tightened purse-string suture forms a small ridge on the patch suture line, allowing fairly easy suture of the smaller bovine patch in an almost two-dimensional manner to exclude the infarcted area.

Komeda-David technique requires a larger patch placed in a three-dimensional manner. We filled the space between the Teflon felt patch on the infarcted septum and the bovine patch in the left ventricular cavity with a generous amount of GRF glue to reinforce the suture lines of both patches and to aid in reconstruction of the septum.

Musumeci et al. Hata et al. Post-operative enhanced CT scan in our patient provided an almost normal shaped interventricular septal wall with full wall thickness by the GRF glue sandwiched between double patches. The double-patch technique is useful to avoid contamination of the systemic circulation by the glue and to provide a dry field before applying the large amount of GRF glue required for septoplasty. The technique described here led to satisfactory for validation of its utility normalization of LV shape and function in our patient.

Further experience with this technique clearly is required. Google Scholar. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

Sign In or Create an Account. Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. Postinfarction ventricular septal perforation repair with endoventricular circular patch plasty using double patches and gelatin—resorcinol—formaldehyde biological glue. Oxford Academic. Satoru Hasegawa. Tohru Sakamoto. Makoto Sunamori. Revision received:. Select Format Select format.

Permissions Icon Permissions. Abstract We describe a technique for repairing the ventricular septal perforation 10 days post acute anteroseptal myocardial infarction using the modified infarction exclusion method. Ventricular septal perforation , Surgical repair , Endoventricular circular patch plasty , Gelatin—resorcinol—formaldehyde biological glue.