Department of Cardiology, St. John's Medical College Hospital, Bangalore, India.
Eur J Cardiothorac Surg. 2011 Jun;39(6):945-51. doi: 10.1016/j.ejcts.2010.09.023. Epub 2010 Oct 22.
Surgical ventricular restoration has been the bailout therapy for end-stage heart failure due to ischemic cardiomyopathy in patients not suitable for cardiac transplantation. The recently concluded STICH trial has stated that surgical restoration of the left ventricle does not benefit this subgroup of patients clinically as compared with revascularization alone. The reasons for failure of this trial are multifactorial. The technique of surgical ventricular restoration employed in the STICH trial was circular endoventricular patch plasty. The various drawbacks related to this technique can be offset by a modification based on a mathematical hypothesis, which should result in a more physiological ventricular geometry, with consequent late reverse remodeling and improved left-ventricular performance.
A total of 54 consecutive patients out of 102 patients with post-infarction left-ventricular aneurysms were studied before and 2 years after surgical ventricular restoration by linear endoventricular patch plasty using two-dimensional (2D) echocardiography and contrast ventriculography.
Linear endoventricular patch plasty resulted in a decrease in end-diastolic volume (EDV) of 40.2 ml (95% confidence interval (CI): 33.6, 46.7) and stroke volume (SV) of 10.0 ml (95% CI: 6.6, 13.5) and increase in ejection fraction (EF) of 6.7% (95% CI: 5.5, 7.9). There was a further 14% decrease in EDV and SV (30%) at 2 years with increase in EF (20%). There was a persistent significant improvement in sphericity index. The changes in EDV and SV were linearly related (r=0.72, p<0.001) and persisted at 2 years following surgery. The change in EDV was linearly related to the EF (r=0.35, p=0.02). The left-ventricular shape analysis showed improvements in the anterior and anterolateral segments (effect size=1.1, p<0.001) with nonsignificant changes in the inferior segments, conforming to an ellipsoid geometry.
Linear endoventricular patch plasty restored a physiological elliptical ventricular geometry with persistent late reverse remodeling. The decreases in EDVs following surgery were significantly linearly proportional to the decreases in SVs at rest, which conforms to the normal left-ventricular geometry.
对于不适合心脏移植的缺血性心肌病所致终末期心力衰竭患者，心室修复术已成为挽救生命的治疗方法。最近结束的 STICH 试验表明，与单纯血运重建相比，修复左心室对这组患者的临床并无益处。该试验失败的原因是多方面的。STICH 试验中采用的心室修复技术为圆形心室内膜补片成形术。该技术的各种缺点可以通过基于数学假设的修改来抵消，这应该会产生更符合生理的心室几何形状，从而导致晚期逆向重构和左心室功能的改善。
对 102 例梗死后左心室瘤患者中的 54 例患者进行前瞻性研究，这些患者在接受线性心室内膜补片成形术的心室修复术前后 2 年分别采用二维超声心动图和对比心室造影进行研究。
线性心室内膜补片成形术使舒张末期容积（EDV）减少 40.2ml（95%置信区间：33.6，46.7），每搏量（SV）减少 10.0ml（95%置信区间：6.6，13.5），射血分数（EF）增加 6.7%（95%置信区间：5.5，7.9）。术后 2 年时 EDV 和 SV 进一步下降 30%（14%），EF 增加 20%。球形指数持续显著改善。EDV 和 SV 的变化呈线性相关（r=0.72，p<0.001），术后 2 年仍持续存在。EDV 的变化与 EF 呈线性相关（r=0.35，p=0.02）。左心室形状分析显示前壁和前侧壁节段改善（效应量=1.1，p<0.001），下壁节段无显著变化，符合椭圆形几何形状。
线性心室内膜补片成形术恢复了生理性的椭圆形心室几何形状，持续进行晚期逆向重构。术后 EDV 的减少与静息时 SV 的减少呈显著的线性比例关系，这符合正常的左心室几何形状。
