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Impact of myocardial infarction on the outcome after partial left ventriculectomy
2088
CORRESPONDENCE
coronary artery bypass grafting without cardiopulmonary bypass: perioperative results. Heart Surg Forum 2000;3:18–23. 3. Kerr PC, Ricci M, Abraham R, D’Ancona G, Salerno TA. Redo LAD grafting via left anterior small thoracotomy: an alternative approach. Ann Thorac Surg 2001;71:384 –5. 4. D’Ancona G, Karamanoukian HL, Ricci M, Bergsland J, Salerno TA. Graft patency verification in coronary artery bypass grafting: principles and clinical applications of transit time flow measurement. Angiology 2000;52:725–31. 5. D’Ancona G, Karamanoukian HL, Salerno TA, Ricci M, Bergsland J. Flow measurement in coronary artery surgery. Ann Thorac Surg 2000;69:300–1.
Impact of Myocardial Infarction on the Outcome After Partial Left Ventriculectomy To the Editor: With great interest we read the paper of Cury and associates [1], who reported their autopsy findings after partial left ventriculectomy (PLV). They found an area of myocardial infarction (MI) measuring from 2.2 to 6.0 cm, adjacent to the surgical incision, which usually extended to the papillary muscles. They attributed this finding to ligation of great marginal branches, which supplied more myocardium than the resected one. Recently, we had the opportunity to study a heart after PLV and also found a large scar that extended beyond the suture used to close the ventriculotomy [2]. As Ratliff (Invited Commentary to reference 1) reported, it appears probable that the extent of this MI influences postoperative left ventricular function and outcome of PLV. We believe a second mechanism may contribute to the extent of the MI. In our department, closure of the ventriculotomy is performed by two 3-0 polypropylene sutures. The first one consists of multiple, transmyocardial, interrupted, pledgeted figure-ofeight sutures, which are reinforced by 2-mm-thick and 1-cmbroad strips of PTFE (Gore-Tex) to avoid stitches cutting through the myocardium. Closure of the ventriculotomy is completed by a superficial uninterrupted suture for hemostasis. We believe that distortion of the myocardium adjacent to the suture line leads to impaired blood supply to these myocardial areas. The lumina of the myocardial vessels are reduced (in some cases the lumina may even be occluded) by this distortion. We speculate that the lumina of the myocardial vessels are progressively reduced with increasing distortion so that the extent of the scar increases with the extent of distortion. Distortion of the myocardium is dependent on the kind of suture chosen for closing the ventriculotomy. We believe that mattress
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2001;71:2081– 8
sutures [3] lead to more distortion of the myocardium than figure-of-eight or running sutures [4], because myocardial edges are everted. This produces an unphysiologic shape of the left ventricle and an unusual pattern of myocardial fibers and vessels adjacent to the suture line. It is preferable to have the edges of the myocardium face each other to produce a more physiologic shape of the left ventricle and a more physiologic course of the myocardial fibers and vessels, and, therefore, less distortion. This goal is reached by using running or interrupted figure-of-eight sutures. The advantage of interrupted figure-ofeight sutures is that the tension on the myocardial fibers and vessels between two figure-of-eight sutures is not as great as with running sutures. Therefore we recommend interrupted figure-of-eight sutures. We have operated on 8 patients suffering from dilated cardiomyopathy with this technique. Only 1 patient (12.5%) died due to pneumonia, which may have been caused by prolonged mechanical ventilation. Therefore, suture technique for closure of the ventriculotomy may affect postoperative left ventricular function and outcome after PLV. Great differences in perioperative mortality rates suggest this possibility (43.2% by Cury and associates [1], 22% by Batista and associates [4], 3.5% by McCarthy and associates [3] with 11 patients [17%] requiring left ventricular assist device support after PLV, 12.5% in our own patient population). Stefan Christiansen, MD Klaus Redmann, MD Dieter Hammel, MD Klinik und Poliklinik fu¨r Thorax-, Herz- und Gefa¨ßchirurgie Westfa¨lische Wilhelms-Universita¨t Mu¨nster Albert-Schweitzer-Str 33 48149 Mu¨nster, Germany
References 1. Cury PM, Higuchi M de L, Gutierrez PS, et al. Autopsy findings in early and late postoperative death after partial left ventriculectomy. Ann Thorac Surg 2000;69:769–73. 2. Lunkenheimer PP, Redmann K, Cryer CW, et al. Late ventricular structure following partial left ventriculectomy: a case report. Ann Thorac Surg 2000;69:1257–9. 3. McCarthy JF, McCarthy PM, Starling RC, et al. Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure. Eur J Cardio-Thoracic Surg 1998;13:337– 43. 4. Batista RJV, Verde J, Nery P, et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;64: 634– 8.
0003-4975/01/$20.00
CORRESPONDENCE
coronary artery bypass grafting without cardiopulmonary bypass: perioperative results. Heart Surg Forum 2000;3:18–23. 3. Kerr PC, Ricci M, Abraham R, D’Ancona G, Salerno TA. Redo LAD grafting via left anterior small thoracotomy: an alternative approach. Ann Thorac Surg 2001;71:384 –5. 4. D’Ancona G, Karamanoukian HL, Ricci M, Bergsland J, Salerno TA. Graft patency verification in coronary artery bypass grafting: principles and clinical applications of transit time flow measurement. Angiology 2000;52:725–31. 5. D’Ancona G, Karamanoukian HL, Salerno TA, Ricci M, Bergsland J. Flow measurement in coronary artery surgery. Ann Thorac Surg 2000;69:300–1.
Impact of Myocardial Infarction on the Outcome After Partial Left Ventriculectomy To the Editor: With great interest we read the paper of Cury and associates [1], who reported their autopsy findings after partial left ventriculectomy (PLV). They found an area of myocardial infarction (MI) measuring from 2.2 to 6.0 cm, adjacent to the surgical incision, which usually extended to the papillary muscles. They attributed this finding to ligation of great marginal branches, which supplied more myocardium than the resected one. Recently, we had the opportunity to study a heart after PLV and also found a large scar that extended beyond the suture used to close the ventriculotomy [2]. As Ratliff (Invited Commentary to reference 1) reported, it appears probable that the extent of this MI influences postoperative left ventricular function and outcome of PLV. We believe a second mechanism may contribute to the extent of the MI. In our department, closure of the ventriculotomy is performed by two 3-0 polypropylene sutures. The first one consists of multiple, transmyocardial, interrupted, pledgeted figure-ofeight sutures, which are reinforced by 2-mm-thick and 1-cmbroad strips of PTFE (Gore-Tex) to avoid stitches cutting through the myocardium. Closure of the ventriculotomy is completed by a superficial uninterrupted suture for hemostasis. We believe that distortion of the myocardium adjacent to the suture line leads to impaired blood supply to these myocardial areas. The lumina of the myocardial vessels are reduced (in some cases the lumina may even be occluded) by this distortion. We speculate that the lumina of the myocardial vessels are progressively reduced with increasing distortion so that the extent of the scar increases with the extent of distortion. Distortion of the myocardium is dependent on the kind of suture chosen for closing the ventriculotomy. We believe that mattress
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2001;71:2081– 8
sutures [3] lead to more distortion of the myocardium than figure-of-eight or running sutures [4], because myocardial edges are everted. This produces an unphysiologic shape of the left ventricle and an unusual pattern of myocardial fibers and vessels adjacent to the suture line. It is preferable to have the edges of the myocardium face each other to produce a more physiologic shape of the left ventricle and a more physiologic course of the myocardial fibers and vessels, and, therefore, less distortion. This goal is reached by using running or interrupted figure-of-eight sutures. The advantage of interrupted figure-ofeight sutures is that the tension on the myocardial fibers and vessels between two figure-of-eight sutures is not as great as with running sutures. Therefore we recommend interrupted figure-of-eight sutures. We have operated on 8 patients suffering from dilated cardiomyopathy with this technique. Only 1 patient (12.5%) died due to pneumonia, which may have been caused by prolonged mechanical ventilation. Therefore, suture technique for closure of the ventriculotomy may affect postoperative left ventricular function and outcome after PLV. Great differences in perioperative mortality rates suggest this possibility (43.2% by Cury and associates [1], 22% by Batista and associates [4], 3.5% by McCarthy and associates [3] with 11 patients [17%] requiring left ventricular assist device support after PLV, 12.5% in our own patient population). Stefan Christiansen, MD Klaus Redmann, MD Dieter Hammel, MD Klinik und Poliklinik fu¨r Thorax-, Herz- und Gefa¨ßchirurgie Westfa¨lische Wilhelms-Universita¨t Mu¨nster Albert-Schweitzer-Str 33 48149 Mu¨nster, Germany
References 1. Cury PM, Higuchi M de L, Gutierrez PS, et al. Autopsy findings in early and late postoperative death after partial left ventriculectomy. Ann Thorac Surg 2000;69:769–73. 2. Lunkenheimer PP, Redmann K, Cryer CW, et al. Late ventricular structure following partial left ventriculectomy: a case report. Ann Thorac Surg 2000;69:1257–9. 3. McCarthy JF, McCarthy PM, Starling RC, et al. Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure. Eur J Cardio-Thoracic Surg 1998;13:337– 43. 4. Batista RJV, Verde J, Nery P, et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;64: 634– 8.
0003-4975/01/$20.00