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2.
Heart Fail Rev ; 9(4): 269-86, 2004 Oct.
Article in English | MEDLINE | ID: mdl-15886973

ABSTRACT

The left ventricular reconstruction (LVR) with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular aneurysm or asynergy after myocardial infarction. Scarred LV wall can be dyskinetic or akinetic according to the type of infarction (transmural or not), and the progressive dilatation of LV (remodeling) depends on the size of the asynergic scar. Assessment of this extension and of LV volume and performances, is easy and reliable by magnetic resonance (CMR). The surgical technique is based on the insertion inside the ventricle on contractile myocardium, of a circular patch restoring curvature and physiological volume, and allowing exclusion of asynergic non resectable regions. The ventricular reconstruction method also has other components that include coronary revascularization (almost always), mitral repair (if needed) and endocardectomy when spontaneous or inducible ventricular tachycardia (VT) are present. The experience of the authors (> 1100 cases) and results obtained by other Centers, allows proposal of this technique as a way to treat the ischemic failing ventricle.


Subject(s)
Cardiac Surgical Procedures , Myocardial Infarction/physiopathology , Myocardial Infarction/surgery , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/surgery , Ventricular Remodeling/physiology , Endocardium/physiopathology , Endocardium/surgery , Heart Aneurysm/physiopathology , Heart Aneurysm/surgery , Heart Ventricles/physiopathology , Heart Ventricles/surgery , Humans , Suture Techniques
3.
Heart Fail Rev ; 9(4): 299-306; discussion 347-51, 2004 Oct.
Article in English | MEDLINE | ID: mdl-15886975

ABSTRACT

UNLABELLED: Ventricular arrhythmias cause ~50% of deaths in remodeled ventricles after myocardial infarction, and the Multicenter Automatic Defibrillator Implantation Trial (MADIT II) showed that the Implantable Cardioverter Defibrillator (ICD) saved lives in high risk coronary patients with advanced left ventricular dysfunction. We studied 382 patients with remodeled hearts by preoperative Ventricular stimulation (PVS) to evaluate surgical ventricular restoration (SVR) that excludes scar and lower ventricular volume alters the early and late arrhythmia process without ICD utilization. METHODS: Clinical and hemodynamic results before and after SVR in post-infarction patients, are compared to contrast spontaneous and/or inducible ventricular tachycardia to patients without arrhythmias. Study arrhythmia groups included: Spontaneous in 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia: Inducible in 105 patients without clinical ventricular arrhythmias but PVS inducible ventricular tachycardia; and No arrhythmias in 190 patients without spontaneous or PVS inducible ventricular tachycardia. RESULTS: Preoperative LV end systolic volume index helped define preoperative arrythmia potential: Spontaneous > 120/m(2), inducible > 100 ml/m(2), and none < 100ml/m(2). Overall operative mortality rate was 7.6% (29/382). Sudden cardiac death rate was 2.5% causing 18.7% of all deaths. Surgical management reduced inducible ventricular tachycardia, from 41% preoperatively (144/352) to 8% (26/307) at early study, and 8% (14/177) one year later. Cardiac mortality was low at 5-years and not different between groups, despite use of only one late ICD device. CONCLUSIONS: Favorable electrical success rate and low mortality always included volume reduction to interrupt functional re-entry circuits, but also added endocardiectomy, cryoablation, CABG and mitral repair when needed. Overall SVR findings show volume and shape alteration limits ventricular arrhythmias that impair prognosis, and suggests ICD devices are not needed.


Subject(s)
Cardiac Surgical Procedures , Defibrillators, Implantable , Electric Countershock , Tachycardia, Ventricular/surgery , Tachycardia, Ventricular/therapy , Ventricular Dysfunction, Left/surgery , Ventricular Dysfunction, Left/therapy , Ventricular Remodeling/physiology , Chi-Square Distribution , Hemodynamics/physiology , Humans , Survival Analysis , Suture Techniques , Tachycardia, Ventricular/complications , Tachycardia, Ventricular/physiopathology , Treatment Outcome , Ventricular Dysfunction, Left/etiology , Ventricular Dysfunction, Left/physiopathology
4.
Heart Fail Rev ; 9(4): 307-15, 2004 Oct.
Article in English | MEDLINE | ID: mdl-15886976

ABSTRACT

Cardiac failure is frequently complicated by intra and or interventricular conduction delay that results in dyssynchronized cardiac contraction and relaxation. In contrast to an electrical intervention by biventricular pacing, this study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern through mechanical reconstruction without exogenous pacing input. Thirty patients (58 +/- 8 years) undergoing SVR at the Cardiothoracic Center of Monaco were prospectively evaluated with a protocol which uses simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Mean QRS duration was within normal limits (100 +/- 17 ms) preoperatively. Preoperative LV contraction was highly asynchronous. Endocardial time motion was either early or delayed at the end-systolic phase, yielding P/L loops with abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized. The hemodynamic consequences of SVR included improved ejection fraction; reduced end-diastolic and end-systolic volume index; more rapid peak filling rate; peak ejection rate and mechanical efficiency resulting in mechanical intraventricular resynchronization that improves LV performance.


Subject(s)
Cardiac Surgical Procedures , Myocardial Infarction/physiopathology , Myocardial Infarction/surgery , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/surgery , Cardiac Catheterization , Female , Heart Failure/etiology , Heart Failure/physiopathology , Heart Failure/surgery , Humans , Male , Middle Aged , Myocardial Infarction/complications , Prospective Studies , Suture Techniques , Treatment Outcome , Ventricular Dysfunction, Left/etiology
5.
Heart Fail Rev ; 9(4): 317-27, 2004 Oct.
Article in English | MEDLINE | ID: mdl-15886977

ABSTRACT

Ischemic functional mitral regurgitation following ischemic cardiomyopathy is a secondary phenomenon to ventricular dilation, and therapeutic approaches to this complication are not uniform. Solutions to improve mitral function include either mitral repair or observing the effects of coronary revascularization and/or ventricular rebuilding during surgical ventricular restoration (SVR). The present study of 108 patients (comprising 18% of our 588 SVR population) reports the effects of mitral repair following SVR and CABG by comparing geometric, functional, hemodynamic and outcome changes to SVR patients without mitral repair. The degree of mitral regurgitation went from 2.9 +/- 1.2 before to 0.7 +/- 0.7 after SVR and mitral repair. SVR improved EF from 29 +/- 7% to 34 +/- 10% p 0.001; reduced end diastolic volume from 243 +/- 74 to 163 +/- 53 ml and end systolic volume from 170 +/- 63 to 107 +/- 41 ml, p 0.000. Ventricular size and shape geometric measurements improved in all patients, either with and without mitral repair. SVR improved tenting and papillary muscle width between muscle heads in all patients, but alterations in mitral annular size improved only following mitral repair. Preoperative mitral regurgitation occurred in patients with larger ventricular volume and lower ejection fraction and was an independent predictor of operative mortality risk.


Subject(s)
Cardiac Surgical Procedures , Mitral Valve Insufficiency/physiopathology , Mitral Valve Insufficiency/surgery , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/surgery , Ventricular Remodeling/physiology , Analysis of Variance , Coronary Artery Bypass , Hemodynamics/physiology , Humans , Logistic Models , Mitral Valve Insufficiency/etiology , Myocardial Ischemia/complications , Myocardial Ischemia/physiopathology , Myocardial Ischemia/surgery , Papillary Muscles/physiopathology , Papillary Muscles/surgery , Suture Techniques , Treatment Outcome , Ventricular Dysfunction, Left/complications
6.
J Am Coll Cardiol ; 37(5): 1199-209, 2001 Apr.
Article in English | MEDLINE | ID: mdl-11300423

ABSTRACT

OBJECTIVES: The goal of this study was to evaluate the safety and efficacy of surgical anterior ventricular endocardial restoration (SAVER). The procedure excludes noncontracting segments in the dilated remodeled ventricle after anterior myocardial infarction. BACKGROUND: Anterior infarction leads to change in ventricular shape and volume. In the absence of reperfusion, dyskinesia develops. Reperfusion by thrombolysis or angioplasty leads to akinesia. Both lead to congestive heart failure by dysfunction of the remote muscle. The akinetic heart rarely undergoes surgical repair. METHODS: A new international group of cardiologists and surgeons from 11 centers (RESTORE group) investigated the role of SAVER in patients after anterior myocardial infarction. From January 1998 to July 1999, 439 patients underwent operation and were followed for 18 months. Early outcomes of the procedure and risk factors were investigated. RESULTS: Concomitant procedure included coronary artery bypass grafting in 89%, mitral valve (MV) repair in 22% and MV replacement in 4%. Hospital mortality was 6.6%, and few patients required mechanical support devices such as intraaortic balloon counterpulsation (7.7%), left ventricular assist device (0.5%) or extracorporeal membrane oxygenation (1.3%). Postoperatively, ejection fraction increased from 29 +/- 10.4 to 39 +/- 12.4%, and left ventricular end systolic volume index decreased from 109 +/- 71 to 69 +/- 42 ml/m2 (p < 0.005). At 18 months, survival was 89.2%. Time related survival at 18 months was 84% in the overall group and 88% among the 421 patients who had coronary artery bypass grafting or MV repair. Freedom from readmission to hospital for congestive heart failure at 18 months was 85%. Risk factors for death at any time after the operation included older age, MV replacement and lower postoperative ejection fraction. CONCLUSIONS: Surgical anterior ventricular endocardial restoration is a safe and effective operation in the treatment of the remodeled dilated anterior ventricle after anterior myocardial infarction.


Subject(s)
Cardiomyopathy, Dilated/surgery , Endocardium/surgery , Myocardial Infarction/surgery , Ventricular Dysfunction, Left/surgery , Ventricular Remodeling/physiology , Adult , Aged , Aged, 80 and over , Cardiomyopathy, Dilated/mortality , Cardiomyopathy, Dilated/physiopathology , Combined Modality Therapy , Coronary Artery Bypass , Endocardium/physiopathology , Female , Heart Valve Prosthesis Implantation , Heart Ventricles/physiopathology , Heart Ventricles/surgery , Humans , Male , Middle Aged , Mitral Valve/physiopathology , Mitral Valve/surgery , Myocardial Infarction/mortality , Myocardial Infarction/physiopathology , Postoperative Complications/etiology , Postoperative Complications/mortality , Postoperative Complications/physiopathology , Survival Rate , Suture Techniques , Ventricular Dysfunction, Left/mortality , Ventricular Dysfunction, Left/physiopathology , Ventricular Function, Left/physiology
7.
Biochemistry ; 39(7): 1890-6, 2000 Feb 22.
Article in English | MEDLINE | ID: mdl-10677240

ABSTRACT

The Wilson disease copper-transporting ATPase plays a critical role in the intracellular trafficking of copper. Mutations in this protein lead to the accumulation of a toxic level of copper in the liver, kidney, and brain followed by extensive tissue damage and death. The ATPase has a novel amino-terminal domain ( approximately 70 kDa) which contains six repeats of the copper binding motif GMTCXXC. We have expressed and characterized this domain with respect to the copper binding sites and the conformational consequences of copper binding. A detailed analysis of this domain by X-ray absorption spectroscopy (XAS) has revealed that each binding site ligates copper in the +1 oxidation state using two cysteine side chains with distorted linear geometry. Analysis of copper-induced conformational changes in the amino-terminal domain indicates that both secondary and tertiary structure changes take place upon copper binding. These copper-induced conformational changes could play an important role in the function and regulation of the ATPase in vivo. In addition to providing important insights on copper binding to the protein, these results suggest a possible mechanism of copper trafficking by the Wilson disease ATPase.


Subject(s)
Adenosine Triphosphatases/chemistry , Carrier Proteins/chemistry , Cation Transport Proteins , Copper/chemistry , Peptide Fragments/chemistry , Adenosine Triphosphatases/metabolism , Carrier Proteins/metabolism , Circular Dichroism , Copper/metabolism , Copper-Transporting ATPases , Humans , Models, Biological , Peptide Fragments/metabolism , Protein Binding , Protein Conformation , Protein Structure, Secondary , Protein Structure, Tertiary , Spectrum Analysis , X-Rays
10.
J Biol Chem ; 272(52): 33279-82, 1997 Dec 26.
Article in English | MEDLINE | ID: mdl-9407118

ABSTRACT

The putative copper binding domain from the copper-transporting ATPase implicated in Wilson disease (ATP7B) has been expressed and purified as a fusion to glutathione S-transferase. Immobilized metal ion affinity chromatography revealed that the fusion protein is able to bind to columns charged with different transition metals with varying affinities as follows: Cu(II)>>Zn(II)>Ni(II)>Co(II). The fusion protein did not bind to columns charged with Fe(II) or Fe(III). 65Zinc(II) blotting analysis showed that the domain is able to bind Zn(II) over a range of pH values from 6.5 to 9.0. Competition 65Zn(II) blotting showed that Cd(II), Hg(II), Au(III), and Fe(III) can successfully compete with Zn(II), at comparable concentrations, for binding to the domain. In contrast, the domain had little or no affinity for Ca(II), Mg(II), Mn(II), and Ni(II) relative to copper. Neutron activation analysis of the copper bound to the domain showed a copper:protein ratio of 6.5-7.3:1. Both Cu(II) and Cu(I) were found to have a higher affinity for the domain relative to Zn(II). In addition, a sharp, reproducible transition was only observed in competition experiments with copper, which may suggest that copper binding has some degree of cooperativity.


Subject(s)
Adenosine Triphosphatases/isolation & purification , Adenosine Triphosphatases/metabolism , Carrier Proteins/isolation & purification , Carrier Proteins/metabolism , Cation Transport Proteins , Hepatolenticular Degeneration/enzymology , Metals, Heavy/metabolism , Binding, Competitive , Cobalt/metabolism , Copper/metabolism , Copper-Transporting ATPases , Escherichia coli , Humans , Hydrogen-Ion Concentration , In Vitro Techniques , Nickel/metabolism , Zinc/metabolism
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