Endoventricular patch reconstruction of ischemic failing ventricle. a single center with 20 years experience. advantages of magnetic resonance imaging assessment.

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.

Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD?

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.

Mechanical synchrony: role of surgical ventricular restoration in correcting LV dyssynchrony during chamber rebuilding.

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.

The endoventricular circular patch plasty ("Dor procedure") in ischemic akinetic dilated ventricles.

From 1984 to 2000, 950 Left Ventricular ischemic asynergy (dyskinetic or akinetic) were operated using the endoventricular circular patch plasty technique. This allows to exclude all asynergic areas of the left ventricular wall and reshape the remaining wall. Both morphology and hemodynamic of left ventricle, are improved. Hospital mortality was below 7%. Life expectancy at 10 years reaches 80% if pre-operative L.V.E.F. is above 30%, and end systolic volume index (E.S.V.I.) below 90[emsp4 ]ml, and 60% in L.V.E.F. is below 30% and E.S.V.I. above 90[emsp4 ]ml. L.V.R. by endoventricular plasty has to be considered in the treatment of ischemic congestive heart failure.

Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV.

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.

Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery.

OBJECTIVES: In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation. METHODS: Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation. RESULTS: Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. CONCLUSIONS: Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively.

Surgical anterior ventricular endocardial restoration (SAVER) for dilated ischemic cardiomyopathy.

Anterior infarction changes ventricular shape and volume. Akinesia is most commonly observed after early reperfusion. Dyskinesia develops in the absence of reperfusion. Both produce heart failure by dysfunction of the remote muscle. Traditional surgery deals with dyskinesia. This study evaluates surgical anterior ventricular endocardial restoration (SAVER), an operation that excludes the apical and septal scar in both akinesia and dyskinesia. A new international group of cardiologists and surgeons from 13 centers, the RESTORE Group) investigated SAVER in ischemic cardiomyopathy following anterior infarction. From January 1998 to July 2000, 662 patients underwent surgery. Early and 3-year outcomes were investigated. Concomitant procedures included coronary artery bypass grafting (CABG) in 92%, mitral repair in 22%, and mitral replacement in 3%. Hospital mortality was 7.7%. Mortality among 606 patients with SAVER and CABG alone was 4.9%. It was 8.1% among 147 patients who underwent concomitant mitral valve repair. Few patients required IABPs (8.4%), LVADs (0.4%), or ECMO (0.6%). Postoperatively, ejection fraction increased from 29.7% +/- 11.3% to 40.0% +/- 12.3% and left ventricular end systolic volume decreased from 96 +/- 63 to 62 +/- 39 mL/m(2) (P <. 05). At 3 years, the survival rate was 89.4% +/- 1.3%. Survival was lower among those with preoperative volume >80 mL/m(2) compared with volume < or = 80 mL/m(2) (83.5% +/- 3.3% v 94.5% +/- 2.0%). Freedom from readmission to hospital for heart failure was at 88.7% at 3 years and was not related to preoperative volume. SAVER is a safe and effective procedure for treating the remodeled dilated anterior ventricle following anterior myocardial infarction.

Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience.

The first experience with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular (LV) geometry made more spheric after myocardial infarction. The consequence is dilated ischemic cardiomyopathy. In anterior infarction, the free LV wall and septum are scarred and become dyskinetic or akinetic. The fundamental approach excludes the noncontractile (asynergy) and nonresectable regions to restore more normal size and shape. The current experience of our group in 2001, includes 1,011 patients, and confirmation of our results by others, including an international team. The basic components are LV reconstruction, revascularization, and mitral repair (when needed), which form an integrated method of surgical management. Endocardiectomy and cryoablation are used with spontaneous and inducible ventricular arrhythmias. 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.

Intermediate survival and predictors of death after surgical ventricular restoration.

This study examined the effects of Dor procedure on long-term survival in patients with previous transmural anterior myocardial infarction who were referred to a single experienced center for left ventricular reconstruction by endoventricular patch-plasty repair. Our aim was to evaluate the impact of this procedure on long-term survival and to assess the ability of preoperative, perioperative, and postoperative variables to predict late survival. Major indications for surgery were left ventricular dysfunction, angina, ventricular arrhythmias, or a combination of the three; 20 patients underwent urgent cardiac surgery. The total group was 245 patients, with 8.1% hospital mortality, and 19 patients lost to follow-up [corrected]. The study group comprised 207 patients. Many pre- and postoperative clinical, hemodynamic, and functional variables, as well as operative parameters, were studied by univariate analysis. During a mean follow-up period of 39+/-19 months, 30 end points were observed, including 27 deaths and 3 heart transplants. Event-free survival was 98%+/-1% at 1 year, 95.8%+/-1.4% at 2 years, and 82.1%+/-3.3% at 5 years. Cox regression analysis showed preoperative New York Heart Association functional class, ejection fraction, end systolic volume index, and remote asynergy as independent predictors of mortality. The procedure has a favorable impact on 5-year survival. Independent predictors of late survival are the preoperative functional status and the left ventricular systolic function.

Surgical ventricular restoration in patients with postinfarction coronary artery disease: effectiveness on spontaneous and inducible ventricular tachycardia.

Surgical ventricular reconstruction (SVR) involves resection of scar, septal exclusion, cavity reduction by endoventricular patch, and complete coronary grafting. At the Cardiothoracic Centre of Monaco, ventricular stimulation (PVS) is performed before SVR, unless contraindicated. In patients with spontaneous and/or inducible ventricular arrhythmias, nonguided endocardiectomy and cryosurgery are added. We report clinical and hemodynamic results after SVR in postinfarction patients, to compare management of patients with spontaneous and/or inducible ventricular tachycardia, with those without arrhythmias. The 3 subsets were: Group A, 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia (Spontaneous); Group B, 105 patients without clinical ventricular arrhythmias but with inducible ventricular tachycardia at PVS (Inducible); and Group C, 190 patients without spontaneous arrhythmias and not inducible ventricular tachycardia at PVS (No arrhythmias). Overall surgical mortality rate was 7.6% (29 of 382). Sudden death mortality was only 18.7% of all deaths. Surgical management caused marked reduction of inducible ventricular tachycardia, from 144 of 352 inducible ventricular tachycardia before surgery (41%), to 26 of 307 (8%) at early study, and 14 of 177 (8%) one year later. Cardiac mortality was low at 5 years, and not different among groups; this indicates that the surgical procedure limits the ventricular arrhythmias that normally impair prognosis in postinfarction dilated cardiomyopathy. We believe the favorable electrical success rate and low mortality are not linked to one aspect of the surgical procedure, but to an integrated approach that relieves ischemia (coronary bypass graft), and reduces left ventricular volumes (SVR) to improve pump function, and nonguided endocardiectomy plus cryoablation, to interrupt functional reentry circuits.

Inferior wall restoration: anatomic and surgical considerations.

Congestive heart failure that results from inferior infarction is caused by a triangular change in ventricular geometry, which involves the septum, lateral wall, and base supplied by the right coronary artery. The extent of damage is determined by the anatomic distribution of coronary blood flow. Mitral insufficiency is accentuated from damage to the basal region, especially when the occluded right coronary vessel has multiple inferior branches and wraps around the apex. Three methods of repair are described, and include direct restoration without a patch, patch repair of the triangular scar, or use of a retriangulation suture in ventricles with trabecular scar to imbricate the noncontractile region to restrict patch size. This triangular reduction in size mirrors the design concept for suture described by Fontan in anterior infarction, which produces an oval apex. Early results in relation to left ventricular end systolic volume index and ejection fraction are defined.

Left ventricular restoration by endoventricular circular patch plasty (EVCPP).

The Endoventricular Circular Patch Plasty technique, developed to reorganize the left ventricular cavity after post-ischemic modification, is described as it has been used since 1984. Experience of more than 900 cases demonstrates the efficiency of the technique in terms of left ventricular shape, left ventricular performances and long-term clinical results. Particular attention is focused on very large asynergia with congestive heart failure.

Left ventricular restoration by endoventricular circular patch plasty (EVCPP).

The Endoventricular Circular Patch Plasty technique, developed to reorganize the left ventricular cavity after post-ischemic modification, is described as it has been used since 1984. Experience of more than 900 cases demonstrates the efficiency of the technique in terms of left ventricular shape, left ventricular performances and long-term clinical results. Particular attention is focused on very large asynergia with congestive heart failure.

Effects of reconstructive surgery for left ventricular anterior aneurysm on ventriculoarterial coupling.

OBJECTIVE: To investigate left ventricular elastance (Emax) and effective arterial elastance (Ea) in postinfarction left ventricular aneurysm and evaluate their role in left ventricular function improvement after endoventricular circular patch plasty (EVCPP). Ventriculoarterial coupling has never been studied in these patients. PATIENTS: 22 consecutive patients (49 to 73 years) with left ventricular anterior aneurysm. METHODS: Haemodynamic studies were done before and two weeks after EVCPP. Ventriculography was performed during atrial pacing (100 beats/min). Pressure/volume loops were analysed and derived parameters measured. Emax was estimated by applying the "single beat" method. Ea was calculated as end systolic pressure/stroke volume. RESULTS: Left ventricular volumes and Ea decreased after surgery: end diastolic volume index from mean (SD) 155 (53) to 106 (29); end systolic volume index from 112 (51) to 62 (30) ml/m2 (both p < 0.0001); Ea from 1.65 (0.70) to 1.39 (0.41) mm Hg/ml (p = 0.04). Ejection fraction and Emax increased, without significant changes in stroke volume and work. The decrease in Ea was directly correlated with its preoperative value. The time interval between left ventricular pressure upstroke and peak systolic pressure decreased, from 237 (39) to 191 (41) ms (p < 0.0001), paralleling morphological changes in pressure tracings. CONCLUSIONS: After EVCPP, ventriculoarterial coupling improves because of the fall in Ea caused by end systolic pressure reduction. The improvement is related to aortic pressure waveform changes and improved relaxation.

Endoventricular patch reconstruction in large ischemic wall-motion abnormalities.

Endoventricular patch plasty (EVPP) has been used since 1984 to rebuild the left ventricle. The global experience of our group includes more than 835 cases. Large wall-motion abnormalities were detected by the center line method when > 60% of the circumference of the left ventricle was asynergic. In this series, 269 patients had an ejection fraction < 30%. Surgery for repair of large wall-motion abnormalities was conducted on the arrested heart with insertion within the left ventricle of a patch rebuilding the contractile area while leaving a residual volume between 50 and 70 cc/m2 of body surface. The global results of the technique of EVPP are analyzed on the last 700 operated patients. Three series of patients with large wall-motion abnormalities were examined. We conclude that this technique is appropriate in advanced stages of ischemic disease as an alternative to cardiac transplant. At an operative risk of approximately 12%, improvement is obtained in 80% of cases.

Cardiac surgery in adults and children without use of blood.

Since 1968, following Cooley's and Zubiate's group presentation, our team has been using extracorporeal circulation (ECC) with hemodilution without use of blood for priming of the circuit. Progressively this technique, that was only reserved to the Jehovah's Witnesses, became routine. Whereas in 1980, 30% of the patients operated by our group had not received any blood products during their stay in hospital, in the last few years, 1987-95, more than 80% of the patients could benefit from this technique. So, out of 15,573 cardiac surgeries under ECC performed between 1972 and 97, 14,798 (95%) were done in auto-perfusion, and 314 to Jehovah's Witnesses. The results of this routine technique, not using blood, was analysed in the adult as well as the child. More precisely, 100 adults operated on consecutively in 1995 and 50 children of less than 15 kilos operated on in 1994 were closely examined clinically and biologically. In adults, biology was studied in the 90 patients who did not receive any blood, and showed, as already quoted in previous studies on identical or larger series, the following evolution of the different parameters: Hematocrit went from 41% in a pre-operative mean value to 33% at the 10th day, which is a decrease of 20%. Hemoglobin went from 14 gr to 11 gr, that is a decrease of 21%. Proteinemia which was at 73 gr pre-operatively decreased to 58 gr at the first day to reach 60 gr at the 10th day (decrease of 13%). In children, blood was necessary in 20 among 28 patients below 8 kg (group I), and no blood was used for the 22 patients above 8 kg (group II). Regarding the biological results, in the group I, hematocrit showed a decrease of 18% between the day before surgery and 1 day after. Hemoglobin a decrease of 17%, platelets a decrease of 56% and Protides 3%. Fibrine showed a decrease of 43% the day of surgery, and an increase of 15% at day 1; and the Prothrombine time finally decreased by 24%. The results are very similar in group II. In conclusion, cardiac surgery without any pre or post-operative use of blood is therefore possible, simply, without pre-donation or without any particular treatment in 90% of adults of all ages and pathologies, and in over 50% of children (78% if category is over 7 kg) and has satisfactory results.

Skeletonized right gastroepiploic artery used for coronary artery bypass grafting.

The right gastroepiploic artery has been definitively recognized as a reliable conduit for coronary artery bypass grafting with excellent clinical results and midterm patency. Our experience with internal thoracic artery skeletonization and the similarities between the gastroepiploic and internal thoracic arteries prompted us to modify the gastroepiploic artery harvesting technique. The purpose of this report is to present the advantages of the skeletonized gastroepiploic artery graft.

Endoventricular patch plasties with septal exclusion for repair of ischemic left ventricle: technique, results and indications from a series of 781 cases.

Most cases of left ventricular aneurysms undergo operation through resection of the exteriorized dyskinetic area with longitudinal suturing of the opening and this technique has been considered by cardiologists (Froehlich et al) to bring no improvement to the morphology and performance of the left ventricle. Some technical modifications have been adopted, such as the septal plicature (Cooley) or circular suturing of the opening (Jatene). Since 1984 our team has used an endoventricular patch, sutured over the contractile area and excluding the akinetic non-resectable scars, bringing a significant and calculable improvement to the left ventricular function. This technique of left ventricular reconstruction (LVR), called endoventricular circular patch plasty (EVCPP) has been already used on more than 750 patients (May 97). Clinical and echographic data for each case are completed by right catheterisation with measurement of the cardiac output, pulmonary arterial pressures (PAP) and programmed ventricular stimulation (PVS), in order to detect eventual ventricular tachycardia (IVT). During left heart catheterisation, the morphology of the left ventricle (LV) is studied on right and left anterior oblique incidences and the LV ejection fraction (EF) is checked globally (GEF) and especially in its contractile portion (CEF). After surgery, a hemodynamic study associated with a PVS, is carried out during the first post-operative month, and again after one year. Results were clinically satisfactory in more than 90% of cases (8.9% of NYHA III-IV), and in more than 90% of cases with ventricular arrhythmia with the hemodynamic persistent EF at one year, superior to the pre-operative CEF. Thus we have to propose the following indications: Elective: This ventricular reconstruction can be recommended for ventricular aneurysms or akinesias with angina, arrhythmias or attacks of cardiac insufficiency, when GEF > 30% and CEF > 40%. The operative mortality rate varies from 1,5 to 3%, which is better than allowing natural evolution. Mandatory: In emergency, when safe immediate circulatory assistance or a cardiac transplant is unavailable, LVR can give hope for survival to more than 80% of patients, whereas natural evolution is without hope. Finally the operative indication is uncertain in two contrasting circumstances: In asymptomatic patients when hemodynamic and angiographic examinations after myocardial infarction show left ventricular dyskinesia. If GEF is below 40% and CEF below 50%, it seems wise to propose LVR in order to prevent unfavourable evolution. In end-stage ischemic cardiomyopathies, if the EF is below 20%, CEF is below 30%, cardiac output is below 1.5 l, and the mean pulmonary pressure is above 25, then a cardiac transplant should be considered. EVCPP with septal exclusion is a safe technique and easily reproduced when associated with coronary revascularization as far as practicable, then EVCPP improves the ventricular function. When associated with sub-total endocardectomy, then EVCPP allows excellent control of VA.

Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars.

BACKGROUND: Many believe that dyskinesia is the only predictor of favorable surgical outcome after large myocardial infarction and that akinetic scars do not recover well in patients with globally depressed ventricular function. METHODS: This study evaluates clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n = 51) or large dyskinetic scar (n = 49) and depressed left ventricular function (ejection fraction <30%). Groups were comparable for symptoms, indication for operation, and delay from myocardial infarction. Heart failure was a major indication for operation in both groups. Coronary grafting was performed in 98% of patients: 10 had mitral valve repair or replacement, and 47 patients with preoperative ventricular arrhythmias had cryotherapy. In-hospital mortality was 12% (five patients in the akinetic group [10%] and seven in the dyskinetic group [14%]). RESULTS: Results showed an early and late improvement in New York Heart Association functional class and ejection fraction (from 23% +/- 5% to 31% +/- 11% to 40% +/- 13% in akinetic patients and from 23% +/- 6% to 41% +/- 10% to 41% +/- 12% in dyskinetic patients). Ventricular tachycardia was reduced significantly in both groups early and late after the operation. CONCLUSION: We conclude that in patients with either large akinetic or dyskinetic scar and severe left ventricular dysfunction, endoventricular circular patch plasty associated with coronary grafting and cryotherapy, when indicated, provides surviving patients with significant improvement in cardiac function. This approach can be considered as an alternative to heart transplantation in patients with severe left ventricular dysfunction.