"Left Ventricular Reconstruction", Is it our coast??
I was lucky to be fellow in the service of Prof. Vincent Dor in Center Cardio-Thoracic of Monaco. I learned a lot from this genius surgeon and had the opportunity to be close to him during performance of The EndoVentricular Circular Patch Plasty Technique (EVCPP).
EVCPP was first employed by Prof. Dor in 1984. This surgical technique was designed to reconstruct of the ischemic ventricle distorted by asynergic scarred transmural or subendocardial areas as well as the septal component. It rebuilds or reshapes the ventricular cavity. The EVCPP is different from other techniques like Linear suture and Jatene technique that it allows restoration of the curvature and septal exclusion of the Left ventricles.
The standard technique which is performing now by Prof. Dor himself and after continuous developing and research efforts was discussed in many papers and book chapters. One of the most detailed papers titled "Surgical remodeling of left ventricle" By Prof. Vincent Dor (Surg Clin N Am 84 (2004) 27-43). I feel it is one of the excellent references for this technique and I suggest it for understanding this technique.
The results of this technique is improving the left ventricular performance due to reorganization of the LV wall as it suppress the wall tension of myocardial remote areas and improves contraction of these areas. Also maintenance of a reasonable physiological cavity in terms of diastolic capacity.
In the personal experience of Prof. Dor of more than 1000 cases shows improvement of the ejection fraction of the LV in between 10 and 15 points and also the diastolic function is improved. The Basel peak filling rate (PFR) mean value below 1.8 ml/s moves to mean value above 3 ml/s postoperatively and remains above 2.5 ml/s after 1 year. Concurrently the time of PFR decrease from basal value of 190 msec to 110 msec after 1 year and the left portion of pressure volume loops moves toward the left
Since 1998, with the balloon sizing of the remaining ventricle mitral annuloplasty is more widely used to maintain the annulus below 30 mm diameter. The tendency to delay impairment decreased from 25% to 10% in the last 200 cases of this series. EVCPP technique is useful for slowing down the remodeling to avoid or even to delay the heart transplantation or the need of mechanical assisted device.(Data obtained from Dor V. Surgical remodeling of left ventricle. Surg Clin N Am 84 (2004) 27-43).
Many countries and areas in the world lack programs for heart transplantation due to facilities or the laws prohibit organ transplantation as in Egypt. In my opinion surgeons in these countries should provide this technique probably to there patients as a good alternative. And choosing the candidate for this surgery with good timing will improve the results of the ischemic heart surgery and will provide a good tool in the hand of these surgeons.
With developing of the imaging techniques will provide day by day better assessment of myocardial wall will give good information which will help to perform this type of surgery widely and will give a much better results.
In the future with more understanding of the cellular component may be promising to provide complement therapy to this procedure by assistant devices for a limited time and cellular therapy to provide a bridge to complete recovery.
