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\begin{document}

\title{AN HISTORICAL APPRAISAL OF THE TECHNIQUES OF LEFT VENTRICULAR VOLUME
REDUCTION IN ISCHEMIC CARDIOMYOPATHY: WHO DID WHAT?}



\author[1]{Antonio Calafiore}%
\author[2]{Antonio Totaro}%
\author[1]{Sotirios Prapas}%
\author[1]{Kostas katsavrias}%
\author[3]{Stefano Guarracini}%
\author[4]{Roberto Lorusso}%
\author[5]{Domenico Paparella}%
\author[5]{Michele Di Mauro}%
\affil[1]{Division of Cardiac Surgery A Henry Dunant Hospital Athens Greece}%
\affil[2]{Department of Cardiovascular Sciences Gemelli Molise Campobasso Italy}%
\affil[3]{Department of Cardiology “Pierangeli” Hospital Pescara Italy}%
\affil[4]{Maastricht Universitair Medisch Centrum+}%
\affil[5]{Universita degli Studi di Foggia Dipartimenti di Area Medica}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Resection or exclusion of scars following a myocardial infarction on the
LAD territory started even before the beginning of the modern era of
cardiac surgery. Many techniques were developed, but there is still
confusion on who did what. The original techniques underwent
modifications that brought to a variety of apparently new procedures
that, however, were only a ``revisitation'' of what described before. In
some case old techniques were reproposed and renamed, without giving
credit to the surgeon that was the original designer. Herein we try to
describe which are the seminal procedures and some of the most important
modifications, respecting however the merit of who first communicated
the procedure to the scientific world.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Surgery for exclusion of scars following LAD infarction started during
the `40s, but changed over time due to a better knowledge of the
pathophysiology of the disease and to the technical improvements in
cardiopulmonary bypass, oxygenators and myocardial protection.

However, many of the techniques described during the last 70 years were
changed, or even copied, and named differently without giving credit to
the surgeon(s) who conceived the original procedure. This peculiar
aspect of the history of left ventricular surgical reshaping (LVSR) has
never been focused correctly. This is evident in reviews about LVSR
techniques\textsuperscript{1-3}, where similar procedures have different
names, generating confusion.

In this report we want to describe the original techniques described
during the decades, that are at the basis of all the procedures applied
in this field, even if differently named.

\textbf{TECHNICAL EVOLUTION OF LVSR}

\textbf{First attempts without cardiopulmonary bypass.}

The first surgical approach was due to Beck\textsuperscript{4} in 1944.
He incised the pericardium around the aneurysm leaving the pericardium
adherent to the lesion. A fascia lata graft was then sutured to the
adherent pericardium and plication sutures were taken centrally to
reduce the size of the aneurysm and graft. The patient died five weeks
later with empyema and encephalomalacia. In 1955 Likoff and
Bailey\textsuperscript{5} described a case successfully treated with a
tangential exclusion with a specially designed side clamp. In 1958
Bailey\textsuperscript{6} reported 6 similar cases with 5 survivors. As
the problem of embolization could be easily controlled flushing out the
thrombi, if any, the Authors concluded that the use of an open technique
using cardiopulmonary bypass was not justified.

\textbf{The era of the open correction.}

\textbf{Cooley} et al in 1958 started the modern era of LVVR reporting
the first case of linear resection of an anterolateral aneurysm using
the cardiopulmonary bypass\textsuperscript{7} (fig. 1A,B), describing
more cases soon after\textsuperscript{8}. The Author used this technique
extensively and his experience was of 1572 cases in
1981\textsuperscript{9} and rose to 4298 in 1992\textsuperscript{10}. He
started to treat the diskinetic septum using a dacron patch which
replaced a diskinetic area with a smaller akinetic
area\textsuperscript{9} (fig. 1C-E). It is noteworthy that the linear
resection of the anterior wall with/out a patch on the septum includes
the incredible work performed by Cooley among the techniques aimed to
reduce the LV volume preserving the conical shape. The linear LV
reconstruction was further developed by Mickleborough et
al.\textsuperscript{11}. The Authors, in presence of a scarred, thinned
and aneurysmal septum, performed a septoplasty using a patch, part of
which, differently from Cooley, was included in the final suture (fig.
2).

In 1973 \textbf{Stoney} et al reported 29 cases of anteroseptal
ventricular aneurysms (the first case done most likely in 1971) where
the technique of LVVR was completely original and conceptually different
from what was done till then\textsuperscript{12}. After the incision of
the aneurysm, the junction of anterior scar tissue with the posterior
viable myocardium was identified and the lateral edge of myocardium was
then advanced down to the junction of scar and functioning myocardial
tissue in the septum with a continuous suture line. Teflon strips were
used to reinforce the lateral margin of the left ventricle, and the
sutures were brought out through the septum to the anterior wall of the
right ventricle. A second continuous suture line completed the closure
(fig. 3). This is the first technique described in the literature where
the septum was considered as important as the free wall. In the
Introduction the Authors stated that ``Conventional anterior
aneurysmectomy in the past has confined excision and repair to diseased
myocardium located to the left of the anterior descending coronary
artery. Restudy of these patients in our institution has shown
inadequate reduction of aneurysm size with residual akinetic myocardium
remaining in the ventricular septum. Attempts to revascularize the
anterior descending artery in patients with an anteroseptal aneurysm
have been equally disappointing.''

A modification if this technique was introduced by Calafiore et
al\textsuperscript{13} in 2003 who proposed, to make simpler the
procedure, a direct suture of the border of the scar in the anterior
wall to the border of the scar in the septum (linear septoexclusion,
fig. 4A). If the resulting cavity was perceived to be too small, an
elliptical patch could be used from the beginning of the septal scar to
the new apex\textsuperscript{14} (septal reshaping, fig. 4B-D).
Interestingly, the Authors referred to the Stoney technique as Guilmet
technique\textsuperscript{15}, as this latter Author redescribed in the
1984 the same procedure described by Stoney.

In 1985 \textbf{Jatene} reported 508 patients operated on between
September 1977 to September 1983\textsuperscript{16}. His approach to
the septum, intially similar to Cooley's technique\textsuperscript{9},
was changed. He used two or three mattress stitches buttressed with
Teflon felt to reduce the elongation of the septal wall. But he was the
first to introduce the concept of intracavitary purse string. It was
placed on the free-wall endocardium at the junction of the endocardial
scar and normal endocardium, never involving the papillary muscles. This
free-wall suture was continued around the anterior base of the aneurysm
until it reaches the junction of the anterior free-wall and anterior
septum at the base of the aneurysm. The other end of the purse-string
suture was continued onto the distal septum at the apex and then
proximally up the anterior septum at its junction with the free-wall.
Both ends of the purse-string suture were then passed transmurally
through the anterior left ventricular free-wall and tied over a felt
pledget. Because the purse-string suture was placed on the anterior edge
of the septum and around the apex onto the free-wall, the septum was
incorporated and remained a part of the wall of the left ventricular
cavity. After the purse string has been tied, the opening could be
closed, at the level of the purse string, with direct suture or with a
patch (fig. 5). Jatene's concept was revolutionary, as he introduced the
concept of geometrical LV reconstruction, using a surgical intracavitary
remodeling by a purse string associated with the treatment of the
diskinetic septum, maintaining a conical LV shape. The use of a patch of
a direct suture allowed to decide the volume of the cavity, even if this
decision, according to the Author, was defined ``empirical''.

In 1989 \textbf{Dor} proposed a technique that he started to use in
1984\textsuperscript{17}. The key points of the procedure were 1)
resection of dyskinetic or akinetic LV free wall and thrombectomy when
indicated; 2) dacron patch lined with pericardium secured at the
junction of the endocardial muscle and scarred tissue, thereby excluding
non-contractile portions of the LV and septum; 3) myocardial
revascularization, in particular of the proximal LAD segments (fig. 6).
To avoid excessive volume reduction, in 1999 Dor suggested to use a
rubber balloon filled with water (50 to 70 ml/m\selectlanguage{ngerman}²)\textsuperscript{18}.
As described initially, this technique was focused on volume reduction,
as the patch was located at the base of the aneurysm and was as large as
the base was, but the shape was often more rectangular than elliptic.
The Dor procedure was initially perceived as functional amputation of
the ventricle with exclusion of the entire akinetic or dyskinetic scar,
leading to increased sphericity of the ventricle in some
patients\textsuperscript{19}. This consequence was considered irrelevant
by Dor et al\textsuperscript{20}, who stated that ``The improvement of
contractility is not related to shape. Although Buckberg and
associates\textsuperscript{21} have suggested that a spherical cavity is
less contractile than an elliptic one, the dogma of elliptic shape was
established without convincing physical or physiologic data.''
Nevertheless, this technique was widely applied, but faced a number of
modifications that improved those perceived as weak points.

Cooley in 1989 published 6 cases with the same principles, but the
excision of the free wall scar (which favored bleeding) was avoided. The
scar was maintained and sutured over the patch, as it is done till
now\textsuperscript{22}.

An important modification was performed by Fontan\textsuperscript{23}who
suggested to reduce the size of the patch applying a purse string (the
Fontan's stitch) to limit the size to the normal size of the LV at the
level of the insertion of the papillary muscles. The Author used an oval
patch sized 25 to 30 mm, with 2-3 mm used for suturing. This variation
was incorporated into the technique and is used till now.

Another important improvement was the use of a LV conical shaper
introduced by Menicanti et al\textsuperscript{19} with two purposes. The
first one was to avoid an excessive volume reduction, the second one was
to maintain a shape as conical as possible. The volume of the shaper
ranged from 60 to 75 ml/m² and the internal correction was completed
with a patch (not larger than 30 mm) or with direct sutures over the
shaper (fig. 7). In his later experience Menicanti et
al\textsuperscript{24} reduced the volume to 50-60 ml/m².

The original Dor technique, as originally described, today does not
exist anymore, as all the modifications changed substantially the
surgical procedure.

\textbf{CONCLUSION}

The techniques previously reported are at the basis of all techniques
described thereafter. Many surgeons re-reported a previously described
technique either after limited and irrelevant changes or simply renaming
the procedure. Original techniques depend on the development of new
concepts and changing the position or the shape of a patch or the number
of purse strings is not enough to identify something new. The memory of
the cardiac surgeons is often short!!

The most innovative techniques reported in the literature are surely the
Stoney technique (the first one that addresses the septum in every
patient) and the Jatene technique, that introduced the concept of
geometric repair of the LV anatomy, described the use of a purse string
to reduce obliquely the cavity and addressed the septum that was changed
from dyskinetic to akinetic with a reduced surface by means of
interrupted sutures. However, we must recognize that the concept to
exclude the dyskinetic septum and to reduce its surface was present
since the early times of the LVSR. Cooley and his group reported 421
cases operated on between 1969 and 1979\textsuperscript{9}. The Dor
technique was aimed to exclude the scarred septum, but without a purse
string and a shaper the remaining cavity would be more rectangular than
conical. However, Dor's concept moved ahead in a new direction a complex
surgery.

All the surgical solutions aimed to solve the problem of LVSR tried to
maintain a conical shape (as much as possible) and a reduction of volume
such to improve the contractility without compromising the diastolic
function. This aspect was evaluated by Lee et al\textsuperscript{25},
who demonstrated that, in patients undergone the Dor technique, the
postsurgical improvement in systolic function was compromised by a
decrease in diastolic distensibility in all investigated patients.
Worsening of the diastolic function was due to increase of sphericity
index, with consequent reduction of stroke volume. By simulating a
restoration of the left ventricle back to its measured baseline
sphericity, the Authors showed that both diastolic and systolic function
improved. The benefit in maintaining a conical shape was demonstrated by
us after a follow up of 15 years in propensity matched
patients\textsuperscript{26}.

These results are consistent with the speculation proposed in the
Surgical Treatment for Ischemic Heart Failure
trial\textsuperscript{27}for the neutral outcome, that ``the lack of
bene\selectlanguage{english}fit seen with surgical ventricular reconstruction is that bene\selectlanguage{english}fits
anticipated from surgical reduction of left ventricular volume (reduced
wall stress and improvement in systolic function) are counter-balanced
by a reduction in diastolic distensibility.'' There is no doubt that,
independently from the surgical procedure applied, postoperative
diastolic function remains the Achille's heel of the left ventricle
reshaping.

The anatomical spectrum of LV aneurysms changed over time. Lack of early
reperfusion selected patients who were able to survive with large scars,
that were, in expert hands, easy to resect or exclude. Nowadays, the
increased use of early coronary reperfusion made the infarcted area
become akinetic rather than dyskinetic, making more difficult patients'
selection and less predictable the clinical results. But this aspect is
outside the purpose of this report.

\textbf{REFERENCES}

1. Ruzza A, Czer LSC, Arabia F, et al. Left Ventricular Reconstruction
for Postinfarction Left Ventricular Aneurysm: Review of Surgical
Techniques. Tex Heart Inst J 2017;44:326-35.

2. Suma H, Anyanwu AC. Current status of surgical ventricular
restoration for ischemic cardiomyopathy. Semin Thorac Cardiovasc Surg
2012;24:294-301.

3. Fathei Hassanabad A, Wiebe K, Ali I. Clinical and henosynamic outcome
of the Dor procedure in adults with ischemic cardiomyopathy. J Card
Surg, 2021, in press.

4. Beck CS. Operation for Aneurysm of the Heart. Ann Surg
1944;120:34-40.

5. Likoff W, Bailey CP. Ventriculoplasty: excision of myocardial
aneurysm; report of a successful case. J Am Med Assoc 1955;158:915-20.

6. Bailey CP, Bolton HE, Nichols H, Gilman RA. Ventriculoplasty for
cardiac aneurysm. J Thorac Surg 1958;35:37-64; discussion -7.

7. Cooley DA, Collins HA, Morris GC, Jr., Chapman DW. Ventricular
aneurysm after myocardial infarction; surgical excision with use of
temporary cardiopulmonary bypass. J Am Med Assoc 1958;167:557-60.

8. Cooley DA, Henly WS, Amad KH, Chapman DW. Ventricular aneurysm
following myocardial infarction: results of surgical treatment. Ann Surg
1959;150:595-612.

9. Reddy SB, Cooley DA, Duncan JM, Norman JC. Left ventricular aneurysm:
Twenty-year surgical experience with 1572 patients at the Texas Heart
Institute. Cardiovasc Dis 1981;8:165-86.

10. Cooley DA, Frazier OH, Duncan JM, Reul GJ, Krajcer Z. Intracavitary
repair of ventricular aneurysm and regional dyskinesia. Ann Surg
1992;215:417-23; discussion 23-4.

11. Mickleborough LL, Maruyama H, Liu P, Mohamed S. Results of left
ventricular aneurysmectomy with a tailored scar excision and primary
closure technique. J Thorac Cardiovasc Surg 1994;107:690-8.

12. Stoney WS, Alford WC, Jr., Burrus GR, Thomas CS, Jr. Repair of
anteroseptal ventricular aneurysm. Ann Thorac Surg 1973;15:394-404.

13. Calafiore AM, Gallina S, Di Mauro M, et al. Left ventricular
aneurysmectomy: endoventricular circular patch plasty or septoexclusion.
J Card Surg 2003;18:93-100.

14. Calafiore AM, Mauro MD, Di Giammarco G, et al. Septal reshaping for
exclusion of anteroseptal dyskinetic or akinetic areas. Ann Thorac Surg
2004;77:2115-21.

15. Guilmet D, Popoff G, Dubois C, et al. {[}A new surgical technic for
the treatment of left ventricular aneurysm: the overcoat
aneurysmoplasty. Preliminary results. 11 cases{]}. Arch Mal Coeur Vaiss
1984;77:953-8.

16. Jatene AD. Left ventricular aneurysmectomy. Resection or
reconstruction. J Thorac Cardiovasc Surg 1985;89:321-31.

17. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left
ventricular aneurysm: a new surgical approach. Thorac Cardiovasc Surg
1989;37:11-9.

18. Dor V, Sabatier M, Montiglio F, Coste P, Di Donato M.
Endoventricular patch reconstruction in large ischemic wall-motion
abnormalities. J Card Surg 1999;14:46-52.

19. Menicanti L, Di Donato M. The Dor procedure: what has changed after
fifteen years of clinical practice? J Thorac Cardiovasc Surg
2002;124:886-90.

20. Dor V, Civaia F, Alexandrescu C, Montiglio F. The post-myocardial
infarction scarred ventricle and congestive heart failure: the
preeminence of magnetic resonance imaging for preoperative,
intraoperative, and postoperative assessment. J Thorac Cardiovasc Surg
2008;136:1405-12.

21. Buckberg GD, Coghlan HC, Torrent-Guasp F. The structure and function
of the helical heart and its buttress wrapping. VI. Geometric concepts
of heart failure and use for structural correction. Semin Thorac
Cardiovasc Surg 2001;13:386-401.

22. Cooley DA. Ventricular endoaneurysmorrhaphy: a simplified repair for
extensive postinfarction aneurysm. J Card Surg 1989;4:200-5.

23. Fontan F. Transplantation of knowledge. J Thorac Cardiovasc Surg
1990;99:387-95.

24. Menicanti L, Castelvecchio S, Ranucci M, et al. Surgical therapy for
ischemic heart failure: single-center experience with surgical anterior
ventricular restoration. J Thorac Cardiovasc Surg 2007;134:433-41.

25. Lee LC, Wenk JF, Zhong L, et al. Analysis of patient-specific
surgical ventricular restoration: importance of an ellipsoidal left
ventricular geometry for diastolic and systolic function. J Appl Physiol
(1985) 2013;115:136-44.

26. Di Mauro M, Iaco AL, Bencivenga S, et al. Left ventricular surgical
remodelling: is it a matter of shape or volume? Eur J Cardiothorac Surg
2015;47:473-9; discussion 9.

27. Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery
with or without surgical ventricular reconstruction. N Engl J Med
2009;360:1705-17.

28. Calafiore AM, Di Mauro M, Mazzei V, Angelini G, Teodori G, Wilde P.
Midterm results after septal reshaping for anteroseptal scars. Heart
Surg Forum 2004;7:E230-6.

29. Jatene AD: Surgical treatment of left ventricular aneurysm. Glenn's
Thoracic and Cardiovascular Surgery. In: Baue AE, Geha AS, Hammond GL,
Laks H, Naunheim KS, eds. Appleton \& Lange, Norwalk, CT,
5\textsuperscript{th} Ed., Vol. \textbf{2,} pp 1829-1836, 1991.

\textbf{FIGURES}

Fig. 1 --Linear excision of an anterolateral aneurysm. A, the aneurysm
is incised and its surface is almost completely excised. B, the defect
is sutured over 2 teflon stripes. In presence of a scarred and
dyskinetic septum (C), a patch was sewn over the septum (D) to reduce
the septal surface and to eliminate the systolic bulging (E).

Fig. 2 -- In presence of a septoapical aneurysm (A), a pericardial patch
is sewn on the borders of the healthy septum on three sides. The
anterior portion of the patch is pulled tight and incorporated in the
modified linear closure as indicated by the arrows (B). The patch
excludes the aneurysmal portion of the septum and helps to maintain a
conical shape (C).

Fig. 3 -- A, the aneurysm is incised and almost completely excised. The
lateral wall of the left ventricle is sutured down in the septum at the
border of the scar with interrupted sutures that are brought out at the
right ventricle. B, a second line of suture is necessary to connect the
scar close to the LAD to the healthy myocardium.

Fig. 4 -- Simplification of the Stoney technique. Linear septoexclusion.
A, the border between the scarred and the healthy portion of the
anterior wall is sutured with the border between the scarred and healthy
septum till the apex. Part of the apical scar, if necessary, is included
in the remaining LV cavity to obtain a longitudinal axis as long as
possible. Septal reshaping (B-D). B, stitches are passed at 4 positions
in the septum: at the highest point where the anterior and septal scars
meet (1); at the level of the new apex (2); deep in the septum at the
border between the scar and the healthy posterior septum (3); and in the
anterior wall, again at the limit of the scar (4). C, a dacron or bovine
patch is tailored and fixed with the 4 stitches previously placed. D, a
new ventricular chamber is created, that has a shape as conical as
possible. Apical scars are often included.

Fig. 5 -- The Jatene technique. A, the septal dyskinesia is treated by
means of e few U stitches, passed in both directions. A purse string
follows the border of the scar, but includes the septum inside the new
cavity. B, Once the purse string is tied, the opening can be closed
directly of by a patch (C).

Fig. 6 -- The Dor technique as originally described. In presence of an
anteroseptal aneurysm (A), the scar is excised as well as the septal
endocardial scar. A patch, of the same size of the defect, is trimmed
(B) and sutured to close the defect (C).

Fig. 7 -- Menicanti's modification of the Dor technique. A, to obtain a
conical shape, a shaper is inserted inside the LV. B, if the inferior
region is severely dilated, it is plicated, placing the apex in a more
anterior position. A circular suture (Fontan stitch) to exclude the
affected anterior and septal tissue starts from this new apex, and the
plane of suture is more oblique with a resultant elliptical shape. C,
the shaper is out from the ventricle and the defect is closed with a
patch.\selectlanguage{english}
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