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 19799. 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 al25, 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 patients26.
These results are consistent with the speculation proposed in the Surgical Treatment for Ischemic Heart Failure trial27for the neutral outcome, that “the lack of benefit seen with surgical ventricular reconstruction is that benefits 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.