COMMENT
Non-ischemic cardiomyopathy (NICM) is a heterogenous group of direct
myocardial dysfunction stemming from a wide range of pathologies.
Dilated NICM was traditionally treated medically and often culminated in
heart transplant for patients at the end stage (1). As for surgical
options, partial left ventriculectomy (PLV) was proposed and performed
sporadically primarily by Dr. Batista. Due to lack of accurate diagnosis
techniques such as the contemporary intraoperative echocardiographic
studies to identify the predominant region of myocardial involvement,
PLV was associated with inconsistent results and thus left ventricular
reconstruction in this population of patients was abandoned all together
(2). The poor outcomes from the PLV in dilated NICM was believed to stem
from the variability in myocardial distribution in this non-homogenous
group of cardiomyopathy and thus the risk of excluding healthy segments
(3). Therefore, the outdated “one size fit all” approach with PLV was
noted to be ineffective in the surgical management of dilated NICM. This
observation has prompted the initiation of targeted surgical approaches
that only exclude the most affected regions. In fact, PLV remains an
option reserved for lateral wall involvement. However, when septal
damage is the most culprit area, a technique developed by Dr.
Torrent-Guasp, termed Septal Anterior Ventricular Exclusion (SAVE) was
developed to exclude the septum with the insertion of an oblique patch
between the apex and high septum, just below the aortic valve with
subsequent closure of the excluded wall over the patch (4). This
technique acts in a fashion similar to the more circular patch used to
exclude the apical wall in the Dor procedure that has been heavily used
in the treatment of ischemic cardiomyopathy to reconstruct the LV (5).
In 2003, Mickleborough et al. published their experience of LV
reconstruction in 108 patients with ischemic cardiomyopathy and
preoperative VT which were treated with direct visual endocardial
excision and peripheral cryoablation. The post-operative freedom from VT
or sudden death was found to be 99%, 97%, and 94% at 1, 5, and 10
years, respectively. This study however only focused on patients who
developed aneurysmal changes to their left ventricle following
myocardial infarction.
In this report, we describe a successful surgical treatment of a patient
who presented with a heavily calcified apical left ventricular aneurysm
secondary to non-ischemic cardiomyopathy in conjunction with prolonged
VT that has failed medical management and was unamenable to previous
endocardial or epicardial ablation. We believed that performing a Dor
procedure would exclude the LV apex that was the most diseased and
akinetic myocardial segment. We also opted to use CryoFlex Probe to
ablate on the area of arrhythmia generation endo- and epicardially to
achieve a transmural isolation to control the patient intractable VT.
The patient had an uneventful course with resolution of his ventricular
tachycardia and was discharge home on the 6thpost-operative day with normalized LVEF and freedom from any recurrent
VT.