CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Constantine L. Athanasuleas, MD and
Gerald D. Buckberg, MD*
* Department of Surgery, UCLA Medical Center, 10833 Le Conte Avenue, Room 62-258 CHS, Los Angeles, CA 90095-1741 (Email: gbuckberg{at}mednet.ucla.edu).
The RESTORE registry was accumulated to confirm the extensive experience of Dor and his colleagues, which dates back about 20 years. The primary reason for presenting these data was to demonstrate that volume reduction and shape changes are valuable components in the treatment of congestive heart failure following infarction. Ejection fraction improved, volume was reduced, and clinical status improved by New York Heart Association (NYHA) functional classification status. Moreover, five-year survival was very gratifying, especially when compared to conventional therapy.
The effects of ventricular restoration have been studied and referenced in our report (1). These include improvement of systolic and diastolic function, confirmed by the centerline method and pressure-volume loop studies. The operation’s primary physiological impact is on the remote noninfarcted myocardium and has been well described.
Our study did not report hemodynamics because we believe that little can be extrapolated from such data. It is well known that heart failure progresses independently of hemodynamic status and is directly related to ventricular size and shape changes (2,3). Indeed, patients with markedly dilated hearts and advanced heart failure often have normal cardiac output and pulmonary pressures at rest. Our reporting is, therefore, consistent with the majority of clinical trials of heart failure, few of which assert that acute resting hemodynamic changes are of functional or prognostic significance.
Hemodynamics, however, may be of value during exercise. Consequently, conversion of 67% in NYHA functional class III/IV category to 85% in class I/II seems an effective functional counterpart. In the meanwhile, the recently documented neuro-hormonal consequences of ventricular restoration are very pertinent to the reviewer’s comments regarding "cause and effect" (4).
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References
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1. Athanasuleas CL, Buckberg GD, Stanley AW, et al. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation J Am Coll Cardiol 2004;44:1439-1445.[Abstract/Free Full Text]
2. Packer M. How should physicians view heart failure? The philosophical and physiological evolution of three conceptual models of the disease Am J Cardiol 1993;71:3C-11C.[CrossRef][Medline]
3. White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction Circulation 1987;76:44-51.[Abstract/Free Full Text]
4. Schenk S, McCarthy PM, Starling RC, et al. Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy J Thorac Cardiovasc Surg 2004;128:38-43.[Abstract/Free Full Text]
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