Surgical Anterior Ventricular Restoration for Ischemic Cardiomyopathy Constantine L. Athanasuleas, Gerald D. Buckberg  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 2, Pages 66-75 (May 2002) DOI: 10.1053/otct Copyright © 2002 Elsevier Inc. Terms and Conditions

1 An incision is made 2.5 cm parallel to the left anterior descending artery in the vented ventricle. Dimpling of the muscle is often not present, even as the vent suction is increased. The surface of the apex often appears normal and rotates because of salvage of the epicardium. The visual appearance of normal epicardial fibers does not exclude ventriculotomy, because thickening alone is a determinant of effective contraction. Absence of thickening is confirmed by TEE during cardiopulmonary bypass with the unloaded and inotrope-stimulated ventricle. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 A small ventriculotomy is initially made and is extended based on palpable findings. The epicardial muscle may bleed. Retraction sutures are placed on the muscle edges for exposure. The endocardium is visually inspected, but only palpation accurately defines contracting or thickening muscle. The high septum is often echocardiographically akinetic before cardiopulmonary bypass, yet palpation of the open beating heart demarcates a contracting segment. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 A 2-0 polypropylene pursestring suture is placed at the junction of contracting and akinetic muscle, as described by Fontan. Repeated palpation of the junction between contracting and noncontracting muscle defines the course of this suture. Visual inspection alone is misleading because of diffuse endocardial scarring. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 The encireling endoventricular “Fontan suture” is tightened to tolerance, transforming the circular opening into an oval one with a raised shelf. Interrupted #0 braided polyester pledgeted sutures are first placed on the septal shelf. Alternatively, felt bovine pericardium pledgets may be used. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 The mattress sutures on the septal side originate just below the Fontan suture and are passed into the akinetic ventricle. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 Braided #0 polyester mattress sutures are passed through a strip of bovine pericardium into the lateral ventricle. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 These sutures enter the ventricle just distal to the encircling Fontan suture. The width of the mattress stitch is about 1 cm. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

8 A conical sizer is used to determine patch size. (Reprinted with permission from Floyd E. Hosmer © 2002). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

9 The central oval patch ranges between three sizes: 1.5 × 2 cm, 2 × 3 cm, or 3 × 4 cm. An outer rim of 1 cm is used for extra suture placement if bleeding occurs around the patch edge. We initially used a Dacron patch and now use a bovine pericardial patch that incorporates a flexible pericardial ring for suture placement. This design permits secure coaption of the prosthetic material to the trabeculated muscle and greatly minimizes leakage around the patch. (Reprinted with permission from Floyd E. Hosmer © 2002). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

10 The patch is gently positioned into the ventricle with the index finger. This avoids pulling fragile muscle toward the patch. Excessive tension may cause tearing at the encircling suture sites, especially if there is minimal endocardial scarring. The patch is lowered into place, and the sutures are tied and cut. Venting of the ventricle may be temporarily discontinued to allow filling of the chamber and inspection for hemostasis. If leakage occurs at the patch edge, then a mattress suture may be placed through the outer rim and secured to the epicardium. Alternatively, a continuous 4-0 polypropylene suture may be used to attach the rim to the endocardium. The ventricle is partially filled as the lungs are inflated to permit air evacuation as the last suture is tied. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

11 Closure of the ventriculotomy is accomplished in a in a “vest over pants”-type closure. The lateral myocardial edge is brought beneath the septal edge, reducing potential restriction of right ventricular filling. Interrupted 0 braided sutures are then passed through the lateral muscle from inside to outside. The needle is then brought across the ventriculotomy and passed through the septal endocardium to the epicardium to enfold the lateral wall beneath the septal wall. (Reprinted with permission from Floyd E. Hosmer © 2002). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions

12 Finally, a 0 polypropolene suture is run continuously to complete a hemostatic closure. When fragile muscle is encountered, this suture line may be buttressed with strips of bovine pericardium. Air is actively removed by an aortic vent and monitored by TEE, which is also useful in monitoring regional wall function. Atrial pacing wires as well as left and right ventricular wires are placed for subsequent electrophysiologic study in selected cases. Routine weaning from cardiopulmonary bypass completes the procedure. (Reprinted with permission from Floyd E. Hosmer © 2002.) Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 66-75DOI: (10.1053/otct) Copyright © 2002 Elsevier Inc. Terms and Conditions