Heart reduction surgery: An analysis of the impact on cardiac function

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Presentation transcript:

Heart reduction surgery: An analysis of the impact on cardiac function Marc L. Dickstein, MD*, Henry M. Spotnitz, MD**, Eric A. Rose, MD***, Daniel Burkhoff, MD, PhD**** The Journal of Thoracic and Cardiovascular Surgery Volume 113, Issue 6, Pages 1032-1040 (June 1997) DOI: 10.1016/S0022-5223(97)70288-5 Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 1 To simulate mass reduction surgery, the total heart, represented by a modified nonlinear time-varying elastance (E tot [t,v]), was functionally divided into two portions: the portion to be excised (E x [t,v]) and the portion that is not excised (E nx [t,v]). Details of the computations are provided in the text (equations 1 to 6). The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 2 Left ventricular pressure-volume loops (LVP and LVV) are shown at each of the four levels of mass reduction (0, 25, 50, and 75 gm of tissue removed). The pressure-volume loops shift to the left in response to mass reduction. Also shown on this graph are the ESPVRs (straight lines that intersect the end-systolic point of the respective pressure-volume loop) and the EDPVRs (curvilinear relations that intersect the end-diastolic point of the respective pressure-volume loop). As mass is reduced from 0 to 75 gm (solid line, dotted line, dashed line, dotted/dashed line), the ESPVR slope increases, and the curvature of the EDPVR increases; both relations tend to move in a parallel fashion. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Appendix Fig. 1. Left ventricular pressure-volume relations determined from finite element analysis at each of the four levels of mass reduction (0 gm, solid line; 25 gm, dotted line; 50 gm, dashed line; 75 gm, dotted/dashed line). As mass is reduced from 0 to 75 gm, the ESPVR slope and curvature of the EDPVR both increase; these changes are similar to that shown in Fig. 2 derived from compartmental modeling. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 3 Left ventricular stroke work–end-diastolic volume relations (SW and EDV). Similar to the ESPVR, the slope increases and volume-axis intercept decreases with incremental reductions in ventricular mass (0 gm, solid line; 25 gm, dotted line; 50 gm, dashed line; 75 gm, dotted/dashed line). The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 4 A, Slope of the end-systolic pressure-volume relation (Ees; filled squares) and ejection fraction (EF; open circles) as a function of amount of LV mass excised (x-axis). Both of these indices of systolic function increase with mass reduction. B, Left ventricular end-diastolic volume (LV EDV; filled circles) and the stiffness coefficient of the end-diastolic pressure-volume relation (K; open squares) also as a function of LV mass excised. Both of these measures reflect the decrease in chamber compliance associated with mass reduction. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 5 Frank-Starling relationship relating stroke volume to LVEDP at the four mass reduction conditions (0 to 75 gm of tissue excision). Notice that mass reduction is associated with a downward shift of the Frank-Starling curves, indicating a reduction in pump function. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 6 Left ventricular stress-strain loops at each of the four levels of mass reduction (0 gm, solid line; 25 gm, dotted line; 50 gm, dashed line; 75 gm, dotted/dashed line). With mass reduction, there is a decrease in the peak stress attained, a small leftward shift of the relations, and a widening of the loops. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 7 Peak stress is shown as a function of peak chamber pressure at each of the four levels of mass reduction. These relations shift downward in response to mass reduction. The implication is that stress is reduced at a given peak chamber as a result of mass reduction. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 1032-1040DOI: (10.1016/S0022-5223(97)70288-5) Copyright © 1997 Mosby, Inc. Terms and Conditions