Himanshu J. Patel, MDa, Edward B. Lankford, MD, PhDb, David J

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Presentation transcript:

Dynamic cardiomyoplasty: Its chronic and acute effects on the failing heart Himanshu J. Patel, MDa, Edward B. Lankford, MD, PhDb, David J. Polidori, MDa, James J. Pilla, PhDa, Theodore Plappert, CVTb, Martin St.John Sutton, FRCPb, Michael A. Acker, MDa The Journal of Thoracic and Cardiovascular Surgery Volume 114, Issue 2, Pages 169-178 (August 1997) DOI: 10.1016/S0022-5223(97)70141-7 Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 1 Experimental design. Our experimental protocol shows that 19 dogs underwent baseline pacemaker installation followed by rapid ventricular pacing (RVP) for 10 weeks at a rate of 215 beats/min to create heart failure. All dogs had pressure-volume analysis (PVA) and two-dimensional echocardiography (echo) studies at baseline and at 4 and 10 weeks of RVP. Eight dogs underwent cardiomyoplasty (CMP) at 4 weeks of RVP. The muscle conditioning protocol is a graded burst-stimulation protocol and is detailed in the text. The Journal of Thoracic and Cardiovascular Surgery 1997 114, 169-178DOI: (10.1016/S0022-5223(97)70141-7) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 2 Echocardiographic results. These echocardiographic data demonstrate the chronic effects of cardiomyoplasty on ventricular function and geometry. Notice that the initial 4 weeks of rapid ventricular pacing (RVP) increased volumes (EDV) and decreased ejection fraction (EF) in all dogs. In contrast to control dogs, in which this process continued for the last 6 weeks of rapid ventricular pacing, volumes and ejection fractions were stabilized in the cardiomyoplasty (CMP) group. Data represented for the cardiomyoplasty group are with the myostimulator “off” to assess chronic effects of cardiomyoplasty on the failing heart. All p values represent comparisons between 4 and 10 weeks of rapid ventricular pacing within each group. The Journal of Thoracic and Cardiovascular Surgery 1997 114, 169-178DOI: (10.1016/S0022-5223(97)70141-7) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 3 Effects of rapid ventricular pacing (RVP) and cardiomyoplasty on composite pressure-volume relationships over time. A, The continued rightward shift in both end-systolic (ESPVR) and end-diastolic pressure-volume relations (EDPVR) over the 10-week RVP period in control dogs. This demonstrates that RVP does lead to long-term remodeling throughout the rapid pacing period in our control group. In contrast, in the dynamic cardiomyoplasty group (B), there is an initial rightward shift over the first 4 weeks of RVP only. Dynamic cardiomyoplasty stabilizes the remodeling process during the ensuing 6 weeks despite ongoing rapid pacing. The ESPVR and EDPVR shown in B represent curves obtained with the stimulator “off.” The p values reflect the differences in position of the ESPVR between different time points, as indicated by the end-systolic volume for an end-systolic pressure of 80 mm Hg. The Journal of Thoracic and Cardiovascular Surgery 1997 114, 169-178DOI: (10.1016/S0022-5223(97)70141-7) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 4 Effect of dynamic assistance on the pressure-volume relationships in heart failure. Typical results are depicted for one dog during dynamic assistance for every beat (stimulator 1:1, solid lines) in comparison with unassisted beats (stimulator “off,” dotted lines). Stroke work and the EDPVR do not change significantly for the assisted beats. Similarly, the position of the ESPVR and the pressure-volume loops do not change. However, a change in the end-systolic elastance (the slope of the ESPVR) for the assisted beats is evident when compared with unassisted beats. Our composite ESPVRs and EDPVRs (not shown) comparing assisted 1:1 and 1:2 beats versus unassisted beats show similar results. This is an increase in effective contractility with skeletal muscle assistance. Because the stroke work (area within the pressure-volume loop) is not changed with assistance, myocardial workload is therefore decreased despite an increase in effective contractility. The Journal of Thoracic and Cardiovascular Surgery 1997 114, 169-178DOI: (10.1016/S0022-5223(97)70141-7) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 5 Proposed mechanisms of cardiomyoplasty. Dynamic cardiomyoplasty acts by at least two mechanisms. Girdling effects on the left ventricle limit the chronic dilation associated with heart failure and thus decrease diastolic strain. Enhancement of effective contractility with skeletal muscle assistance decreases myocardial workload and thus decreases cardiac oxygen consumption and increases myocardial efficiency. Both of these effects presumably act to stabilize cardiac function over time. The Journal of Thoracic and Cardiovascular Surgery 1997 114, 169-178DOI: (10.1016/S0022-5223(97)70141-7) Copyright © 1997 Mosby, Inc. Terms and Conditions