2. cardiomyopathy or heart failure

Cardiomyopathy includes ischemic one, idiopathic (i.e., its cause is unknown, e.g., dilated one, etc) one and so forth.  For ischemic cardiomyopathy, please see the pages of ischemic heart disease.  Here, non-ischemic, surgical and non-surgical treatment of dilated cardiomyopathy will be discussed. In this page, we do not discuss heart transplant, since availability of donor hearts in Japan is very limited.

Q: What is “Cardiomyopathy”?

A: It is a disease of the heart muscle (myocardium), and as a result the heart loses its power.  In dilated cardiomyopathy, the myocardium is diseased and the wall of heart chamber (left ventricle, LV) becomes thin or solid, losing its power.

Q: What does “ischemic” in ischemic cardiomyopathy mean?

A:

”Ischemic” means the condition where coronary artery(ies) is narrowed or blocked, resulting in loss/shortness of blood supply to the heart and loss of heart muscles or its function.

Ischemic cardiomyopathy usually develops after myocardial infarction; because of dilationor sphericalization of the LV, even relatively healthy part of LV become less powerful.

Q:  What is “dilated”?

A:

”Dilated” means a condition where heart chambers especially left ventricle (LV)becomes large in size;

under the condition, LV often become spherical and has lesseffective function. 

LV wall usually becomes thin and less powerful.

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Q:  What is Batista surgery for dilated cardiomyopathy?

A: It is a surgical method to fix dilated cardiomyopathy. In idiopathic dilated cardiomyopathy, patients’ prognosis with medical treatment was poor, but there was no effective surgical treatment except for heart transplant until 1990s.  In 1990s, however, Dr. Randas Batista from Brazil showed the effects of Batista surgery where lateral wall of the LV is excised and the LV becomes smaller, and since then, some patients with dilated cardiomyopathy became candidates of surgical treatment.  Unfortunately Batista surgery (formally called partial left ventriculectomy, PLV) gave inhomogeneous and unpredictable results, and as a result, it became less popular.  In USA, the Batista surgery is now almost abandoned. In Japan, Dr. Suma introduced and improved the surgery, and it became accepted in some centers, but not many.

Q:  What is modified Batista surgery?

  A: 

We kept working on improving the Batista surgery by collaborating with Dr. Suma and late Prof. Torrent-Guasp (Photo) and some European surgeons.

We did not only clinical research but also experimental study by developing animal model of dilated cardiomyopathy and developed modified Batista surgery.

In the modified Batista surgery LV apex is not amputated but preserved, and we showed better results than conventional Batista surgery at American Association of Thoracic Surgery (AATS) meeting in 2002 (Figure). (Dilated cardiomyopathy case 1, case 2)

The method is based on late Professor Torrent-Guasp’s theory that LV apex has a pivotal role in the structure of the heart (“muscle band” structure).

In the figure, left panel and right upper panel shows conventional Batista surgery where LV apex is amputated.

Right lower panel shows our method where LV apex is preserved in the Batista surgery.

The method has been applied in 14 patients, and all of them except for one survived and doing well. The only exceptional patient required multiple LV restoration surgery as well as other surgery and also senile patient with the history of stroke before.

In Japan, donor heart has been extremely limited in supply, and thus the modified Batista surgery is expected to save more patients.  In Europe, some surgeons who have lots of experiences of LV restoration surgery recovered their interest in the Batista surgery. Especially the patients over 60 years old are outside of indication for transplant and LV assist device is too risky, therefore the modified Batista surgery may be more beneficial for them.

Q: What type of LV restoration surgery besides Batista surgery?

A: In patients with Dilated Cardiomyopathy (DCM) who have disease in interventricular septum, we do SAVE procedure, with good results for those who had good general conditions before the surgery. Even in patients who had LV ejection fraction of less than 20% (Note: normal range 55-65%), sometimes ejection fraction even around 10%, were usually saved by the surgery. Even in patients with very poor LV, if they have elective operation, about 90% of them survived the surgery (DCM case 3).

In children patients, the method works very well (DCM case 4)。

Besides the LV restoration methods as described above, we sometimes do Overlap surgery where LV antero-lateral wall is put inside of the LV to overlap the septum;

the method has theoretically weak point (i.e., leaving scar and border zone are which can re-dilate later), but it also has some merits. 

We try to use the most suitable method to each patient. (Please see 4. Ischemic Heart Disease)

Dor’s surgery has several potential problems or limitations in its effects, but depending on the patient’s anatomy and disease area and surgical techniques, Dor’s surgery can often benefit the patients. We develop new Dor’s procedure which is free from geometrical distorsion; we will publish it soon.

In addition, we showed in experimental study that mitral annuloplasty (MAP) can improve function of LV base, and we apply it to more patients than before.  Moreover, in patients whom bi-ventricular pacing or cardiac resynchronization therapy (CRT) was effective in intraoperative test, we do it by collaborating with cardiologists.  (For Dor’s surgery or CRT, please see 4. Ischemic Heart Disease)

The figure shows the outline of the patient who had combined surgery of LV restoration etc..

It was something novel at that time and was reported on newspapers. 

Before the surgery, the patient was in a shock state and critical condition, but after the surgery he recovered well and doing fine more than 5 years thereafter.

From the figure, geometrical relationship between the modified Batista surgery (for LV lateral wall) and SAVE procesure (for interventricular septum) can be seen well.

Q: Does LV restoration surgery help the patients with cardiac sarcoidosis or LV noncompaction?

A: In dilated cardiomyopathy (DCM) there are various causes. For example, when sarcoidosis affects heart (i.e., cardiac sarcoidosis), the heart often develops DCM. We repair the LV on case-by-case basis by considering the etiology and characteristics of the disease. (Dilated cardiomyopathy Case 5 and Case 6)

LV noncompaction (LVNC) is a congenital disease and the patient with LVNC often develop DCM.

In LVNC, the myocardium (heart muscle) does not grow compacted or integrated, and thus the LV wall has lots of spaces inside, causing thrombi and cerebral embolism or heart failure. 

We repair the LV successfully by considering the characteristics of the disease, and reported it in an American major journal. To our knowledge, it is the first report of LV repair (restoration) surgery for LVNC. We try to prevent both thrombi/embolism and heart failure. (DCM case 7)

Q: What is the key to succeed in LV repair or restoration surgery for DCM?

A: In short, we believe that LV should be down-sized by excising or repairing the worst part of the LV with DCM. By doing that way we can maximize the power of residual LV muscles. When the LV is not too much dilated, the benefit of LV restoration is limited; but, even under the situation, if the bad part of the LV is clear, LV repair has a merit. Thus, it is important to check details of the heart before and during the surgery and do the most appropriate surgery.  In some patients, general condition did not improve as much as heart did after the surgery, and they could not recover in spite of dense intensive care.  Majority of them had some dysfunction of liver and kidney before the surgery, or had raipid progression of heart failure and required emergency surgery, or were on steroid medication for bronchial asthma etc. before the surgery; a little earlier surgery could have benefit the patients.  We recommend patients to consult doctors without hesitation before heart failure and general condition becomes too grave.
Once they recover from the surgery, not only heart but also general condition improves; by using protective medication such as ARB or beta-blockers the prognosis may become further better. We showed in experimental series the benefit of those medications after LV repair surgery. 

In the near future we plan to introduce regenerative medicine or tissue engineering using slow-release of growth factor without using cells or genes or vectors. In fact, we did therapeutic angiogenesis using the slow-release of protein and had very promising results; we will resume it first in Thailand and hopefully in Japan thereafter.