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Causes of repeated remodeling of left ventricle after Dor procedure

Cardio-vascular Department, Tomsk Institute of Cardiology, Kievskaya street 111a, Tomsk, Russia, 634012

*Corresponding author. Tel./fax: +7 3822 555483.

E-mail address: shipulin{at}cardio.tsu.ru (V.M. Shipulin).

Objective: To reveal morphological factors causing unfavorable follow-up outcome of surgical treatment of patients with ischemic cardiomyopathy (ICMP) and with left ventricle (LV) aneurysm according to the data of intraoperative biopsies of LV myocardium and right atrium (RA) auricle. Methods: The object of the study was to examine biopsy material of LV myocardium and RA auricle from 36 patients with ICMP. Clinical criteria of patients' inclusion into the study were: ESI LV >80 ml/m², EDP LV >30 mmHg, LV EF <40%, presence of akinetic and dyskinetic areas in LV, angina of II–IV class CCS, heart failure of II–IV class NYHA. The following morphometrical parameters were estimated for revelation of postoperative remodeling risk factors: parenchymal–stromal ratio (PSR), trophic index (TI), pericapillar diffusion zone (PDZ), Kernogan index (KI) and specific volume of granules of natriuretic factor (NUF) in atrial cardiomyocytes. Results: In all the patients LV EF increased significantly (from 36.4±4.1% to 46.3±4.2%) (P<0.05) in the early postoperative period; LV EDI decreased (from 139.3±11.2 ml/m² to 108.4±8.9 ml/m²) (P<0.05). In the follow-up period (one year) all the patients were divided into two groups: in 28 patients (the 1st group) volume of the cavity, contractile function of LV remained satisfactory. In the other eight patients (the 2nd group) there was significant decrease of LV EF (up to 33.9±10.2%) due to increase of LV EDI [up to 129.2±10.1 ml/m² (P<0.05)]. Grade of MR preoperatively was 1.21±0.5 and 1.47±0.9, correspondingly, for the patients with positive and negative changes in the follow-up postoperative period. Drawing morphological parallels of postoperative heart remodeling in patients with ICMP showed that diffusive, lymphocytic-macrophage inflammatory infiltration of myocardial stroma in combination with severe fibrosis (PSR<1.5), low TI (<0.015) and greater value of PDZ (>1000 µm) and KI (>1.6) of LV myocardium are the factors connected with unfavorable follow-up results of surgical treatment. Moreover, we showed an inverse correlative relationship between content of NUF granules in the cardiomyocytes of RA auricle and the outcomes of the Dor procedure. Conclusions: Thus, a combination of the foregoing features is a morphological predictor of postoperative heart remodeling in patients with ICMP.

Key Words: Ischemic cardiomyopathy; Left ventricular reconstruction; Pathomorphological predictors