Mid-Term Outcome After Partial Left Ventriculectomy in Pediatric Patients

Abstract

From May 1998 to April 2000, we performed partial left ventriculectomy (PLV) in 3 pediatric patients with dilated cardiomyopathy (DCM). At the time of the surgery, their age ranged from eight months to three years. The first patient eventually had to receive a heart transplant, but all patients treated with PLV are alive to this day. Patient #1 was diagnosed with DCM at the age of five months, PLV was done on a semi-urgent basis at the age of eight months, when medium dose IV catecholamine therapy and mechanical ventilation were required. Fraction shortening (FS) as shown by echocardiography increased postoperatively from 8% to 15% along with marked clinical improvement. Her heart failure deteriorated three months after the surgery, and received a heart transplant in the United States when she was one year and two months old. Patient #2 developed severe heart failure two months after correction of a ventricular septal defect. Aggressive medical therapy failed to improve his condition, therefore PLV was done on an elective basis at the age of three years and five months. [The patient was initially hospitalized and underwent low dose catecholamine.] Postoperative course was well. The ventriculography one year after surgery showed an improvement of the left ventricular FS from 12% to 27% after PLV. He was still doing well at his most recent check up. Patient #3 was diagnosed with DCM as a neonate. PLV was done on an elective basis at the age of two years and five months. Her postoperative course was generally well. FS on echocardiography increased postoperatively from 10% to 25% along with marked clinical improvement. The timing of performing PLV is the most essential factor for postoperative course in our experiences. We consider that the best timing is when aggressive catecholamine infusion or mechanical ventilation is required. The mid-term outcome of PLV of pediatric patients is considered to be acceptable. We believe that PLV should be considered as a viable option for severe DCM patients.

Partial left ventriculectomy: Have well-succeeded cases and innovations in the procedure been observed in the last 12 years?

“…It can be seen the clear predominance of Japan as a leader in publications of work relating to success case studies and developments in the PLV, with 46.5% of the 43 analyzed studies, followed by Germany with 20.9%. From what it can be seen, the Japanese dominance in these studies may have intimate relation with the legal difficulty, because in Japan the organ donation is forbidden for children under 15 years [ 5 ] . In addition, religious issues also influence the decision making for transplants [ 6 ] .…”

“…One of them was the case report of three Japanese children aged between 8 months and 3 years and a half, all with DCM. They had undergone PLV and repair of the mitral valve (RMV) at the Yamanashi Medical University hospital from May 1998 to April 2000 [ 5 ] . The procedure that was performed in the first child was urgently done and after 3 months her condition got worse and she had to be transferred to the US for transplantation, since in Japan organ donation for children under the age of 15 years is not allowed.…”

Outcome of Non-Transplant Surgical Strategy for End-Stage Dilated Cardiomyopathy in Young Children

“…[17][18][19] We have reported successful cases of PLV in young children and shown that the procedure is feasible even in very young children. 7,9,10 However, body growth needs to be considered, as well as the short-term outcome. The increase in body size associated with normal growth in children places greater demands on the heart, so we use Alfieli's methods, which allow for valvular growth with age, instead of using valvular ring annuloplasty.…”

“…[11][12][13] However, the longer-term outcomes after the procedure are still largely unknown. [4][5][6][7]10 MVR is another option for cases of DCM with severe MR, [20][21][22] To a greater or lesser degree, MR coexists with severe DCM and the mechanism of MR is considered to involve tethering of the mitral leaflet by the papillary muscles, with dilatation of the mitral annulus. Mitral insufficiency leads to a vicious cycle of increasing volume overload of the dilated left ventricle, thus leading to progression of annular dilatation, worsening of MR and volume overload.…”

“…The as much myocardium as possible is resected from the posterolateral wall between the 2 papillary muscles, followed by Alfieli's mitral valve repair. 7,[10][11][12][13] Indications for MVR were: (1) more than moderate MR with a severely dilated left atrium on echocardiography; (2) >10% FS or >25% EF on echocardiography; (3) >1,000 pg/ml BNP, and (4) previous mitral repair (Alfieri procedure) or coexisting mitral stenosis. All the criteria had to be fulfilled.…”