Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Surgery Insight: surgical methods to reverse left ventricular remodeling

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 507–513 (2006)Cite this article

Abstract

The management of patients with congestive heart failure (CHF) is challenging and the mortality with medical therapy alone is high. Left ventricular dilatation represents one of the strongest predictors of mortality in CHF, and a variety of surgical interventions have been proposed over the years to reverse ventricular remodeling. The most common surgical methods currently used are myocardial revascularization, left ventricular restoration, mitral valve repair, surgical ablation of atrial fibrillation, and employment of diastolic support and ventricular assist devices. In many patients a combination of these procedures is required to address the multiple pathophysiologic components of CHF. As techniques are refined and more data become available, the results of surgical treatment of heart failure are likely to improve. In addition, advances in innovations such as gene therapy, cell therapy and engineered artificial myocardial tissue will hopefully bring additional benefits to this problematic therapy over the next few years. In this review we discuss the characteristics of the most common surgical techniques for reversing left ventricular remodeling.

Key Points

  • Mortality is high among patients with congestive heart failure who are treated with medical therapy alone

  • The severity of left ventricular dilatation and remodeling represents one of the strongest predictors of mortality

  • Myocardial revascularization, left ventricular restoration, mitral valve repair, surgical ablation of atrial fibrillation, and diastolic support and ventricular assist devices represent the most common current surgical therapies for reversal of ventricular remodeling

  • Most surgical approaches yield notable improvements in terms of symptoms and quality of life

  • Trials assessing survival benefit are ongoing

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: The Acorn CorCap® Cardiac Support Device before implantation.

Similar content being viewed by others

References

  1. Pieske B (2004) Reverse remodeling in heart failure—fact or fiction? Eur Heart J 6 (Suppl D): S55–S78

    Google Scholar 

  2. Pfeffer MA et al. (1992) Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the survival and ventricular enlargement trial. The Save Investigators. N Engl J Med 327: 669–677

    Article  CAS  Google Scholar 

  3. Cohn JN (1995) Structural basis for heart failure. Circulation 91: 2504–2507

    Article  CAS  Google Scholar 

  4. Alfieri O et al. (1993) Recovery of myocardial function: the ultimate target of coronary revascularization. Eur J Cardiothorac Surg 7: 325–330

    Article  CAS  Google Scholar 

  5. Bax JJ et al. (2001) Relationship between preoperative viability and postoperative improvement in LVEF and heart failure symptoms. J Nucl Med 42: 79–86

    CAS  PubMed  Google Scholar 

  6. Bax JJ et al. (1999) Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol 34: 163–169

    Article  CAS  Google Scholar 

  7. Di Carli MF et al. (1995) Quantitative relation between myocardial viability and improvement in heart failure symptoms after revascularization in patients with ischemic cardiomyopathy. Circulation 92: 3436–3444

    Article  CAS  Google Scholar 

  8. Allman KC et al. (2002) Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 39: 1151–1158

    Article  Google Scholar 

  9. Rizzello V et al. (2004) Opposite patterns of left ventricular remodeling after coronary revascularization in patients with ischemic cardiomyopathy: role of myocardial viability. Circulation 110: 2383–2388

    Article  Google Scholar 

  10. Mule J et al. (2002) The beneficial effect of revascularization on jeopardized myocardium: reverse remodeling and improved long-term prognosis. Eur J Cardiothorac Surg 22: 426–430

    Article  Google Scholar 

  11. Bax JJ et al. (2004) Extensive left ventricular remodeling does not allow viable myocardium to improve in left ventricular ejection fraction after revascularization and is associated with worse long-term prognosis. Circulation 110 (Suppl II): SII18–SII22

    Google Scholar 

  12. Yamaguchi A et al. (1998) Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg 65: 434–438

    Article  CAS  Google Scholar 

  13. McCarthy PM (1999) New surgical options for the failing heart. J Heart Valve Dis 8: 472–475

    CAS  PubMed  Google Scholar 

  14. Dor V (2001) The endoventricular circular patch plasty (“Dor procedure”) in ischemic akinetic dilated ventricles. Heart Fail Rev 6: 187–193

    Article  CAS  Google Scholar 

  15. Kramer CM et al. (2002) Reverse remodeling and improved regional function after repair of left ventricular aneurysm. J Thorac Cardiovasc Surg 123: 700–706

    Article  Google Scholar 

  16. Schenk S et al. (2004) Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy. J Thorac Cardiovasc Surg 128: 38–43

    Article  CAS  Google Scholar 

  17. Athanasuleas CL et al. (2004) Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. J Am Coll Cardiol 44: 1439–1445

    Article  Google Scholar 

  18. Castiglioni A et al. (2002) Surgical restoration of the left ventricle for postinfarction aneurysm. Ital Heart J 3: 370–374

    PubMed  Google Scholar 

  19. Koelling TM et al. (2002) Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 144: 524–529

    Article  Google Scholar 

  20. Trichon BH et al. (2003) Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol 91: 538–543

    Article  Google Scholar 

  21. Robbins JD et al. (2003) Prevalence and severity of mitral regurgitation in chronic systolic heart failure. Am J Cardiol 91: 360–362

    Article  Google Scholar 

  22. Wu AH et al. (2005) Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol 45: 381–387

    Article  Google Scholar 

  23. Bolling SF et al. (2005) Reforming LV geometry in CHF with MR: a unique valvular solution for a ventricular problem [abstract #T2]. In American Association for Thoracic Surgery, 85th Annual Meeting Abstract Book: 2005 April 10–13; San Francisco, CA, 216; AATS: Beverly, MA

    Google Scholar 

  24. De Bonis M et al. (2005) Mitral valve repair for functional mitral regurgitation in end-stage dilated cardiomyopathy: role of the “Edge-to-Edge” technique. Circulation 112 (Suppl I): SI402–SI408

    Google Scholar 

  25. Tibayan FA et al. (2004) Undersized mitral annuloplasty alters left ventricular shape during acute ischemic mitral regurgitation. Circulation 110 (Suppl 1): SII98–SII102

    Google Scholar 

  26. Bolling SF et al. (2001) Surgical alternatives for heart failure. J Heart Lung Transplant 20: 729–733

    Article  CAS  Google Scholar 

  27. Bax JJ et al. (2004) Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation 110 (Suppl 1): SII103–SII108

    Google Scholar 

  28. Acker MA et al. (2005) Mitral valve surgery in heart failure: results of the Acorn CorCapTM randomized trial [abstract #1]. In American Association for Thoracic Surgery, 85th Annual Meeting Abstract Book: 2005 April 10–13; San Francisco, CA, 64; AATS: Beverly, MA

    Google Scholar 

  29. Hung J et al. (2004) Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 110 (Suppl 1): SII85–SII90

    Google Scholar 

  30. Grossi EA et al. (2005) Intraoperative effects of the coapsys annuloplasty system in a randomized evaluation (RESTOR-MV) of functional ischemic mitral regurgitation. Ann Thorac Surg 80: 1706–1711

    Article  Google Scholar 

  31. Hetzer R et al. (2001) Bridging-to-recovery. Ann Thorac Surg 71 (Suppl): S109–S113

    Article  CAS  Google Scholar 

  32. Frazier OH et al. (2004) Mechanical bridging to improvement in severe acute “nonischemic, nonmyocarditis” heart failure. Congest Heart Fail 10: 109–113

    Article  CAS  Google Scholar 

  33. Dandel M et al. (2005) Long-term results in patients with idiopathic dilated cardiomyopathy after weaning from left ventricular assist devices. Circulation 112 (Suppl): SI37–SI45

    Google Scholar 

  34. Barbone A et al. (2001) Comparison of right and left ventricular responses to left ventricular assist device support in patients with severe heart failure: a primary role of mechanical unloading underlying reverse remodeling. Circulation 104: 670–675

    Article  CAS  Google Scholar 

  35. Bartling B et al. (1999) Myocardial gene expression of regulators of myocyte apoptosis and myocyte calcium homeostasis during hemodynamic unloading by ventricular assist devices in patients with end-stage heart failure. Circulation 100 (Suppl): SII216–SII223

    Google Scholar 

  36. Goldstein DJ et al. (1997) Circulatory resuscitation with left ventricular assist device support reduces interleukins 6 and 8 levels. Ann Thorac Surg 63: 971–974

    Article  CAS  Google Scholar 

  37. James KB et al. (1995) Effect of implantable left ventricular device on neuroendocrine activation in heart failure. Circulation 92 (Suppl): SII191–SII195

    Article  Google Scholar 

  38. Yacoub MH (2001) A novel strategy to maximize the efficacy of left ventricular assist device as a bridge to recovery. Eur Heart J 22: 534–540

    Article  CAS  Google Scholar 

  39. Anversa P and Nadal-Ginard B (2002) Myocyte renewal and ventricular remodeling. Nature 415: 240–243

    Article  CAS  Google Scholar 

  40. Menasche P et al. (2001) Myoblast transplantation for heart failure. Lancet 357: 279–280

    Article  CAS  Google Scholar 

  41. Orlic D et al. (2001) Bone marrow cells regenerate infracted myocardium. Nature 410: 701–705

    Article  CAS  Google Scholar 

  42. Tomita S et al. (2002) Improved heart function with myogenesis and angiogenesis after autologous porcine bone marrow stromal cells. J Thorac Cardiovasc Surg 123: 1132–1140

    Article  Google Scholar 

  43. Wang JS et al. (2001) The coronary delivery of stromal cells for myocardial regeneration: pathophysiology and therapeutic implications. J Thorac Cardiovasc Surg 122: 699–705

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. staff cardiac surgeon and O Alfieri is Professor of Cardiac Surgery and Chief of the Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy

    Michele De Bonis & Ottavio Alfieri

Authors
  1. Michele De Bonis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ottavio Alfieri
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michele De Bonis.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

De Bonis, M., Alfieri, O. Surgery Insight: surgical methods to reverse left ventricular remodeling. Nat Rev Cardiol 3, 507–513 (2006). https://doi.org/10.1038/ncpcardio0631

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpcardio0631

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing