Left ventricular reconstructive surgery (Dor Procedure)

What is left ventricular reconstructive surgery?

Left ventricular reconstructive surgery is a procedure sometimes used to treat heart failure. When a heart attack occurs in the left ventricle (left lower pumping chamber of the heart), a scar may form. The scarred area can become thin and bulge out with each beat. The bulging thin area is called an aneurysm. The aneurysm, along with other heart damage you may have, makes your heart work harder to pump blood throughout your body. Initially your heart is able to handle the additional work, but over time, your left ventricle becomes larger than normal and pumps less effectively.

Left ventricular reconstructive surgery allows the surgeon to remove the scarred, dead area of heart tissue and/or the aneurysm and return the left ventricle to a more normal shape. The goal is to improve heart failure and/or angina (chest pain) symptoms and possibly improve the pumping ability of your heart. The Cleveland Clinic Heart Center has been performing these surgeries for many years with great success.

Am I eligible for left ventricular reconstructive surgery?

Not all patients with heart failure are eligible for this procedure. Patients who may benefit from left ventricular reconstructive surgery include patients who:

• Have had a heart attack that resulted in an aneurysm or a scar in the left ventricle and have symptoms of heart failure (such as shortness of breath, fatigue, swelling and others) that are not relieved with medications and lifestyle changes
• Have severe coronary artery disease with symptoms of angina
• Have valve problems that require surgical treatment

Some patients who have these conditions may also have ventricular tachycardia (an abnormal rhythm originating in the left ventricle that makes it beat too quickly). Symptoms include passing out, feeling lightheaded, or feeling a rapid pounding in the chest.

If you have one or more of the conditions listed above, you may be a candidate for left ventricular reconstructive surgery. The surgeon will determine if left ventricular reconstructive surgery is an appropriate treatment for your condition.

What happens during left ventricular reconstructive surgery?

During this procedure, the surgeon makes a small incision in the left ventricle and finds the exact location of the dead or scarred tissue. The surgeon then places two or more rows of circular stitches around the border of the dead tissue to separate it from healthy tissue. The stitches are then pulled together (like a purse-string) to permanently separate the dead tissue from the rest of the heart. Sometimes an area of scar tissue is removed first before the stitches are pulled together.

On rare occasions, if there is a lot of dead tissue to remove and standard stitches are not enough to exclude the area, a patch may be placed. Lastly, the surgeon closes the outside of the ventricle and reinforces the area with another row of stitches.

1. Incision is made through dead, scarred tissue	2. "Purse-string" stitches are sewn around the infarcted (dead) area	3. Stitches are pulled together and left ventricle is closed

In addition to this procedure, coronary artery bypass graft (CABG) surgery is often performed
to improve oxygen supply to the heart muscle. In about half of the patients undergoing the left ventricular reconstruction surgery, mitral valve leaks are also repaired.

Is the left ventricular reconstruction surgery a type of open-heart surgery?

Yes, left ventricular reconstructive surgery is major open-heart surgery, requiring the use of the heart-lung machine. Because you are already undergoing open heart surgery, your surgeon may also perform coronary artery bypass graft surgery (CABG) and/or valve repair surgery, if needed.

What types of tests are needed before the surgery?

You will need a MRI (if you do not have an implantable defibrillator or pacemaker) or PET can done at The Cleveland Clinic Foundation to determine if you have enough healthy heart tissue to benefit from the surgery. An echocardiogram will be needed to provide information about the pumping ability of your heart and how well your valves are functioning. You will also need to have a cardiac catheterization (performed within one year of the surgery). Routine blood tests, a chest Xray and an electrocardiogram will also be performed.

How can I be evaluated?

If you are currently being treated by a doctor outside of The Cleveland Clinic Foundation, please contact us via webmail or call the Heart Center Resource and Information Nurse toll-free at 1-866-289-6911 or 216/445-9288. If you are determined to be a good candidate for the surgery, you will be asked to send your medical records, echocardiogram, cardiac catheterization films and other pertinent information. The nurse will tell you where to send your medical records. A review of your echocardiogram and cardiac catheterization films will be performed by a cardiologist in the Department of Cardiovascular Medicine and will be charged to your insurance. There is no charge for a review of your medical records.

If you are already being seen at The Cleveland Clinic for treatment of your heart failure, talk to your cardiologist about whether left ventricular reconstructive surgery is an appropriate treatment option for you.

What can I expect before the surgery?

For most patients, left ventricular reconstructive surgery is elective. This allows you to qualify for our TCI program. This means you can arrive at The Cleveland Clinic on the same day of your scheduled surgery, instead of being admitted to the hospital several days before the surgery.

Before your scheduled surgery date, you will have a preoperative appointment where you will receive specific instructions to help you prepare for surgery. At this visit, you will also meet with your anesthesiologist, nurse clinician and your cardiologist and surgeon. Inpatients (hospitalized patients) who elect to have left ventricular reconstructive surgery will receive information about pre-surgical procedures and preparation from their health care providers.

What should I expect after the surgery?

You can expect to stay in the hospital about 5 to 7 days, depending on the course of your recovery. During your hospital stay, you will work with a cardiac rehabilitation specialist who will help you gradually increase your activity. This will help speed up your recovery.

Some patients may require a special device called an implantable cardioverter-defibrillator (ICD) to treat a serious abnormal heart rhythm. If this is required, your cardiologist will discuss the details about the device and the implantation procedure. Under specific circumstances, you may have a test called an EP study (electrophysiology study) before you go home to evaluate your heart rhythm.

Before you leave the hospital, you will receive specific information about wound care, medications, warning signs to look for and who to call if you experience any problems after you go home.

Will my symptoms improve after surgery?

Yes. Surgical results indicate that patients experience an improvement in their symptoms after the procedure. Most patients also experienced an improved pumping ability of the left ventricle (ejection fraction).

Please understand that left ventricular reconstructive surgery is NOT a cure for heart failure. You will still need to manage your condition by following your doctor’s recommended guidelines.

Do I still have to watch my diet and fluid intake after the procedure?

Yes, it is very important to continue (or to begin) managing your heart failure by:

• Following a 2,000 mg sodium (salt) diet;
• Restricting fluids to 8 cups or less per day;
• Staying active and exercising;
• Weighing yourself every day and monitoring for sudden weight gain of more than 2 pounds in a day or 5 pounds in a week;
• Taking your heart failure medications as prescribed; and
• Notifying your cardiologist of weight gain or other signs and symptoms of worsening heart failure.

Most patients experience an improved quality of life after the surgery, making it easier to follow these guidelines.

FREQUENTLY ASKED QUESTIONS

Q: Is the heart stopped during left ventricular reconstructive surgery?
A: Yes. During left ventricular reconstructive surgery, the surgeon stops the heart and uses cardiopulmonary bypass, also known as the heart-lung machine. In order to cut into the left ventricle, locate the scar tissue and place the stitches, the heart must not be beating.

Your blood will be routed through the heart lung machine that takes over the heart’s normal functions. Oxygen and carbon dioxide are exchanged in your blood by the machine and then pumped back into your body. By doing the work of the heart, the heart-lung machine helps protect your other organs while your heart is stopped.

Q: How often will I need to go to The Cleveland Clinic for follow-up care?

A: After you are discharged, you will need to see the surgeon within 5-7 days to ensure you are healing properly. After that time, you will need to continue with your regular heart failure follow-up appointments (with your local doctor or with a Cleveland Clinic heart failure doctor). These regular follow-up appointments are important to maintain your health and ensure that your heart failure is not progressing.

During these regular visits, your medications may be adjusted to relieve symptoms or optimize your heart function. Even if you are not having symptoms and you feel fine, you must still see your doctor regularly. The frequency of your follow-up visits are based on your current health, but generally occur at least twice a year. We encourage you to see the heart failure cardiologists at The Cleveland Clinic Foundation, but you may see your local cardiologist for your follow-up visits. In addition, you will receive regular phone calls from us so we can evaluate your postoperative progress.