The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on this procedure.
As part of the NICE's work programme, the current guidance was considered for review but did not meet the review criteria as set out in the IP process guide. The guidance below therefore remains current.
Partial left ventriculectomy is used to treat patients with irreversible (end-stage) heart failure secondary to dilated or hypertrophic cardiomyopathy, valvular disease, or Chagas' disease. Although more generally indicated in patients with non-ischaemic disease, it has also been used in some patients with ischaemic heart disease.
Dilated or congestive cardiomyopathy occurs when the left ventricle becomes dilated and loses function as a result of globally reduced muscle function.Hypertrophic cardiomyopathy results from the thickening of the heart wall muscles and in its obstructive form leads to reduced blood flow. Symptoms of heart failure include oedema, shortness of breath, dizziness, fainting, fatigue and angina pectoris. Arrhythmias and thrombus or embolus may result from the reduced function of the left ventricle and if left untreated may lead to heart attack and death.
Partial left ventriculectomy (PLV) seeks to restore left ventricular function by reducing cardiac volume (and left ventricular wall tension) through the resection of the posterolateral wall of the left ventricle. In lateral PLV, either on a beating heart, or via cardiopulmonary bypass, an incision is made at the apex of the left ventricle and extended towards the base and a wedge shaped portion of the left ventricle is resected, leaving the papillary muscles intact where possible.
PLV is often accompanied by valvuloplasty (or mitral annuloplasty) to prevent postoperative mitral regurgitation. Extended PLV additionally excises the papillary muscles and the mitral valve where there is organic disorders, or if the distance between the papillary muscles is insufficient to allow adequate reduction in ventricular dimensions. In anterior PLV the area between the left anterior descending artery and the attachment of the left anterolateral papillary muscle is resected and closed as per lateral PLV (i.e. sutured in two layers).
Surgical alternatives to PLV include coronary artery bypass grafting (CABG), cardiac transplant, intraaortic balloon pumping and left ventricular assist devices (LVAD). Conceptually similar ventricular volume reduction procedures include mitral valve repair (mitral annuloplasty), endoventricular circular patch plasty and left ventricular aneurysmectomy. Medical therapy includes vasodilator therapy, digitalis, and dobutamine infusion.
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.