2 The procedure

2.1 Indications

2.1.1 PLV is used to treat patients with irreversible (end-stage) heart failure secondary to dilated disease, or Chagas' disease. It has also been used in some patients with ischaemic heart disease.

2.1.2 Surgical alternatives to PLV may include coronary artery bypass grafting (CABG), cardiac transplant and left ventricular assist devices (LVAD). Ventricular volume reduction procedures include mitral valve repair (mitralannuloplasty), endoventricular circular patch plasty and left ventricular aneurysmectomy. Medical therapy includes diuretics, vasodilator therapy, beta blockers and digoxin.

2.2 Outline of the procedure

2.2.1 Partial left ventriculectomy 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. It is often accompanied by valvuloplasty (or mitral annuloplasty) to prevent postoperative mitral regurgitation. Variations of the technique for PLV include lateral PLV, extended PLV and anterior PLV. The procedure is usually performed with the aid of cardiopulmonary bypass.

2.2.2 In lateral PLV, an incision is made at the apex of the left ventricle and extended towards the base. A wedge-shaped portion of the left ventricle is resected, leaving the papillary muscles intact where possible. Extended PLV additionally excises the papillary muscles and the mitral valve. 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 in lateral PLV.

2.3 Efficacy

2.3.1 Studies reported 30-day survival rates of between 50% and 99%. In one non-randomised study, there was no difference in survival rates between patients undergoing this procedure and patients undergoing heart transplant at 1 year. In a case series of 62 patients, survival was 80% and 60%, and event-free survival was 49% and 26%, at 1 and 3 years, respectively, after surgery. The survival rate at 1 year was achieved with the frequent use of ventricular assist devices and transplantation as salvage therapy. For more information, refer to the 'Sources of evidence' section.

2.3.2 All the Specialist Advisors thought that efficacy, especially long-term efficacy, was uncertain. One Advisor commented that it is difficult to establish which patients would benefit from the procedure and that there is often no improvement in myocardial function.

2.4 Safety

2.4.1 As noted in Section 2.3.1, 30-day mortality ranged from 1% to 50%. However, it is unclear from the studies whether these deaths were the result of the procedure or were attributable to the underlying condition. Reported complications included congestive heart failure, bleeding, arrhythmias, renal failure, respiratory failure and infection. For more information, refer to the 'Sources of evidence' section.

2.4.2 The Specialist Advisors were concerned about the high (30-day) mortality rate associated with this procedure. One Advisor listed late complications as arrhythmias, mitral regurgitation, and progressive dilation of the left ventricle. The same Advisor considered the main disadvantage of the procedure to be the need for resection of viable myocardium.

2.5 Other comments

2.5.1 The evidence for this procedure is difficult to interpret because of:

  • inconsistencies in patient selection

  • the variable nature of the surgery performed

  • inadequate information about duration and quality of life after the operation.

Andrew Dillon
Chief Executive
February 2004