The effect of preoperative diastolic dysfunction on outcome after surgical ventricular remodeling.

80 The Journal of Thoracic and Cardio n this issue, Menicanti and colleagues describe the experience with surgical ventricular restoration (SVR) procedures at the San Donato Hospital between 1989 and 2005. The study is important for a number of reasons. First, 300 patients underwent SVR. This is the largest single-center experience to ate, and the authors are to be commended for the excellent overall operative ortality of 4.7%. A subgroup of 488 patients in Menicanti and colleagues’ study had echocariograms before, early after (7–10 days), and late after (6 months to 2 years) SVR. n 254 patients who have undergone operations since 2001, echocardiographic easures of diastolic function, including the early-to-late mitral valve flow ratio E/A), isovolumic relaxation time, and deceleration time (DT) of early mitral flow E wave), were collected. Normally, early flow (E wave) is higher than that ssociated with atrial contraction (A wave). Early diastolic dysfunction is typically ssociated with a reversal of the E/A ratio. However, as diastolic compliance orsens and left ventricular end-diastolic pressure increases, the E/A ratio becomes pseudo-normalized.” End-stage or restrictive diastolic dysfunction is associated ith an E/A greater than 2. In Menicanti and colleagues’ study, an E/A ratio greater han 2 was associated with early mortality after SVR. Isovolumic relaxation time nd DT have also been associated with ventricular cavity stiffness; however, the ffects of isovolumic relaxation time and DT were not statistically significant in enicanti and colleagues’ study. This is the first time that severe diastolic dysfuncion has been identified as a risk factor for SVR. The effect of SVR on ventricular function and the related effect of diastolic ysfunction on outcome after SVR have not been well studied until recently. owever, in September, 2006, an article by Tulner and colleagues and accompaying editorial by Burkhoff and Wechsler were published in the Journal. The study y Tulner and colleagues was the first in which the diastolic pressure-volume elationship was measured in patients before and after SVR. The editorial by urkhoff and Wechsler discussed SVR and its effect on left ventricular function ithin the framework of end-systolic pressure-volume relationship (ESPVR) and nd-diastolic pressure–volume relationship (EDPVR). The readers are referred to hese two excellent publications. However, to put Menicanti and colleagues’ findngs in context, it is important to briefly review these topics again. The primary goal of SVR is to reduce left ventricular wall stress, and there is vidence that this is occurs. For instance, Dang and colleagues used a finite element odel of the left ventricle with an akinetic but contractile anteroapical left ventriclar wall to calculate the mean myofiber stress after SVR and found that SVR educes end-diastolic and end-systolic border zone and infarct myofiber stress. owever, most would say that SVR should also improve pump function and would ite improvements in the ejection fraction (EF) and ESPVR (slope end-systolic lastance [EES]) as evidence that pump function is better after SVR. However, we uggest that focus on indices of systolic function alone, such as EF and EES, is isleading.