Dynamic cardiomyoplasty: time to wrap it up?

Fifteen years ago Larry Stevenson, in his memorable lectures, pointed to the great sheet of muscle that is the lat-issimus dorsi, and proposed that this potential power source should be harnessed for the purpose of circulatory assistance, and put to much better use as a cardiac muscle in patients handicapped and dying of heart failure. 1 Salmons and others 2 3 had demonstrated that this fast twitch fatiguable muscle retained within its genome the potential to be transformed into a slow contracting, fatigue resistant phenotype, similar to cardiac muscle. The logic seemed inescapable. It seemed inevitable that this resource would be used routinely to rescue the many with shortened miserable lives because of end stage heart failure. 4 The combination of advances in muscle physiology, electronic engineering, and experimental surgery, 5–7 culminated in 1985 in the first successful use of stimulated skeletal muscle to aid the circulation 8 in a patient with a left ventricular defect following excision of a tumour. That patient has survived—unlike the operation that saved her life. What happened? Four UK units embarked on well thought out and carefully planned collaborative trials of what became known as dynamic cardiomyoplasty. In this application the muscle was mobilised on an intact extrathoracic neurovascular pedicle, wrapped around the heart, and stimulated to contract in time with ventricular systole. None of the four units are currently performing this surgery. About 35 patients were operated on in the UK, of whom none from our unit are still alive. The experience was similarly dismal in the other units. Experience in the USA is similar with very little reported evidence of success. Of the many European centres originally performing this surgery, only one has published any encouraging data in the past four years, 9 with the results inviting the comment that the authors had learned from the experience of earlier trials to select fitter candidates for the surgery, and in particular those with only modest cardiomegaly. Animal and clinical experiments also explored using skeletal muscle ventricles, constructed to beat in series with the heart, 10 11 and procedures generating counterpulsation where muscle is wrapped around either the descending or ascending aorta (aortomyoplasty). Cardiomyoplasty was taken up with enthusiasm in Brazil, a country with many young patients with end stage left ven-tricular failure caused by Chagas' disease. The early results there were better than those achieved in Europe, a diVerence later attributed to the …