Pacopexy: Restoration Procedure for Nonischemic Dilated Cardiomyopathy Sergio A. Oliveira, Hisayoshi Suma, Gerald D. Buckberg, Constantine L. Athanasuleas, Friedhelm Beyersdorf  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 2, Pages 76-83 (May 2002) DOI: 10.1053/otct.2002.31467 Copyright © 2002 Elsevier Inc. Terms and Conditions

1 Access to the heart is achieved through a median sternotomy. Cardiopulmonary bypass is established by ascending aortic cannulation. Ventricular restoration is usually performed in the beating heart. The left ventricle is decompressed via a cannula placed into its cavity through the right superior pulmonary vein. The left ventricle is opened from the apex toward the base, through an incision made about 2 to 3 cm lateral to the left anterior descending coronary artery. Clot is evacuated if present. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 The decision to preserve or replace the mitral valve depends on surgical judgement and is more common when left ventricular volume index is more than 120 mL/m2. (A) If a prosthesis is implanted, we try to preserve as much of the native mitral valve and the subvalvular apparatus as possible. To do this, we detach the anterior leaflet near the annulus, fold it over, and suture it over the posterior annulus, thus preserving both papillary muscles and their chordae tendinea. (B) An undersized prosthesis is then implanted, with the intention of shrinking the base of the heart. (B) As an alternate technique to preserve the tethering apparatus of the valve, we excise a triangle in the central part of the anterior leaflet, leaving in place all the chord and papillary muscles to preserve the elliptical shape. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 (A) When a preoperative decision is made to replace the mitral valve, the procedure is usually performed through the left ventriculotomy. This method avoids opening the left atrium or the interatrial septum. For mitral valve repair, access is usually through the interatrial septum with the possibility of extending the incision to the roof of the left atrium. (B) A posterior annuloplasty is used for mitral repair. The tricuspid valve ring is usually repaired by a annuloplasty by using the imbrication technique described by De Vega.10 Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 After treating the mitral valve problem, the aortic clamp is removed so that ventricular restoration can be performed while the decompressed heart is beating. A small vent is positioned in the ascending aorta to remove any remnant of air. The ventricular cavity is inspected for any residual thrombus and to identify any endocardial scar. Palpation of the left ventricle is a very important maneuver to identify noncontracting areas of the myocardium. Using the thumb and the index finger, we can analyze the contraction of the septum and anterolateral wall. A transitional line is traced from the base of the anterior papillary muscle toward the septum to within 2 cm of the aortic valve as the site for septal suture placement. Interrupted intraventricular mattress multifilament polyester sutures containing Teflon felt pledgets are attached to the septum approximately 1 cm apart. We use the same approach for suture placement on the lateral wall, but the stitches are passed from the external surface to the internal one. An internal neck is made by the septum and lateral wall that will be covered by a patch. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 A small oval patch of Dacron (Haemashield; Meadox Corp., Oakland, NJ) or pericardium 2 to 3 × 4 cm in size is used to reduce the ventricular cavity and to restore the elliptical shape of the left ventricle. The previously placed sutures are transferred to the patch, leaving a rim of approximately one cm around the edges of the patch. The external rim of the patch is secured to the underlying muscle by a running suture to help in the hemostasis. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 The left ventriculotomy is closed by direct suture with or without a pledget. A transesophageous echocardiogram is performed after ventricular closure to evaluate the anatomic and functional results of the surgical procedure. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 An example of the preoperative spherical shape of a dilated heart (left panel) and the postoperative elliptical shape that can be attained after surgical restoration (right panel). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 76-83DOI: (10.1053/otct.2002.31467) Copyright © 2002 Elsevier Inc. Terms and Conditions