Congestive heart failure: Treat the disease, not the symptom

Abstract

he report by Zhang and associates 1 in this issue applies an important 3-dimensional magnetic resonance imaging (MRI) tagging method to demonstrate that altering ventricular geometry by using the Dor procedure (as they interpreted this operation) in sheep in congestive heart failure increases systolic circumferential shortening in remote muscle. These experimental changes document the clinical improvement in remote muscle function reported worldwide with left ventricular (LV) restoration. 2,3 Such application of advanced imaging methods allows studies to focus on how interventions improve function by changing ventricular muscle deformation that occurs sequentially during the cardiac twisting motion. Furthermore, these regional functional data allow differentiation from nonfunctional remote regions that echocardiographic analysis shows are displaced without contracting, together with providing a time course for displaying how global function is affected by cardiac rebuilding. Normal and Abnormal FormThe surgical approach to congestive heart failure, like other operative objectives, should treat the disease and not the symptom and return structures toward normal shape, as described by others, 4 and this became the title of my 2001 Journal of Thoracic and Cardiovascular Surgery editorial. 5 The geometric disease in ischemic dilated cardiomyopathy is the spherical chamber, which is different than the elliptical or conical normal heart shape (Figure 1). The symptom is the spherical chamber, whereby the normal helical chamber develops a more circular configuration thl at might flatten fiber orientation and alter performance. 6,7 Despite imaging advantages, the experimental design of this study has a major flaw because baseline is ascribed to the infarction state rather than to the normal heart. The authors held fast to repeated requests to supplement their database with a design that introduces normality as a reconstructive guideline for operative interventions. It seems that, aside from supplying superb imaging technology, the surgical planning strategy must also recognize and codify normality (which exists before the infarction), show how disease distorts this (their preoperative control), identify how and why the intervention selected rebuilds normality, and relate results toward the limitations of the selected procedure. For example, if normality was not recaptured, the discussion should identify whether this is a problem with the operative method or related to the timing of postoperative measurements. Border and Remote MusclePrior studies addressed the peri-infarction border zone, showing that the issue was impaired contractile function rather than increased wall stress, 8 and directed