The role of left ventricular reconstruction for cardiogenic shock

Left ventricular remodeling after myocardial infarction is recognized as an early adaptive mechanism that later results in adverse physiologic changes. Surgical therapy for this condition includes exclusion of nonfunctional segments of ventricular wall and restoration of more normal ventricular geometry. The Dor procedure, or endoventricular patch plasty, is recognized as an excellent means of accomplishing this goal. Most series in regard to the Dor procedure report results in patients who electively come to surgery after developing global ventricular distension after an area of akinesia or dyskinesia. We report a small series of 6 patients who presented with acute myocardial infarction and who developed cardiogenic shock after ventricular dilation. Each patient underwent emergent revascularization and left ventricular reconstruction using the Dor technique. A seventh patient with akenesia, but without preoperative shock, required the Dor procedure to wean from cardiopulmonary bypass. There were no in-hospital deaths, and follow-up showed good outcomes. In certain select acute subsets (large anterior myocardial infarction, cardiogenic shock, and ventricular dilation), immediate revascularization and restoration of left ventricular size improves outcomes by changing left ventricular shape and thereby pre-empting remodeling and restoring blood flow to ischemic myocardium.