Despite the improvements in the treatment of myocardial infarction that have translated into a decline in mortality rates, the incidence of heart failure has increased and, because of the limited number of cardiac donors, non-transplant heart surgery has developed in the past 10 years. Surgical ventricular reconstruction was launched by Dor and defined as endoventricular circular patch plasty repair. It represents a relatively novel surgical approach aiming to restore (bring back to normal) the dilated, distorted left ventricular (LV) cavity in order to improve function. The term `surgical ventricular reconstruction/restoration' includes operative methods that reduce LV volume and restore its shape. The concept of reducing wall stress through surgical restoration of chamber size and geometry remains the guiding principle behind this innovative technique. Results from different Institutions are uniform and show an improvement in cardiac and clinical status and in survival. The present review will approach the rationale to re-shape the heart on the basis of pathophysiology and cardiac architecture, and will describe the efficacy of the Dor procedure in ischemic dilated cardiomyopathy, as well as some technical aspects and patient selection pathway. (Circ J 2009; Suppl A: A-1-A-5)

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Congestive heart failure has become a major problem and the only surgical treatment for end-stage heart failure caused by dilated cardiomyopathy (DCM) had been heart transplantation. However, because of the shortage of donors, several procedures for non-transplant surgery have been developed. Published literature on left ventricular (LV) restoration was searched to review the new surgical procedures for treating patients with ischemic or non-ischemic DCM. LV restoration was initiated in the 1980s for repairing LV aneurysm. In the 1990s several surgical procedures were introduced for treating DCM, and the new evolving surgical treatment plays an important role in the management of DCM in the 21st century. (Circ J 2009; Suppl A: A-6-A-12)

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Cardiac transplantation, a final option of treatment for refractory heart failure, has not been a standard procedure in Japan especially, mainly because of the shortage of donors. However, surgical methods to restore native heart function, such as surgical ventricular restoration (SVR), are often effective for these cases. The Dor procedure has been used for ischemic cardiomyopathy cases presenting with broad akinetic segments. This is a fine method to exclude the scarred septum and to reduce the intraventricular cavity by encircling purse-string suture, but it may produce a postoperative spherical ventricular shape as a result of endoventricular patch repair. Also, partial left ventriculectomy is not recommended for non-ischemic dilated cardiomyopathy cases for now. A modification of these SVR and surgical approaches to functional mitral regurgitation has been named "overlapping ventriculoplasty" without endoventricular patch and resection of viable cardiac muscle, and "mitral complex reconstruction", which consists of mitral annuloplasty, papillary muscle approximation, and suspension. Although the long-term prognosis of these procedures is undetermined, they could be an important option, at least as an alternative bridge to transplantation. This review will describe the concepts and some technical aspects of these procedures for the end-stage heart. (Circ J 2009; Suppl A: A-13-A-18)

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Batista introduced the partial left ventriculectomy (PLV), which is based on physics alone. With experience, it has been found that the extent of myocardial disease and viability of retained muscle is an important determinant of early and late survival. Although the PLV has been almost abandoned in many countries following the negative message from the Cleveland Clinic, it is still alive in Japan with a refined concept, surgical technique and patient selection. In a series of 63 patients undergoing PLV for idiopathic dilated cardiomyopathy since 1996, operative mortality was 9.5%, and 1-, 3- and 5-year survival rates were 71.1%, 56.2% and 45.9%, respectively. Improved survival has obtained by using appropriate patient selection and concomitant restrictive mitral annuloplasty (1-, 3- and 5-year survival rate =86.5%, 78.6% and 59.4%, respectively, in the most recent 33 patients). Because of insufficient availability of donors for heart transplantation, nontransplant cardiac surgery for medically refractory heart failure is important. Ventricular restoration procedures, including PLV, should be seriously considered as an important option for endstage heart failure. (Circ J 2009; Suppl A: A-19-A-22)

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Surgery for functional mitral regurgitation (FMR) was reviewed. As the mechanism of FMR is still being elucidated, surgery for FMR, especially ischemic mitral regurgitation evolved from coronary bypass surgery (CABG) with/without mitral valve replacement, to repair mitral leaflet/chordate/papillary muscles and the left ventricle is required. Currently, the best efforts are made regarding the treatment of mitral leaflet tethering or tenting including that of the posterior leaflet and the treatment of ventricular disease. Although the understanding of FMR is increased and the surgical repair technique becomes more sophisticated, prognosis of the patient is not necessarily satisfactory when the amount of residual myocardium is limited. Further investigation is necessary to solve the problem of ventricular disease. (Circ J 2009; Suppl A: A-23-A-28)

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Cardiac resynchronization therapy (CRT) is recommended to reduce morbidity and mortality in patients with New York Heart Association class III/IV, who are symptomatic despite optimal medical therapy, and who had a reduced left ventricle (LV) ejection fraction and electrical dyssynchrony. The effects of CRT are reflected mainly by the degree and location of dyssynchrony and by working in insertion of optimal LV lead site. Echocardiography and Doppler echocardiography are considered to be good tools to measure LV dyssynchrony directly. However, the large randomized trials have shown that no single echocardiographic measure of dyssynchrony is recommended to improve patient selection for CRT beyond current guidelines. There were several unsolved issues on CRT, such as patient selection, electrical or electromechanical dyssynchrony criteria to patients for CRT, indication of patients with a narrow or slightly prolonged QRS width, indication of patients with atrial fibrillation, and indication of patients with mild heart failure or asymptomatic LV dysfunction, and device selection; CRT alone (CRT-P) or CRT in combination with implantable cardioverter therapy (CRT-D). This review paper summarized the concept of therapy, the current evidence regarding the indications, effectiveness and safety of CRT-P and CRT-D in patients with LV dysfunction, and unsolved issues. (Circ J 2009; Suppl A: A-29-A-35)

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Patients admitted to the hospital with heart failure (HF) include those with new-onset of acute HF and those with acute exacerbation of chronic HF (CHF). In therapy for new-onset acute HF associated with acute myocardial infarction, therapy to inhibit left ventricular (LV) remodeling in the convalescent phase is required in addition to that needed to overcome the acute phase. Hitherto, CHF therapy was aimed at improving LV contractability, whereas more recently the aim has shifted to resting the heart. Most patients with HF should be routinely managed with a combination of 3 types of drugs: a diuretic; an angiotensin converting enzyme inhibitor and/or an angiotensin II receptor blocker; and a β-blocker. The administration of β-blockers is of particular importance. For HF unresponsive to medical therapy, non-pharmacological therapies are considered. When a HF patient fails to respond to all available therapies, heart transplantation becomes necessary. Of the 1,000 HF patients admitted to our hospital, two cases received heart transplants. 11 cases were indicated for heart transplantation but died before registration. It should be remembered that although in Japan the possibility of receiving a heart transplant is very low, it is by no means entirely impossible. (Circ J 2009; Suppl A: A-36-A-41)

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Acute cardiogenic shock has a high mortality and rescue with mechanical circulatory support remains the only means of survival in most cases. Over the past decade, an increasing number of assist devices have been developed for both temporary and long-term circulatory support. Different types of devices are placed either percutaneously or surgically in different scenarios. Extracorporeal percutaneous devices are useful for rapid implementation of support aimed at stabilizing the patient's general condition by providing enough systemic circulation and improvement of native heart function to allow removal of the device. Instead of veno-arterial bypass, new percutaneous devices that directly drain the left atrium or ventricle seem a promising option. If recovery is unlikely, further assessment and additional treatment should be considered for longer term support aiming at bridging to transplantation or chronic assistance. Short-term support with extracorporeal devices to bridge the patient to long-term therapies is becoming a more and more important strategy. Paracorporeal pulsatile devices still have an important role for patients requiring biventricular support or in the pediatric population. Chronic support aiming at heart transplantation using a paracorporeal device is an alternative option until the new rotary blood pumps become available in Japan. (Circ J 2009; Suppl A: A-42-A-47)

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The first clinical application of the first-generation pulsatile implantable left ventricular assist system (LVAS) was in the mid 1980 s as a bridge to transplantation and contributed to an advancement of this field from a clinical experiment to an established therapeutic option for treating advanced heart failure patients. However, there have been technological limitations that have surfaced as longer-term experience has been gained. These include a high incidence of thromboembolic complications, infection, mechanical failures associated with moving parts, and the large size of both implantable pump and percutaneous cable. In order to overcome the limitations of the first-generation pulsatile LVAS, a smaller rotary blood pump LVAS emerged as a possible alternative in the 1990 s and these new generation LVAS are in various stages of development and clinical application. This article reviews the history and current status of the implantable LVAS. (Circ J 2009; Suppl A: A-48-A-54)

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A total of 59 heart transplantations (HTx) have been performed in Japan as of September, 2008, since the Organ Transplantation Law was settled in October 1997. The majority of recipients were suffered from dilated cardiomyopathy and waiting condition of all recipients were status 1. The mean waiting time was 777 day; 50 patients (85%) were supported by several types of left ventricular assist systems (LVAS) and the mean duration of support was 780 days. The majority of patients underwent operation by modified bicaval method with Celsior solution for cardiac preservation, and 64% of recipients were administered triple therapy with cyclosporine, mycophenolate mofetil, and steroid as the initial immunosuppressive regimen. The 9-year survival rate was 94%, which was superior to that of the international registry. HTx in Japan has been very limited by a severe shortage of donors, but the results have been excellent even though the majority of recipients were waiting for long-term with a LVAS as a bridge to HTx. (Circ J 2009; Suppl A: A-55-A-60)

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Interest in regenerative medicine has grown worldwide, not only in academic circles, but also in the mass media. Cardiac disease is a leading cause of death, and many more randomized controlled trials investigating the use of regenerative therapy have been reported for the heart than for other organs. This review discusses the candidates for donor cells to be used in cell transplantation and the mechanisms for improving injured heart function. (Circ J 2009; Suppl A: A-61-A-67)

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