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Volume 3 Number 1, January - April, 1988

ORIGINAL ARTICLE

DOI: http://dx.doi.org/10.1590/S0102-76381988000100002

Experimental basis of cardiomyoplasty utilization in the treatment of myocardial insufficiency

Bases experimentais da utilização da cardiomioplastia no tratamento da insuficiência miocárdica

Luiz Felipe P Moreira; Antônio C. P Chagas; Gustavo P Camarano; Idagene A Cestari; Milton S Oshiro; Eduardo Nakayama; Adolfo Leirner; Protásio Lemos da Luz; Edgard A Lopes; Noedir A. G Stolf; Adib D Jatene

Correspondence To:
Luiz Felipe Moreira
Divisão Cirúrgica
Av. Dr. Enéas Carvalho de Aguir, 44
05403 São Paulo, SP, Brasil

ABSTRACT
Beneficial effects of cardiomyoplasty have been documented and the use of this technique in the treatment of dilated cardiomyopathy have been suggested. This study was undertaken to evaluate the contracting and fatigue characteristics of normal and conditioned Latissimus Dorsi and the effectiveness of stimulated preconditioned skeletal muscle flaps wrapped around the heart to restore ventricular contractility in presence of myocardial dysfunction. Thirteen adult mongrel dogs were studied after burst stimulation of left Latissimus Dosi for six to eight weeks. In seven animals, conditioned muscles were compared with unconditioned contralateral controls by isometric force development. Normal and transformed muscles exhibited the same optimum pacing parameters (burst frequencies from 5o Hz up, train duration from 150 ms up). Conditioned muscles showed a smaller force (-27%) and a longer contraction time (+32%). Fatigue curves of unconditioned muscles under different duty cycles showed marked initial decrease and inversely proportional stable values of force after some minutes with equal final tension time indexes (18 ± 2 KgF. seg/min). Conditioned Latissimus Dorsi maintained stable force during prolonged stimulation under same conditions with a greater tension time index (68 ± 6 KgF. seg/min). The other six animals were submited to cardiomyoplasty; hemodynamic and echocardiographic evaluation were performed after induction of myocardial dysfunction by betablockers administration and volume loading. With synchronous pulse train stimulation increases of cardiac index by an average of 36 ± 4% (p<0.01) were observed, associated with a decrease of pulmonary wedge pressure. Ejection fraction augmentation of 51 ± 3% above the control was also documented in same conditions (p<0.01), even when muscle flap was wrapped only around the left ventricle. In conclusion, this study reveals that skeletal muscles are capable to maintain steady-state work similarly to the myocardium with a power dependent of their aerobic capacity. It also suggests the occurrency of muscle adaptive transformation, increasing its steady-state work capacity, with chronic pulse train stimulation. In addition, cardiomyoplasty may be an alternative method of treatment for irreversible cardiomyopathy, including when muscle flap may wrapp only partially the heart.

Keywords cardiomyoplasty. circulatory support. myocardial insufficiency, surgery. skeletal muscle stimulation.


RESUMO
A cardiomioplastia é uma técnica que utiliza enxertos musculares esqueléticos, estimulados síncronamente ao coração, para substituir, ou envolver o miocárdio. O objetivo deste trabalho foi analisar as características contrateis e a resistência à fadiga do músculo grande dorsal normal e estimulado cronicamente, bem como avaliar a eficiência da cardiomioplastia como método de suporte circulatório. Treze cães foram estudados, após condicionamento elétrico do músculo grande dorsal esquerdo, por período de 6 semanas. Sete deles foram submetidos a medida isométrica da força exercida pelos músculos condicionados e pelos controles contralaterais e a estudo morfológico. Os parâmetros ideais de estimulação foram semelhantes para os músculos normais e os condicionados. Os músculos condicionados, constituídos, predominantemente, de fibras de ação lenta, apresentaram uma força de amplitude menor (-27%) e um tempo de contração mais longo (+32%). Por outro lado, as curvas de fadiga dos músculos normais, constituídos de fibras mistas, mostraram a queda inicial da força de contração e valores estáveis, após 30 minutos, inversamente proporcionais à freqüência das contrações, resultando em um mesmo índice tensão-tempo (18 ± 2 kgF. seg/min). Já os músculos condicionados apresentaram um desempenho estável nas mesmas freqüências, mantendo um índice tensão-tempo elevado (68 ± 6 kgF. reg/min). Os outros 6 animais foram submetidos a cardiomioplastia, sendo estudados hemodinâmica e ecocardiograficamente, após a indução de disfunção miocárdica. Com a estimulação síncrona do músculo esquelético, observou-se a elevação do índice cardíaco em 36 ± 4% (p<0,01), associada a queda da pressão capilar pulmonar. O aumento da fração de ejeção foi documentado (51 ± 3%), inclusive quando o enxerto foi colocado apenas sobre o ventrículo esquerdo (p < 0,01). Em conclusão: 1) os músculos esqueléticos são capazes de manter atividade semelhante ao trabalho cardíaco, com um desempenho que depende de sua capacidade aeróbica; 2) a estimulação crônica leva à transformação adaptativa das fibras musculares, aumentando a sua capacidade de trabalho aeróbico; 3) a cardiomioplastia pode ser um método alternativo, no tratamento da insuficiência miocárdica, mesmo quando é possível apenas o envolvimento parcial do coração pelo enxerto.

Palavras-Chave cardiomioplastia. substituto miocárdico. suporte circulatório. miocárdio, insuficiência, cirurgia. estimulação muscular esquelética.

Full text available only in portuguese PDF format.

REFERENCES

1. ACKER, M. A.; ANDERSON, W. A.; HAMMOND, R. L.; CHIN, A. J.; BUCHANAN, J. W.; MORSE, C. C.; KELLY, A. M.; STEPHENSON, L. W. - Skeletal muscle ventricles in circulation: one to eleven weeks' experience. J. Thorac. Cardiovasc. Surg., 94(2): 163-174, 1987. [MedLine]

2. ACKER, M. A.; ANDERSON, W. A.; HAMMOND, R. L.; DiMEO Jr., F.; Mc CULLUM, J.; STAUM, M.; VELCHIK, M.; BROWN, W. E.; GALE, D.; SALMONS, S.; STEPHENSON, L. W. - Oxygen consumption of chronically stimulated skeletal muscle. J. Thorac. Cardiovasc. Surg., 94(5): 702-709, 1987. [MedLine]

3. ACKER, M. A.; HAMMOND, R. L.; MANNION, J. D.; SALMONS, S.; STEPHENSON, L. W. - An autologous biologic pump motor. J. Thorac Cardiovas. Surg., 92(4): 733-746, 1986.

4. ACKER, M. A.; HAMMOND, R. L.; MANNION, J. D.; SALMONS, S.; STEPHENSON, L. W. - Skeletal muscle as the potential power source for a cardiovascular pump: assessment in vivo. Science, 236(4799): 324-327, 1987. [MedLine]

5. APPIANI, E.; ALMADA, H.; GARLANDO, C.; MILET, J.; BASTAROLI, J. - Potential myocardial revascularization and mechanical effects of pectoral muscle transplant. Ann. Plast. Surg., 10(3): 252-263, 1983. [MedLine]

6. CARPENTER, A. & CHACHQUES, J. C. - Myocardial substitution with a stimulated skeletal muscle: first successful clinical case. Lancet, 2(8440): 1267, 1985. (Resumo).

7. CARPENTER, A.; CHACHQUES, J. C.; GRANDJEAN, P.; PERIER, P.; MITZ, V.; BOURGEOIS, I. - Transformation dún muscle squelettique par stimulation sequent'elle progressive en vue de son utilisation comme substitut myocardique. C. R. Acad. Sc. Paris, 301 (Serie III, nº 11): 581-586, 1985.

8. CHACHQUES, J. C. - Cardiomioplastia: reconstruccion anatomica y funcional del corazon. Rev. Fed. Arg. Cardiol., 16(3): 185-193, 1987.

9. CHACHQUES, J. C.; GRANDJEAN, P. A.; MIHAILEANU, S.; BOURGEOIS, I.; CARPENTIER, A. - Dynamic cardiomyoplasty: a surgical approach to restore ventricular contractility. In: BELHASSEN, B.; FELDMAN, S.; COPPERMAN, Y. Cardiac pacing and electrophysioiogy. Tel Aviv, Israel, 1987. p. 531-534.

10. CHACHQUES, J. C.; MITZ, V.; HERO, M.; ARHAN, P.; GALLIX, P.; FONTALIRAN, F.; VILAIN, R. - Experimental cardioplasty using the latissimus dorsi muscle flap. J. CArdiovasc. Surg., 26(5): 457-462, 1985.

11. CHIU, R. C. J.; WALSH, G. L.; DEWAR, M. L.; DE SIMON, J. H.; KHALAFALLA, A. S.; IANUZZO, D. - Implantable extra-aortic baloon assist powered by transformed fatigue-resistant skeletal muscle. J. Thorac. Cardiovasc. Surg., 94(5): 964-701, 1987.

12. CHIU, R. C. J. - Biomechanical cardiac assist: cardiomyoplasty and muscle-powered devices. New York, Futura, Publishing Company, 1986. 210 p.

13. CHRIST, J. E. & SPIRA, M. - Application of the latissimus dorsi muscle to the heart. Ann. Plast. Surg., 8(2): 118-121, 1982. [MedLine]

14. DEWAR, M. L. & CHIU, R. C. J. - Skeletal muscle graft for myocardial repair. J. Thorac. Cardiovasc. Surg., 88(5 Pt. 1): 734, 1984. [MedLine]

15. DEWAR, J. L.; DRINKWATER, D. C.; WITTNICH, C.; CHIU, R. C. J. - Synchronously stimulated skeletal muscle graft for myocardial repair: an experimental study. J. Thorac. Cardiovasc. Surg., 87(3): 325-331, 1984. [MedLine]

16. DEWAR, M. L.; WALSH, G.; ABRAHAM, R.; DeSIMON, J.; FOOT, E.; STEWART, J.; FRASER, R.; CHIU, R. C. J. - Left ventricular full-thickness cardiomyoplasty with pericardial neoendocardium: experimental development of a surgical procedure. Ann. Thorac. Surg., 44(6): 618-624, 1987. [MedLine]

17. EISENBERG, B. R. & SALMONS, S. - The reorganization of subcellular structure in muscle undergoing fast-to-slow type transformation: stereological study. Cell. Tissue Res., 220(3): 449-471, 1981. [MedLine]

18. HUDLICKÁ, O.; BROWN, M.; COTTER, M.; SMITH, M.; VRBOVÁ, G. - The effect of long-term stimulation of fast muscles on their blood flow, metabolism and ability to withstand fatigue. Pflugers Arch., 369(2): 141-149, 1977. [MedLine]

19. IMAKITA, M.; TAZELAAR, H. D.; BILLINGHAM, M. E. - Heart allograft rejection under varyng immunosuppressive protocols as evaluated by endomyocardial biopsy. J. Heart Transpl, 5(4): 279-285, 1986.

20. KANTROWITZ, A. & Mc KINNON, W. M. P. - The experimental use of the diaphragm as an auxiliary myocardium. Surg. Forum, 9: 266-268, 1958. [MedLine]

21. KAYE, M. P. - The registry of the International Society for Heart Transplantation: fourth official report, 1987. J. Heart Transpl., 6(2): 63-67, 1987.

22. KOCHAMBA, G. & CHIU, R. C. J. - The physiologic characteristics of transformed skeletal muscle for cardiac assist. Trans. Am. Soc. Artif. Intern. Organs, 33(3): 404-407, 1987.

23. KUSABA, E.; SCHRAUT, W.; SAWATANI, S.; JARON, D.; FREED, P. ; KANTROWITZ, A. - A diaphragmatic graft for augmenting left ventricular function: a feasibility study. Trans. Am. Soc. Artif. Intern. Organs. 19: 251-257. 1973. [MedLine]

24. LERICHE, R. & FONTAINE, R. - Essai expérimentale de traitement de certains infarctus du myocarde et de I anévrisme du coeur par une graffe du muscle strié. Bull. Soc. Nat. Chir., 59: 229-232, 1933.

25. MACOVIAK, J. A.; STEPHENSON, L. W.; SPIELMAN, S.; GREENSPAN, A.; LIKOFF, M.; SUTTON, M. S. J.; REICHEK, N.; RASHKIND, W. J.; EDMUNDS Jr., L. H. - Replacement of ventricular myocardium with diaphragmatic skeletal muscle: short-term studies. J. Thorac. Cardiovas. Surg., 81(4): 519-527, 1981.

26. MACOVIAK, J. A.; STINSON, E. B.; STARKEY, T. D.; HANSEN, D. E.; CAHILL, P. D.; MILLER, D. G.; SHUMWAY, N. E. - Myoventriculoplasty and neoventricle myograft cardiac augmentation to establish pulmonary blood flow: preliminary observations and feasibility studies. J. Thorac. Cardiovasc. Surg., 93(2): 212-220, 1987. [MedLine]

27. MAGOVERN, G. J.; HECKLER, F. R.; PARK, S. B; CHRISTLIEB, I. Y.; MAGOVERN Jr., G. J.; KAO, R. L.; BENCKART, D. H.; TULLIS, G.; ROZAR, E.; LIEBLER, G. A.; BURKHOLDER, J. A.; MAHER, T. D. - Paced latissimus dorsi used for dynamic cardiomyoplasty of left ventricular aneurysms. Ann. Thorac. Surg., 44(4): 379-388, 1987. [MedLine]

28. MANNION, J. D.; ACKER, M. A.; HAMMOND, R. L; FALTEMEYER, W.; DUCKETT, S.; STEPHENSON, L. W. - Power output of skeletal muscle ventricles in circulation: short-term studies. Circulation, 76(1): 155-163, 1987.

29. MANNION, J. D.; BITTO, T.; HAMMOND, R. L.; RUBINSTEIN, N. A.; STEPHENSON, L. W. - Histochemical and fatigue characteristics of conditioned canine latissimus dorsi muscle. Circ. Res., 58(2): 298-304, 1986. [MedLine]

30. MANNION, J. D.; HAMMOND, R.; STEPHENSON, L. W. - Hydraulic pouches of canine latissimus dorsi: potential for left ventricular assistance. J. Thorac. Cardiovas. Surg., 91(4): 534-544, 1986.

31. MANNION, J. D.; VELCHIK, M. A.; ACKER, M. A.; HAMMOND, R.; ALAVA, A.; STEPHENSON, L. W. - Transmural blood flow of multi-layered latissimus dorsi skeletal muscle ventricles during circulatory assistance. Trans. Am. Soc. Artif. Intern. Organs, 32: 454-460, 1986.

32. MASSIE, B. M. & CONWAY, M. - Survival of patients with congestive heart failure: past, present and future prospects. Circulation, 75(Supl. 4): 11-19, 1987.

33. NAKAMURA, K. & GLENN, W. L. - Graft of the diaphragm as a functioning substitute for the myocardium. J. Surg. Res., 4 (3): 435-439, 1964.

34. PAE, W. E. & PIERCE, W. S. - Combined registry for the clinical use of mechanical ventricular assist. Pumps and the total artificial hearts: first official report. J. Heart Transpl., 6(2): 68-70, 1987.

35. PETTE, D. & VRBOVÁ, G. - Neutral control of phenotypic expression in mammalian muscle fibres.Muscle Nerve, 8(8): 676-689, 1985. [MedLine]

36. PHILLIPS, W. L.; PALLIN, S.; CRASTNOPOL, P. - Diaphragm transplantation: a preliminary report on an experimental form of permanent myocardial assistance. Angiology, 20(11): 628-933, 1969.

37. SALMONS, S. & SRÉTER, F. A. - Significance of impulse activity in the transformation of skeletal muscle type. Nature, 263(5572): 30-34, 1976. [MedLine]

38. SALMONS, S. & VRBOVÁ, G. - The influence of activity on some contractile characteristics of mammalian fast and slow muscles. J. Physiol., 201(3): 535-540, 1969.

39. SHEPHERD, M. P.; TAMAKI, H.; MUSTARD, W. T. - Experimental study of the paced denervated diaphragmatic pedicle graft. Br. J. Surg., 55(2): 91-92, 1968. [MedLine]

40. SOLA, O. M.; DILLARD, D. H.; IVEY, T. D.; HANEDA, K.; ITOH, T.; THOMAS, R. - Autotransplantation of skeletal muscle into myocardium. Circulation, 71(2): 341-348, 1985. [MedLine]

41. SPOTNITZ, H. M.; MERKER, C.; MALM, J. R. - Applied physiology of the canine rectus abdominis: forcelength curves correlated with functional characteristics of a rectus powered "ventricle" potencial for cardiac assistance. Trans. Am. Soc. Artif. Intern. Organs, 20(Pt. B): 747-756, 1974.

42. SRETER, F. A.; PINTER, K.; JOLESZ, F.; MABUCHI, K. - Fast to slow transformation of fast muscles in response to longterm phasic stimulation. Exp. Neurol., 75(1): 95-102, 1982. [MedLine]

43. TERMET, H.; CHALENCON, J. L.; ESTOUR, F. - Transplantation sur le myocarde d'un muscle strié excité par pacemaker. Ann. Chir. Thorac. Cardiovas. (Paris), 5(2): 260-263, 1966.

44. VACHON, B. R.; KUNOV, H.; ZINGG, W. - Mechanical properties of diaphragm muscle in dogs. Med. Biol. Eng., 13(3): 252-260, 1975.

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