This procedure was named after Dr Vincent Dor who first described it as endoventricular circular patch plasty. This procedure is what people generally are referring to when they use the terms SVR, remodeling, or reconstruction or the surgical anterior ventricular endocardial reconstruction (SAVER) procedure. The technique was introduced to improve geometric reconstruction compared to standard linear repair of left ventricle (LV) aneurysms [10]. Subsequently, Dor and colleagues showed that it was applicable not only to classic aneurysms but also to large akinetic ventricles. Results with the Dor procedure have changed the approach to patients with CHF. SVR has become a standard part of the heart failure surgical armamentarium in patients with advanced heart failure and dilated and dysfunctional ventricles [13, 14].

The procedure begins with CABG and valve repair if indicated, on an arrested heart. The heart is vented through the aortic root which results in a collapsed left ventricle in patients with the classic thinned-out anterior wall (Fig. 6.1a). In patients without full-thickness infarction and thinned-out walls, collapse may not occur. A ventriculotomy is then made in the anterior wall parallel to the left anterior descending coronary artery through the center of the scarred tissue (Fig. 6.1b). It is extended proximally and distally as necessary. Retraction sutures are then placed to aid in exposure.

The LV is assessed by visualization and palpation to identify the presence or absence of ventricular thrombus, the extent of septal anterior, lateral, and inferior wall infarction, papillary muscle infarction and the interpapillary muscle distance.

An encircling stitch is then placed which outlines the margins of the reconstructed anterior wall (Fig. 6.1c). It runs from the point selected as the new apex cephalad along the septum and then crosses over the most superior margin of the anterior ventriculotomy and down the anterolateral wall back to the new apex. This is commonly referred to as the “Fontan stitch” after Dr Francis Fontan [15]. I routinely use two stitches. Many select the location of this stitch at the visual border of the infarcted and normal tissue; some will perform the ventricular reconstruction on a beating heart and will use the border of the beating and non beating myocardium or between the palpably thinned-out and normal tissue as a guide. Many others will use homemade or commercially available sizing devices. The concept of ventricular sizing was introduced by Dr Dor who used an inflated balloon to size the ventricles. I routinely use a device inflated to a volume of 50–60 cc/m² body surface area to estimate the patients’ own end-diastolic volume. As a general rule of thumb the height of the septum is not reduced greater than 50 % regardless of the extent of septal infarction.

The encircling stitch is tied to reduce the size of the opening. If the residual opening is greater than 3 cm, a patch is used to close the opening (Fig. 6.1d). If smaller, a linear closure is then performed (Fig. 6.1e). If the quality of the remaining tissue is suboptimal, the linear closure is reinforced with wither bovine pericardium or felt strips.

This technique is very similar to a standard linear closure technique for ventricular aneurysms. In this technique, the anterior wall is opened as described above. Once the margins of reconstruction of the anterior wall are identified, horizontal mattress sutures are placed externally through the anterior wall down through the scarred septum medially and continued laterally up through the endocardial scar of the anterolateral wall. These sutures are generally reinforced externally with felt or pericardial strips (Fig. 6.2a, b). A standard linear ventricular closure is performed in layers.

What makes this technique unique is when a septoplasty is added in patients with large septal infarctions to reduce the volume of the septum. Dr Linda Mickleborough of Toronto has popularized this technique [16, 17]. A curvilinear patch of Dacron or pericardium is sewn along the margins of the septal wall along three sides (Fig. 6.2c). The anterior linear closure sutures are then placed in such a fashion to sandwich the remaining side of the patch between the medial and lateral walls creating a new septum and anterior wall (Fig. 6.2d). This can be seen diagrammatically in Fig. 6.2e.

The technique introduced and popularized by Dr Adib Jatene [18]. This technique is similar to the Dor technique in that it utilizes a concentric purse string to demarcate the border of the new anterior wall and can be performed with or without a patch.

It is rendered a unique technique by the addition of a septoplasty to reduce the volume in the septum. The septoplasty is accomplished by imbricating the septum with several horizontal mattress sutures which are placed along the septum taking multiple bites of scar tissue beginning near the apex of the heart and running towards the base of the heart until normal tissue is encountered. Sutures are placed in the full height of the infarcted septal tissue and when tied reduce the length of the septum. The encircling stitch is then placed, and the remainder of the reconstruction and closure of the ventricle can proceed in a ­fashion with or without a patch analogous to the Dor procedure [19].

This technique was described by the French ­surgeon Guillmet in 1984 to treat aneurysms which primarily involved the septum [20]. This technique is quite unique in that it employs interrupted U-shaped stitches to reapproximate the anterior wall to the septum directly from within the ventricle. The procedure begins like any of the SVR procedures with an anterior ventriculotomy (Fig. 6.3a). A series of interrupted horizontal mattress or U-shaped sutures are placed from the most lateral portion of the anterior wall and anchored on the septal scar (Fig. 6.3b). The sutures are placed from the base towards the apex, and after all the sutures are placed, they are tied in the same sequence. The remaining tissue is reapproximated providing a hemostatic closure in a standard fashion (Fig. 6.3c) [21].