A new surgical ventricular restoration technique to reset residual myocardium's fiber orientation: the "KISS" procedure

We set a new surgical procedure for endoventricular patch reconstruction technique with the aim to rebuild a physiologic shape and volume of the left ventricle caring about realignment of myocardial fibers orientation. Peculiarities of this reconstruction are the shape of the patch (reduction of minor axis compared with currently used oval-shaped patch) and the asymmetrical way of suturing it inside the ventricle.We present a detailed description of operative steps of this procedure, and we add some relevant surgical hints to clarify its peculiarities. Most of the patients operated on with this technique showed the original renewal of apical rotation and left ventricular torsion as specific index of the restoration of physiologic fiber orientation: we report an exemplary case of at-sight recovery of apical rotation in the operating room.This technique can represent a reproducible new way to realign myocardial fibers in a near-normal setting, improving the physiological restoration of ischemically injured left ventricle. It could be also the basis to reconsider surgical treatment for heart failure.Surgery for left ventricular anterior reconstruction in the setting of ischemic cardiomyopathy has a long history. It has evolved over the years from linear closure of large aneurysms to present geometric reconstruction by means of endoventricular patch [1-4]. Surgical and clinical outcome have extensively been revised in many retrospective studies, highlighting a variability in the results of this surgical treatment [5-10]. The internal border zone between normal and infarcted tissue was usually encircled by the Fontan purse-string, a running circular suture with the aim to approach residual walls and reduce the tissue gap to be closed by the patch. The original circular patch used in the reconstruction of the residual tissue gap has been replaced by an oval-shaped patch [11,12], able to assure a better ventricular shape and volume, which have been pointed out as two of th