Cardiomyoplasty: long-term results in ischemic cardiomyopathy

INTRODUCTION: Cardiomyoplasty was introduced into clinical practice in 1985 by Alain Carpentier. Since then, the procedure has been performed on more than 400 patients worldwide. The latissimus dorsi muscle is prepared maintaining the vascular supply, then the muscle flap is wrapped around the heart and connected to a cardiomyostimulator. The muscle is later stimulated synchronously with ventricular systole to augment the cardiac contractility. METHODS: To evaluate the long-term outcome of cardiomyoplasty, we investigated 3 patients electively undergoing this procedure in our hospital. All of these patients (2 male, 1 female) had severe chronic heart failure which did not respond to optimal medical treatment. The mean follow-up time was 42 months (range 24 - 60). All patients showed symptoms corresponding to NYHA class III, and one patient intermittently showed class IV despite conventional medical therapy. Patients were evaluated at 6-month intervals for 2 years with right heart catheterization, radionuclide scans, echocardiography, as well as questionnaires for assessing quality of life. RESULTS: There was no operative mortality. One patient experienced sudden death 2 years after operation. There were no significant changes in hemodynamic variables at 6, 12 or 24 months after surgery, respectively. Left ventricular ejection fraction increased from 20.0 ( 9.2 to 40.0 +/- 7.1 % (p = 0.05) 1 year after operation. Considerable improvement of symptoms was seen in all, and 1 patient returned to work. NYHA-class decreased from 3.1 to 2.0 (p = 0.02). CONCLUSIONS: Following cardiomyoplasty, patients may exhibit impressive clinical improvement with less striking changes of objective hemodynamic parameters. Thus, in our patients, dynamic cardiomyoplasty improves quality of life. We do not consider this treatment to be an alternative to heart transplantation. It does, however, provide a therapeutic option for patients for whom transplantation is contraindicated.     

Congestive heart failure due to mitochondrial cardiomyopathy in kearns-sayre syndrome

Summary Despite extensive analysis of the ultrastructural changes in skeletal muscle fibers in chronic progressive external ophthalmoplegia (CPEO), similar changes in the heart muscle fibers of patients with cardiac involvement in CPEO, called Kearns-Sayre syndrome, have not been described in detail. We report the clinical long-term course in a patient with Kearns-Sayre syndrome in whom mitochondrial cardiomyopathy was suspected in vivo and was confirmed at autopsy as the underlying cause of severe dilative cardiomyopathy. Enlarged, abnormally structured, excessively augmented mitochondria and loss of myofibrils could be shown both in skeletal and heart muscle cells.Abbreviations CPEO chronic progressive external ophthalmoplegia - EMG electromyogram - ENT department ear, nose, and throat department - LAH left anterior hemiblock - LVEDP left ventricular end-diastolic pressure - LVEDVI left ventricular end-diastolic volume index - LVEF left ventricular ejection fraction - LVESVI left ventricular end-systolic volume index - PAP pulmonary artery pressure - RAP right arterial pressure Supported by the Dr. Sepp and Hanne-Sturm-Stiftung     

血浆脑钠素水平与心衰患者左心功能关系的临床研究

为探讨血浆脑钠素(BNP)水平与心力衰竭患者临床心功能变化之间的关系,本文采用IRMA法测定患者血浆BNP水平,同时采用NYHA心功能分级和超声心动图检查评定患者左心功能。结果表明,随着心功能恶化,血浆BNP水平呈上升趋势。各级心功能间均有显著性差异(P<0.05)。经抗心衰药物综合治疗后,BNP水平降低(P<0.01)。BNP水平与左心室射血分数(LVEF)、左心室短轴缩短率(△D%)呈负相关;与左室收缩末内径(LVDS)、左室舒张末内径(LVDd)呈正相关。总之,在患者心力衰竭的进展中其血浆中BNP水平与心衰程度密切相关,测定患者血浆BNP水平是监测心衰程度的有效手段之一。     

Hemodynamic support with TandemHeart? in tako-tsubo cardiomyopathy – a case report

Tako-tsubo cardiomyopathy is characterized by chest pain, electrocardiographic abnormalities mimicking acute myocardial infarction, akinesis or dyskinesis of apical or mid left ventricular segments, and the absence of obstructive coronary artery disease. Tako-tsubo cardiomyopathy is usually a potentially reversible form of cardiac dysfunction. A careful literature search revealed no previous report of a patient requiring mechanical circulatory support in tako-tsubo cardiomyopathy. We report a patient with tako-tsubo cardiomyopathy, ventricular fibrillation, and hemodynamic instability requiring a left ventricular assist device (TandemHeart^™) followed by improvement of left ventricular ejection fraction to 45%.     

Determinants of Right Ventricular Muscle Mass in Idiopathic Dilated Cardiomyopathy: Impact of Left Ventricular Muscle Mass and Pulmonary Hypertension

Introduction: Although chronic pulmonary hypertension and right ventricular (RV) function carry important functional and prognostic implications in idiopathic dilated cardiomyopathy (IDC), little information on RV muscle mass (RVMM) and its determinants has been published.Methods: Our study comprised thirty-five consecutive patients with IDC, left ventricular (LV) ejection fraction <40% and NYHA class ≥2. Hemodynamic data and parameters on LV and RV geometry were derived from right heart catheterisation and cardiac magnetic resonance imaging.Results: RVMM was normalized to body size using a common linear, body surface area based approach (RVMMI) and by an allometric index (RVMM-AI) incorporating adjustment for age, height and weight. Stepwise multiple regression analysis revealed that pulmonary artery pressure and left ventricular muscle mass were independent predictors of RVMM-AI. The interventricular mass ratio of RV and LV mass (IVRM) was closely related to RVMM (r = 0.79, p < 0.001) and total muscle mass (r = 0.39, p < 0.02). However, there was no significant relationship between LVMM and IVMR (r = 0.17, p = 0.32).Conclusion: Our data suggest that an increase in RV mass in IDC may be explained by two mechanisms: First, as a consequence of the myopathic process itself resulting in a balanced hypertrophy of both ventricles. Second, due to the chamber specific burden of pulmonary artery pressure rise, resulting in unbalanced RV hypertrophy.     

Surgical Myocardial Revascularization of Patients with Ischemic Cardiomyopathy and Severe Left Ventricular Disfunction

OBJECTIVE:

To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction.

METHODS:

Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis.

RESULTS:

Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27±8%/23±7% to 37±5%/31±6%, p <0.001.

CONCLUSIONS:

In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.     

Successful weaning from the DuraHeart with a low left ventricular ejection fraction

We report a case in which the DuraHeart (Terumo Heart, Ann Arbor, MI, USA) was successfully removed despite a low ejection fraction. A 33-year-old man who suffered from dilated cardiomyopathy underwent implantation of the DuraHeart. The assist flow decreased to less than 1.0 l/min 3 months after the implantation. Echocardiography demonstrated a low left ventricular ejection fraction (26 %) and left ventricular dilatation (64 mm). Right heart catheterization revealed a cardiac index of 2.9 l/min/m² with a DuraHeart flow of 0.7 l/min. The patient underwent DuraHeart explantation without cardiopulmonary bypass. He was stable at 10 months post-explant.     

Retrospective evaluation of antibody index of human parvovirus B19 as a prognostic factor in patients with dilated and ischemic cardiomyopathy

Cardiotropic viral infections are important causative factors in dilated cardiomyopathy. This retrospective study examined the antibody index for human parvovirus B19 in patients suffering from dilated or ischemic cardiomyopathy as a prognostic factor for stable left ventricular function. Blood specimens from 43 patients with the diagnosis of dilated or ischemic cardiomyopathy were analyzed for human parvovirus B19 by polymerase chain reaction (PCR) and enzyme immunoassay kit for qualitative determination of IgG and IgM antibodies. To exclude patients with acute myocarditis, only patients with onset of symptoms more than 4 months previously were included. Patients with dilated cardiomyopathy and a high antibody index showed a significantly better clinical outcome when compared to patients with a low IgG antibody index (8.5 ± 2.4 vs. 3.1 ± 2.6; P = 0.006). There was no significant difference in left ventricular ejection fraction between patients with a high antibody index and patients with a lower antibody index (P = 0.59). The presence of human parvovirus B19 antibodies is associated with protective immunity. A high antibody index seems to be a good prognostic factor for the disease correlating to a relatively stable left ventricular ejection fraction. J. Med. Virol. 85: 1111–1114, 2013. © 2013 Wiley Periodicals, Inc.     

超声心动图对扩张型心肌病左室收缩功能的研究

应用二维超声心动图对50例不同心功能级别的扩张型心肌病(DCM)患者左室收缩功能进行检测,并与40例健康查体者对照,结果:DCM全组及各组EF、FS均明显下降,其中心功能Ⅲ、Ⅳ级组相差非常显著;心功能Ⅱ级组SV、CO、CI略增高;Ⅲ级组SV下降,CO、CI正常;Ⅳ级组SV、CO、CI均下降明显,相差显著。提示:DCM心功能Ⅱ、Ⅲ级时心肌收缩力下降,但心脏代偿功能好,心排量正常;Ⅳ级时心肌纤维收缩无力,心排严重不足,处于失代偿状态。     

Triple-site pacing: a new supported therapy approach for bridge to recovery with a left ventricular assist system in a patient with idiopathic dilated cardiomyopathy

Left ventricular assist devices (LVAD) are widely used as bridges to cardiac transplantation or for destination therapy. LVAD support may also function as a bridge to ventricular recovery, but a sufficient rate of recovery has not been obtained, even with various adjuvant therapies. Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure, and there is a report of successful weaning off LVAD with CRT. However, some patients with CRT could not improve their cardiac function because of residual dyssynchrony. Herein, we describe a case of a successful bridge to recovery with triple-site pacing for residual dyssynchrony after biventricular pacing. A 34-year-old woman with heart failure due to dilated cardiomyopathy whose condition deteriorated underwent Toyobo LVAD implantation, resulting in improvement of the left ventricular ejection fraction (LVEF) from 12 to 36%. Because of left ventricular dyssynchrony, we performed CRT, but residual dyssynchrony impeded cardiac recovery. We inserted an additional ventricular lead at the right ventricular outlet to achieve triple-site pacing in order to obtain complete synchronization. The LVEF improved to 45%, and the patient was successfully weaned off the LVAD. In LVAD-supported cases of persistent left ventricular dyssynchrony with CRT, implantation of triple-site pacing could potentially accelerate recovery.     

An Engineering Model of Dynamic Cardiomyoplasty. I.

Dynamic cardiomyoplasty (DCM) is an emerging surgical procedure for heart failure in which the patient's latissimus dorsi (LD) muscle is wrapped around the heart and stimulated to contract in synchrony with the heartbeat as a cardiac assist measure. A 6 week training protocol of progressive electrical stimulation renders the normally fatigueable skeletal muscle fatigue-resistant and suitable for chronic stimulation. To date, over 500 procedures have been performed in worldwide clinical trials. Investigators typically report symptomatic improvement and modest hemodynamic improvement in patients. Controversy exists regarding the exact mechanism of DCM. To test the hypothesis that DCM augments cardiac stroke volume through improvement in systolic function, we formulated an engineering model of dynamic cardiomyoplasty to predict stroke volume. The heart and the LD were modeled as nested (series) elastance chambers, and the vasculature was represented by a two-element Windkessel model. Using five healthy goats, we verified model predictions of stroke volume for both stimulator ON beats (y=1.00x–0.08, r=0.87, p < 0.0001) and OFF beats (y=1.01x+1.06, r=0.91, p < 0.0001), where x and y are the measured and predicted stroke volumes, respectively. The model confirms that using untrained latissimus dorsi applied to the normal myocardium produces only moderate increases in stroke volume and suggests that future research should focus on increasing LD strength after training.     

Use of minimal extracorporeal circulation circuit for left ventricular assist device implantation

We describe successful use of a minimal extracorporeal circulation circuit (MECC) as an alternative to conventional cardiopulmonary bypass (CPB) for the implantation of left ventricular assist device (LVAD) in a 65-year-old patient with ischemic dilated cardiomyopathy. A Jarvik 2000 was implanted through a median sternotomy with the outflow graft anastomosed to the ascending aorta. MECC circuit provides optimal circulatory support throughout the procedure and prevents hemodynamic instability caused by marked displacement of the heart for exposure of the left ventricular apex, while minimizing the adverse effects of conventional CPB.     

Association of angiotensin converting enzyme gene polymorphism with tachycardia cardiomyopathy

Despite incessant tachycardia, not all patients develop tachycardia-mediated cardiomyopathy. The cardiac renin-angiotensin system may be involved in cardiac remodelling and fibrosis. The level of angiotension-converting enzyme (ACE) in the serum is associated with a 287 bp insertion (I)/deletion (D) polymorphism in intron 16 of the ACE gene. The DD genotype is associated with increased serum ACE levels and a higher incidence of idiopathic dilated and ischemic cardiomyopathy. The objective of this study was to assess whether the ACE gene I/D polymorphism is responsible for development of tachycardia-mediated cardiomyopathy. We identified 20 consecutive patients with persistent tachycardia and cardiomyopathy who showed significant improvement in ejection fraction after rate control (group A, tachycardia cardiomyopathy group). We compared the I/D genotype frequency of group A with the gene frequency of a separate group of 20 patents who, despite rapid atrial arrhythmias had preserved left ventricular ejection fraction (group B, tachycardia without cardiomyopathy group). These two groups were then compared with 24 healthy normal volunteers (group C). After a mean follow-up of 30 months, group A patients showed improvement in ejection fraction from 20+/-7 to 43+/-9% (p<0.001). Group A had a significantly higher frequency of the DD genotype than groups B and C (p-value <0.035 and <0.009 respectively). The profile of group B patients was intermediate between normal and patients with tachycardia-mediated cardiomyopathy. I/D polymorphism of the ACE gene may account for cardiomyopathy secondary to tachycardia.     

Prognostic value of left ventricular apical tissue removed for HeartMate II left ventricular assist device placement

BackgroundWith the increasing use of left ventricular assist devices, the left ventricular apical core has become a more frequently encountered surgical pathology tissue. We investigated the prognostic value of this cardiac tissue in short-term patient mortality. Previous studies have shown that the degree of cardiac fibrosis correlates with improvements in ejection fraction and the likelihood of weaning from an assist device.MethodsLeft ventricular apical core tissues from 29 sequential subjects who received a HeartMate II continuous axial flow left ventricular assist device were studied retrospectively to determine whether interstitial fibrosis, replacement fibrosis (scar), the presence of mural thrombus, or other histopathologic findings were associated with hemodynamic changes or mortality in this population. Patients received left ventricular assist devices as bridges to transplantation or as destination therapy. Interstitial fibrosis was determined by observer scoring and digital scoring methods. Before and after left ventricular assist device procedure, right heart catheterizations were reviewed for clinical cardiac data.ResultsThe presence of replacement fibrosis in the apical core tissue significantly correlated with decreased improvement in pulmonary capillary wedge pressure after left ventricular assist device placement (P=.02). Ten subjects died over the course of this study. No specimen variables, including scar, interstitial fibrosis, and the presence of mural thrombosis, correlated with patient mortality.ConclusionsPathologic findings in left ventricular apical cores have little prognostic utility in guiding patient management as related to overall 1-year mortality, but may indicate patients who are more likely to positively remodel their hearts.     

Depressed Systemic Arterial Compliance is Associated with the Severity of Heart Failure Symptoms in Moderate-to-Severe Aortic Stenosis: a Cross-Sectional Retrospective Study

Background: Patients with aortic stenosis (AS) may develop heart failure even in the absence of severe valve stenosis. Our aim was to assess the contribution of systemic arterial properties and the global left ventricular afterload to graded heart failure symptoms in AS.Methods: We retrospectively reviewed medical records of 157 consecutive subjects (mean age, 71±10 years; 79 women and 78 men) hospitalized owing to moderate-to-severe degenerative AS. Exclusion criteria included more than mild aortic insufficiency or disease of another valve, atrial fibrillation, coronary artery disease, severe respiratory disease or anemia. Heart failure symptoms were graded by NYHA class at admission. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Zva) were derived from routine echocardiography and blood pressure.Results: Sixty-one patients were asymptomatic, 49 presented mild (NYHA II) and 47 moderate-to-severe (NYHA III-IV) heart failure symptoms. Mild symptoms were associated with lower SAC and transvalvular gradients, while more severe exercise intolerance coincided with older age, lower systolic blood pressure, smaller aortic valve area and depressed ejection fraction. By multiple ordinal logistic regression, the severity of heart failure symptoms was related to older age, depressed ejection fraction and lower SAC. Each decrease in SAC by 0.1 ml/m² per mmHg was associated with an increased adjusted odds ratio (OR) of a patient being in one higher category of heart failure symptoms graded as no symptoms, mild exercise intolerance and advanced exercise intolerance (OR: 1.16 [95% CI, 1.01-1.35], P=0.045).Conclusions: Depressed SAC may enhance exercise intolerance irrespective of stenosis severity or left ventricular systolic function in moderate-to-severe AS. This finding supports the importance of non-valvular factors for symptomatic status in AS.     

The effects of alcoholism on skeletal and cardiac muscle

To determine the prevalence of alcoholic myopathy and cardiomyopathy, we studied a group of 50 asymptomatic alcoholic men (mean age, 38.5 years) entering an outpatient treatment program. Studies performed included an assessment of muscle strength by electronic myometer, muscle biopsy, echocardiography, and radionuclide cardiac scanning, with comparison to healthy control subjects of similar age. The patients' mean (+/- SEM) daily alcohol consumption was 243 +/- 13 g over an average of 16 years. These patients had no clinical or laboratory signs of malnutrition or electrolyte imbalance. Forty-two percent of the patients, as compared with none of the controls, had strength of less than 20 kg as measured in the deltoid muscle. Muscle-biopsy specimens from 23 patients (46 percent) had histologic evidence of myopathy. In the cardiac studies, when the alcoholic patients were compared with 20 healthy controls, the patients had a significantly lower mean ejection fraction (59 vs. 67 percent), a lower mean shortening fraction (33 vs. 38 percent), a greater mean end-diastolic diameter (51 vs. 49 mm), and a greater mean left ventricular mass (123 vs. 106 g per square meter of body-surface area). One third of the alcoholics had an ejection fraction of 55 percent or less, as compared with none of the controls. Endomyocardial biopsy specimens from six patients with ejection fractions below 50 percent showed histologic changes of cardiomyopathy. The estimated total lifetime dose of ethanol correlated inversely with muscular strength (r = -0.65; P less than 0.001). In an analysis that also included six patients with symptomatic alcoholic cardiomyopathy, the estimated total lifetime dose of ethanol correlated inversely with the ejection fraction (r = -0.58; P less than 0.001) and directly with the left ventricular mass (r = 0.59; P less than 0.001). We conclude that myopathy of skeletal muscle and cardiomyopathy are common among persons with chronic alcoholism and that alcohol is toxic to striated muscle in a dose-dependent manner.     

Improved clinical course of autologous skeletal myoblast sheet (TCD-51073) transplantation when compared to a propensity score-matched cardiac resynchronization therapy population

We recently reported a multi-center, single-arm, phase II study that evaluated the efficacy and safety of autologous skeletal myoblast sheet (TCD-51073) transplantation. The advantage of this procedure over a control group has not yet been analyzed. Seven patients with advanced heart failure due to ischemic etiology (TCD-51073 group, New York Heart Association (NYHA) class III; left ventricular ejection fraction (LVEF) <35 %) refractory to optimal medical and coronary revascularization therapy, received TCD-51073 at 3 study centers between 2012 and 2013 with a 2-year follow-up period. As previously reported, 112 patients received cardiac resynchronization therapy (CRT) with follow-up at the University of Tokyo Hospital between 2007 and 2014. Of them, 21 patients were selected for the control group by propensity score matching. No significant difference in baseline variables between the groups was observed. LVEF and NYHA class improved significantly in the TCD-51073 group during the 6-month study period (p < 0.05). During the 2-year follow-up, 7 patients (33 %) in the CRT group and no patient in the TCD-51073 group died due to cardiac disease or received VAD implantation (p = 0.128 by the log-rank test). In conclusion, transplantation of TCD-51073 is clinically advantageous in facilitating LV reverse remodeling, improving HF symptoms, and preventing cardiac death in patients with ischemic etiology when compared to background-matched patients receiving CRT.     

参芪扶正注射液对老年慢性心力衰竭患者心功能的影响

目的观察参芪扶正注射液对老年慢性心力衰竭患者的临床疗效及对其心功能、脑钠肽（BNP）的影响。方法将64例65岁以上的慢性心力衰竭患者随机分为治疗组（n=34）和对照组（n=30）。对照组常规使用吸氧、强心、利尿、扩张血管、纠正水电解质紊乱等治疗,治疗组则在对照组的基础上加用参芪扶正注射液（250ml/d）,疗程3周。观察治疗前后患者的NYHA心功能分级、左心室舒末内径（LVEDD）、左室射血分数（LVEF）、心排血量（CO）与血浆脑钠肽（BNP）含量。结果治疗后两组患者的心功能各项指标与BNP均得到显著改善（P〈0.05）。其中治疗组的NYHA心功能分级改善有效率明显高于对照组（P〈0.05）,治疗后治疗组的LVEF、CO与血浆BNP含量与对照组有显著差异（P值均〈0.05）,两组治疗后的LVEDD则无明显差异（P〉0.05）。结论参芪扶正注射液联合常规治疗可以提高对老年慢性心力衰竭患者的疗效,改善心功能。     

单胺氧化酶对老年心力衰竭患者临床应用价值

目的 研究老年心力衰竭患者的单胺氧化酶变化情况及单胺氧化酶对老年心力衰竭诊断及病情评估的临床应用价值。方法 选择2012年1月~2018年1月在我院心内科＞60岁老年慢性心力衰竭住院患者412 例,按纽约心脏病协会（NYHA）心功能分级分为四组,心力衰竭I级31例、Ⅱ级78例、Ⅲ级182例、Ⅳ级121例,选取同期健康体检老人62例为对照组,所有患者进行血清单胺氧化酶及NT-proBNP、超敏C反应蛋白浓度检测对比;同时比较收缩性心力衰竭者与舒张性心力衰竭者单胺氧化酶及浓度变化,研究单胺氧化酶与超声心动图指标左心室射血分数、左心室舒张末期内径的相关性。结果 单胺氧化酶对照组与心力衰竭I级组比较,差异无统计学意义（P＞0.05）,心力衰竭Ⅱ~Ⅳ级组单胺氧化酶、NT-proBNP、Hs-CRP均高于心力衰竭Ⅰ级组与对照组,差异有统计学意义（P＜0.05）。收缩性心力衰竭平均MAO、Hs-CRP、NT-proBNP、LVEDD 较高,舒张性心力衰竭平均LVEF较高;老年心力衰竭患者单胺氧化酶与LVEF 呈负相关（r=-0.647,P＜0.05）;与LVEDD 呈正相关（r =0.726,P＜0.05）。结论 单胺氧化酶能较好的反映心力衰竭患者心脏结构及功能的变化,在心力衰竭的早期诊断、病情及预后的评估有重要的临床应用价值。     

Cardiocirculatory bio-assist: is it time to reconsider demand dynamic cardiomyoplasty? Review and future perspectives

In the last 15 years, dynamic cardiomyoplasty has remained an experimental procedure even after the enthusiastic short- and mid-term results, mainly because of the disappointing long-term outcome caused by muscular degeneration secondary to chronic continuous electrical stimulation of the latissimus dorsi. In Italy, a group of muscular pathologists, cardiologists, and cardiac surgeons conducted an experiment of an activity-rest stimulation protocol in humans that should avoid complete transformation of the skeletal muscle, maintaining its properties overtime. This "demand" stimulation protocol gave good results, improving New York Heart Association class, ejection fraction value, and survival. Even though dynamic cardiomyoplasty was excluded from the recent international guidelines for the management of heart failure, the discussion on the ability of this unique kind of cardiocirculatory bio-assistance is due to be reopened, thanks to the results of the new stimulation protocol. Heart transplantation, circulatory supporting devices, multisite stimulation therapy, and the total artificial heart are not always and in all countries the best solutions: the great economic cost, the numerous contraindications, the need for immunosuppression and antithrombotic therapy, and the troublesome follow up constitute important drawbacks. For patients in whom transplant surgery cannot be performed, as well as in developing countries, the nonprohibitively expensive demand dynamic cardiomyoplasty may still play a role.