Long-Term Results of Left Ventricular Reconstructive Surgery in Patients With Ischemic Dilated Cardiomyopathy

Abstract

urgical treatment of congestive heart failure associated with myocardial infarction (MI) is attracting much attention because its prognosis is still poor despite recent improvements in medical treatment. 1 Post-MI left ventricular (LV) remodeling is characterized by chamber dilatation and abnormal geometric change, which leads to heart failure progressing to ischemic cardiomyopathy. Heart transplantation is widely accepted as the optimal surgical therapy for heart failure patients, including those associated with ischemic etiology, but unfortunately transplantation is limited by the lack of donors and many exclusion criteria such as age and end-organ dysfunction. As an alternative surgical therapy, Dor at el introduced endoventricular circular patch plasty for patients with ischemic cardiomyopathy that has developed after a large anteroseptal MI. 2 Several modifications of LV restoration (LVR) have been proposed and some retrospective data, including largescale studies, have shown safety and efficacy in terms of survival benefit and LV functional recovery. 3,4 Moreover, there is an ongoing multicenter, randomized, international trial (Surgical Treatment for Ischemic Heart Failure trial) to elucidate the real benefits of LVR. 5 However, there are only limited data about the long-term results of LVR in Japan. Furthermore, because of a specific situation related to the severely limited supply of organ donors and the limited availability of cardiac support devices, such as the ventricular assist system, 6 we have adopted liberal inclusion criteria for LVR, even for critically ill patients who are generally treated with mechanical circulatory support and subsequent heart transplantation. 7 Consequently, it is meaningful to examine our own experiences of LVR.We conducted a multicenter retrospective study to analyze the long-term outcomes of LVR and examine its efficacy and limitations. Methods PatientsFour university-affiliated hospitals participated in the study. Ethical committee approval was obtained in each institution. We retrospectively reviewed 72 patients who underwent LVR from January 1999 to June 2007. All patients included in the analysis had preoperative global LV dysfunction (LV ejection fraction (EF) <40%) and significantly enlarged LV (end-systolic volume index (ESVI) Received April 18, 2008; revised manuscript received June 9, 2008; accepted June 17, 2008; released online September 18, 2008 Background Left ventricular restoration (LVR) is increasingly used for treatment of chronic heart failure following myocardial infarction. The present multi-institutional retrospective study analyzed the long-term efficacy and limitations of LVR. Methods and Results Seventy-two (58 males, mean age 62±10) patients who underwent LVR between January 1999 and June 2007 were included. Preoperatively, 50 (68.5%) were in New York Heart Association (NYHA) functional class III or IV. Mean left ventricular end-diastolic and end-systolic volume indexes were 145±43 ml/m 2 and 111±40 ml/m 2 , respectively, and ejection fraction...

Review of surgical ventricular restoration: A procedure to treat cardiac failure

“…The Osaka Cardiovascular Surgery Research (OSCAR) group observed signifi cant decreases in LVEDD and LVESD with increased LVEF postoperatively [9]. These LV functional improvements persisted for 3 years.…”

Myocardial Recovery by Mechanical Unloading With Left Ventricular Assist System

“…Mean age was 32.8±17.8 years (range, 7-69 years) and the diagnosis was DCM in 20 patients, ischemic cardiomyopathy in 9, secondary cardiomyopathy in 3, and myocarditis in 2. Our protocol for scheduled LVAS weaning is shown in Figure. To facilitate future LVAS explantation, adjunctive operative procedures such as mitral annuloplasty (n=17), LV pacing lead implantation for cardiac resynchronization therapy (CRT) (n=5) or LV restoration (n=4) 39 were performed at the time of LVAS implantation if indicated. As soon as the patient's general condition was stabilized and organ dysfunction recovered, medical treatment for HF was instituted.…”

Surgical Treatment for Heart Failure

“…Mean EF significantly improved to 39±11%, and after a mean of 3.3±2.4 years of follow-up, 90% of the survivors were in NYHA functional class I or II. 35 In patients with ischemia, the prognosis is associated with the presence of more than moderate MR. 36 In ischemic DCM, the operative results are different with and without ischemic MR. In patients with MR, the preoperative status is severe and operative mortality seems to be high because of the severity of the disease and requirement for emergency operation.…”