Surgical Remodeling in Ischemic Cardiomyopathy

Postmyocardial infarction left ventricular dysfunction - assessment and follow up of patients undergoing surgical ventricular restoration by the endoventricular patchplasty

BACKGROUND

Surgical ventricular restoration with endoventricular patchplasty improves left ventricular function and restores left ventricular shape.

METHOD

The study included patients who presented with transmural anterior myocardial infarctions between June 2007 and May 2008. Briefly the technique included - coronary revascularization, resection of the endocardial scar, left ventricular reconstruction using an endoventricular synthetic patch. Left ventricular geometric parameters were studied preoperatively, early postoperatively, at 3 and 6 months and statistically analyzed by SPSS 14 software package.

RESULTS

The ejection fraction increased from 33.5 ± 5.02 to 37.77 ± 7.17 immediate postoperatively. The preoperative left ventricular ejection fraction - a mean of 33.25% (±5.02%), increased by 10.3%-11% at the third and fourth follow up respectively after surgical ventricular restoration (p ≤ 0.001). The left ventricular end systolic volume index improved from a mean of 48.84 ± 11.37 preoperatively to 24.66 ± 5.92 postoperatively (p ≤ 0.001).

CONCLUSIONS

Surgical ventricular restoration in our study has clearly demonstrated a positive effect on LV geometry.

Residual high incidence of ventricular arrhythmias after left ventricular reconstructive surgery

OBJECTIVE

Left ventricular reconstruction is performed in patients with ischemic cardiomyopathy and akinetic or dyskinetic left ventricular regions. These patients may remain at risk for malignant ventricular arrhythmias and hence may benefit from prophylactic implantable cardioverter-defibrillators. Specific guidelines for electrophysiologic testing and implantable cardioverter-defibrillator implantation in patients undergoing left ventricular reconstruction are lacking. We aimed to assess the residual risk and timing of ventricular arrhythmias after left ventricular reconstruction to determine whether electrophysiologic risk stratification or implantable cardioverter-defibrillator implantation can be safely deferred.

METHODS

Data were prospectively gathered on 217 consecutive patients with left ventricular ejection fractions less than 40% undergoing left ventricular reconstruction at our institution from 1997 to 2002. Patients were divided into 3 groups: group 1, implantable cardioverter-defibrillator present before surgery; group 2, implantable cardioverter-defibrillator implanted early after surgery; and group 3, no implantable cardioverter-defibrillator implanted. End points were all-cause mortality (censored for cardiac transplantation) and appropriate implantable cardioverter-defibrillator therapies.

RESULTS

Of 217 patients (mean age, 61 +/- 10 years [mean +/- SD]), survival after a median follow-up of 381 days was 90%. Electrophysiologic studies successfully identified patients at low risk. Appropriate implantable cardioverter-defibrillator therapies occurred in 20% of group 1 and 12% of group 2. The median time to the first implantable cardioverter-defibrillator therapy from the time of left ventricular reconstruction was 43 days, and most first therapies (67%) occurred within the first 63 days.

CONCLUSIONS

The early event rates (occurring in the first 90 days after left ventricular reconstruction) support the use of predischarge electrophysiologic studies, implantation of implantable cardioverter-defibrillators before discharge from the hospital, or both.