Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration

Concomitant Mitral Valve Repair vs Replacement During Surgical Ventricular Restoration for Ischemic Cardiomyopathy

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.

Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial

OBJECTIVE

The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data.

METHODS

Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality.

RESULTS

The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001).

CONCLUSIONS

Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.

An Off-Pump Repair Technique for Postinfarction Apical Left Ventricular Aneurysm

PURPOSE

The conventional surgical treatment for postinfarction left ventricular aneurysm (LVA) is open-heart repair with cardiopulmonary bypass. However, the risk of the open-heart surgery under cardiopulmonary bypass may result in an unacceptable risk for many patients with multiple comorbidities. Here, we reported a new off-pump repair technique for postinfarction apical LVA.

METHODS

A new off-pump repair technique, circular banding and occlusion technique, was applied to repair the postinfarction apical LVA in 12 patients. Clinical data of all those 12 patients were retrospectively reviewed. Patients were followed up prospectively by direct interviews and echocardiographic examination.

RESULTS

The new repair technique was successfully performed in all these 12 patients. Acute reduction of the LVA mouth diameter, the left ventricular (LV) end-diastolic volume and end-systolic volume, and an increase in the LV ejection fraction (EF) were immediately obtained after the repair. Patients had an uneventful postoperative course. They were in New York Heart Association class 1-2, and the LV volume and EF detected by echocardiography remained unchanged during an average 28.4 ± 9.9 months (range 13 to 45 months) follow-up.

CONCLUSIONS

Circular banding and occlusion is a simple, safe, and effective off-pump repair technique for postinfarction apical LVA. It can allow effective LV remodeling and improve heart function.

Elucidating the mechanisms underlying left ventricular function recovery in patients with ischemic heart failure undergoing surgical remodeling: A 3-dimensional ultrasound analysis

OBJECTIVE

The study objective was to elucidate the mechanisms of left ventricle functional recovery in terms of endocardial contractility and synchronicity after surgical ventricular reconstruction.

METHODS

Real-time 3-dimensional transthoracic echocardiography was performed on 20 patients with anterior left ventricle remodeling and ischemic heart failure before surgical ventricular reconstruction and at 6-month follow-up, and on 15 healthy controls matched by age and body surface area. Real-time 3-dimensional transthoracic echocardiography datasets were analyzed through TomTec software (4D LV-Analysis; TomTec Imaging Systems GmbH, Unterschleissheim, Germany): Left ventricle volumes, ejection fraction, and global longitudinal strain were computed; the time-dependent endocardial surface yielded by 3-dimensional speckle-tracking echocardiography was postprocessed through in-house software to quantify local systolic minimum principal strain as a measure of fiber shortening and mechanical dispersion as a measure of fiber synchronicity.

RESULTS

Compared with controls, patients with heart failure before surgical ventricular reconstruction showed lower ejection fraction (P < .0001) and significantly impaired mechanical dispersion (P < .0001) and minimum principal strain (P < .0001); the latter worsened progressively from left ventricle base to apex. After surgical ventricular reconstruction, global longitudinal strain improved from -6.7% to -11.3% (P < .0001); mechanical dispersion decreased in every left ventricle region (P ≤ .017) and mostly in the basal region, where computed mechanical dispersion values were comparable to physiologic values (P ≥ .046); minimum principal strain improved mostly in the basal region, changing from -16.6% to -22.3% (P = .0027).

CONCLUSIONS

At 6-month follow-up, surgical ventricular reconstruction was associated with significant recovery in global left ventricle function, improved mechanical dispersion indicating a more synchronous left ventricle contraction, and improved left ventricle fiber shortening mostly in the basal region, suggesting the major role of the remote myocardium in enhancing left ventricle functional recovery.

Analysis of influencing factors for prognosis of patients with ventricular septal perforation: A single-center retrospective study

Background

Ventricular septal rupture (VSR) is a type of cardiac rupture, usually complicated by acute myocardial infarction (AMI), with a high mortality rate and often poor prognosis. The aim of our study was to investigate the factors influencing the long-term prognosis of patients with VSR from different aspects, comparing the evaluation performance of the Gensini score, Sequential Organ Failure Assessment (SOFA) score and European Heart Surgery Risk Assessment System II (EuroSCORE II) score systems.

Methods

This study retrospectively enrolled 188 patients with VSR between Dec 9, 2011 and Nov 21, 2021at the First Affiliated Hospital of Zhengzhou University. All patients were followed up until Jan 27, 2022 for clinical data, angiographic characteristics, echocardiogram outcomes, intraoperative, postoperative characteristics and major adverse cardiac events (MACEs) (30-day mortality, cardiac readmission). Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality.

Results

The median age of 188 VSR patients was 66.2 ± 9.1 years and 97 (51.6%) were males, and there were 103 (54.8%) patients in the medication group, 34 (18.1%) patients in the percutaneous transcatheter closure (TCC) group, and 51 (27.1%) patients in the surgical repair group. The average follow-up time was 857.4 days. The long-term mortality of the medically managed group, the percutaneous TCC group, and the surgical repair group was 94.2, 32.4, and 35.3%, respectively. Whether combined with cardiogenic shock (OR 0.023, 95% CI 0.001–0.054, P = 0.019), NT-pro BNP level (OR 0.027, 95% CI 0.002–0.34, P = 0.005), EuroSCORE II (OR 0.530, 95% CI 0.305–0.918, P = 0.024) and therapy group (OR 3.518, 95% CI 1.079–11.463, P = 0.037) were independently associated with long-term mortality in patients with VSR, and this seems to be independent of the therapy group. The mortality rate of surgical repair after 2 weeks of VSR was much lower than within 2 weeks (P = 0.025). The cut-off point of EuroSCORE II was determined to be 14, and there were statistically significant differences between the EuroSCORE II &lt; 14 group and EuroSCORE II≥14 group (HR = 0.2596, 95%CI: 0.1800–0.3744, Logrank P &lt; 0.001).

Conclusion

Patients with AMI combined with VSR have a poor prognosis if not treated surgically, surgical repair after 2 weeks of VSR is a better time. In addition, EuroSCORE II can be used as a scoring system to assess the prognosis of patients with VSR.

Effect of Left Ventricular geometric remodeling on restrictive filling pattern and survival in ischemic cardiomyopathy

Background

To evaluate the effects of Left ventricular remodeling patterns in patients with left ventricular restrictive filling pattern (RFP; E/A>2) in ischemic cardiomyopathy (ICM) on prognosis.

Methods

Patient data was retrospectively analyzed over a period of 4.5 years to determine the effect of LV geometry by Echocardiographic parameterson survival and re-admission for heart failure. All patients with previous history of transmural myocardial infarction were studied and all were on guideline directed medical therapy. None underwent device therapy or surgery. The stored 2D Echocardiograms were studied. Left ventricular dimensions were noted, including the relative wall thickness (RWT). The patients were grouped based on RWT<0.34 and ≥ 0.34 and were compared for clinical outcomes of mortality and re-admissions for heart failure, over a period of 54 months.

Results

There were 102 ICM patients who had baseline RFP. We identified two sub-groups based on geometric phenotypes of left ventricular eccentric remodeling and dilated remodeling based on the relative wall thickness (RWT >0.34 or <0.34). The patients with preserved RWT had significantly more dilated ventricles (LVIDd and LVIDs), greater pulmonary artery systolic pressures (PASP), greater diatolic dysfunction (E/A) and less left ventricular ejection fraction (LVEF); p < 0.001. The number of deaths was higher in the reduced RWT patients, as were the number of re-admissions, although the time to survival and time to re-admission was not significant.

Conclusions

In this pilot study on ICM patients in advanced heart failure with baseline RFP, the presence of preserved RWT indicative of eccentric remodelling demonstrated a better clinical outcome.

Predictive Value of Two-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Ventricular Restoration

Objectives

Parameters of left ventricular (LV) mechanics, obtained from speckle-tracking echocardiography (STE), were found to be of prognostic value in patients with heart failure and those who underwent cardiac surgery. This study aimed to assess the value of STE in patients scheduled to undergo surgical ventricular restoration (SVR).

Methods

A total of 158 consecutive patients with baseline STE who underwent SVR due to an LV anteroapical aneurysm were included in the analysis. Preoperative longitudinal STE parameters were evaluated for their association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The echocardiographic follow-up to assess the change in the regional function of the segments remote from the aneurysm was performed in 43 patients at a median of 10 months [interquartile range (IQR): 6–12.7 months] after SVR.

Results

During a median follow-up of 5.1 years (IQR: 1.6–8.7 years), events occurred in 68 patients (48%). Less impaired mean basal end-systolic longitudinal strain (BLS) with a cutoff value ≤ −10.1 % demonstrated a strong association with event-free survival, also in patients with an LV shape corresponding to an intermediate shape between aneurysmal and globally akinetic. Initially hypo- or akinetic basal segments with preoperative end-systolic strain ≤ −7.8% showed a greater improvement in wall motion at the short-term follow up.

Conclusion

Patients with less impaired preoperative BLS exhibited a better event-free survival after SVR, also those with severe LV remodeling. The preserved preoperative segmental longitudinal strain was associated with a greater improvement in regional wall motion after SVR. BLS assessment may play a predictive role in patients with an LV anteroapical aneurysm who are scheduled to undergo SVR.

Postmyocardial infarction ventricular septal defect and ventricular aneurysm repair with a "double-patch frame" technique

BACKGROUND

Postmyocardial infarction intraventricular septal rupture is a life-threatening medical condition. Surgical management of postmyocardial infarction ventricular septal defects (PIVSDs) is associated with a 60% mortality and a 40% incidence of residual ventricular septal defects (rVSDs). Our study aimed to describe our modification of the "Double-patch" technique of PIVSD repair without using a biological glue and present its postoperative complications and survival.

METHODS

This was a retrospective observational study. The Bakoulev's Scientific Center of Cardiac Surgery patient admission and discharge database was reviewed from March 2002 to April 2021. The inclusion criterion was PIVSD. Exclusion criteria were conservative treatment, transcatheter closure of PIVSD, PIVSD closure with an interventricular septum patch, and chronic PIVSDs. The study outcomes were echocardiographic parameters of cardiac function, postoperative complications, and mortality.

RESULTS

Forty nine patients met the study eligibility criteria. Comparison of echocardiographic data of cardiac function demonstrated reduction in the postoperative period end-diastolic (201.4 ± 59.6 ml vs. 118 [range: 76-207] ml; p < .0005) and end-systolic volumes (106 [51-208] ml vs. 66 [40-147] ml; p < .0005). One (2%) patient developed hemodynamically significant rVSD that required the second run of cardiopulmonary bypass and rVSD closure. Thirteen (26.5%) patients died in the hospital. The overall mortality rate for the study period was 11.4/100 person-years (95% confidence interval [CI]: 6.9-19.0/100 person-years). In these patients, 1-year survival was 68.2% (95% CI: 52.3%-79.8%) and 5-year survival was 63.1% (95% CI: 45.1%-76.7%).

CONCLUSION

The "Double-patch frame" technique restores LV dimensions, has a low rate of hemodynamically significant rVSDs and mortality.

Effects of trehalose on recurrence of remodeling after ventricular reconstruction in rats with ischemic cardiomyopathy

Recurrence of left ventricular (LV) remodeling after surgical ventricular reconstruction (SVR) for ischemic cardiomyopathy has been reported to be partially attributed to autophagy. We aimed to examine the effects of trehalose, an autophagy inducer, on the recurrence of LV remodeling after SVR. After SVR in rats with ICM, trehalose was orally administered. The changes in LV end-diastolic dimension (LVEDD) and fractional shortening (FS) were evaluated. The activation of myocardial autophagy was also estimated by autophagy markers: microtubule-associated light chain 3 II (LC3-II) and p62; the former usually increases and the latter decreases if autophagy is activated. Significant LV reverse remodeling was observed early after SVR. On the other hand, the 28th postoperative day SVR + trehalose was associated with smaller LVEDD and better FS than SVR alone (LVEDD, P = 0.043; FS, P < 0.01). LC3-II increased comparably in both groups, while p62 was significantly lower in the SVR + trehalose group than in the SVR alone group (P < 0.01). In conclusion, trehalose attenuated the recurrence of LV remodeling and changed autophagy markers after SVR in rats with ICM. Trehalose may be a candidate for adjuvant therapy to retain the effects of SVR.

A historical appraisal of the techniques of left ventricular volume reduction in ischemic cardiomyopathy: Who did what?

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

Long-Term Results of Hybrid Left Ventricular Reconstruction in the Treatment of Ischemic Cardiomyopathy

The evidence supporting surgical aneurysmectomy in ischemic heart failure is inconsistent. The aim of the study was to describe long-term effect of minimally invasive hybrid transcatheter and minithoracotomy left ventricular (LV) reconstruction in patients with ischemic cardiomyopathy. Twenty-three subjects with transmural anterior wall scarring, LV ejection fraction 15–45%, and New York Heart Association class ≥ II were intervened using Revivent TC anchoring system. LV end-systolic volume index was reduced from 73.2 ± 27 ml at baseline to 51.5 ± 22 ml after 6 months (p < 0.001), 49.9 ± 20 ml after 2 years (p < 0.001), and 56.1 ± 16 ml after 5 years (p = 0.047). NYHA class improved significantly at 5 years compared to baseline. Six-min walk test distance increased at 2 years compared to the 6-month visit. Hybrid LV reconstruction using the anchoring system provides significant and durable LV volume reduction during 5-year follow-up in preselected patients with ischemic heart failure.

Restoring ventricular restoration: A call to re-evaluate a surgical therapy considered ineffective

The technique of surgical restoration of postischemically dilated left ventricles (SVR) has almost disappeared from operating theaters after the Surgical Treatment of IsChemic Heart failure (STICH) Trial demonstrated no treatment effect in patients with CAD and ejection fraction below 35%. Criticism on the trial was expressed stating that surgical expertise and patient selection (i.e., almost no aneurysm patients included) may have been inadequate to test the procedure s potential. Gaudino and colleagues now propose to conduct an analysis comparing the STICH patient population to a group of comparable SVR patients treated by a center with documented specific expertise for this technique. We here address the background of the trial and the following controversy and suggest a rationale why the suggested analysis has the potential to add valuable information to the field.

Left ventricular surgical remodeling 2.0

Left ventricular surgical remodeling has been, for a long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, mainly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular (LV) cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes a hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario.

Surgical ventricular restoration-meta-analysis of observational studies

Background

Technique of surgical ventricular restoration (SVR) may impact its outcomes. Therefore, we conducted a meta-analysis of studies on SVR performed by using different techniques and studied outcomes.

Methods

Scientific databases were searched for studies on SVR. End points assessed were NYHA class, left ventricular ejection fraction (LVEF), end-systolic volume index (ESVI), sphericity index, apical rotations, mortality, and re-admissions for heart failure.

Results

Circular patch use showed significant increases in LVEF by 9.53% (7.62, 11.45), decreases in ESVI by - 35.16 ml (- 44.97, - 25.34), improvements in NYHA class by - 1.29 (- 1.45, - 1.13), and decreases in sphericity index by - 0.04 (- 0.08, 0.00) . In studies using rectangular patch, the LVEF showed an increase by 5.75% (3.52, 7.98,), the NYHA class improved by - 2.45 (- 2.59, - 2.32). The decrease in ESVI was - 40.36 ml (- 62.2, - 18.52). The apical rotation increased by 3.45 ⁰ (0.62, 6.29,). Re-admission for heart failure and mortality was less.When the magnitude of ESVI decrease were compared within studies using rectangular patch, the greatest decrease in ESVI was notedwith use of a rectangular patch. (- 59 ml versus - 40 ml a very narrow patch and - 22 ml use of oval patch) The improvements in sphericity index at 2 years in use of rectangular patch study was - 0.78 ± 0.11 versus 0.00 ± 0.03 in use of oval patch study.

Conclusions

Rectangular patch use resulted in maximal decreases in ESVI and sphericity index. Mortality and re-admissions for heart failure were also significantly less at mid-term after SVR.

Prognostic value of natriuretic peptides and restrictive filling pattern before surgical ventricular restoration

OBJECTIVE

Both increased natriuretic peptide levels and restrictive filling pattern (RFP) are important risk predictors in patients with heart failure. The aim of this study was to examine the role of the combined use of natriuretic peptide and RFP for the prognostic stratification of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration in the Biomarker Plus study.

METHODS

A total of 186 patients (aged 64 ± 10 years) underwent echocardiographic study and N-terminal pro-B-type natriuretic peptide assay at baseline (before surgical ventricular restoration). Patients were divided into 4 groups depending on baseline diastolic filling pattern (RFP/no RFP) and N-terminal pro-B-type natriuretic peptide level (less than or greater than or equal to the upper tertile value of 2003 ŋg/L). RFP was defined as E/A ratio ≥2. All-cause death or heart failure hospitalizations within 36-month follow-up were analyzed.

RESULTS

Despite similar ejection fraction, volumes, and mass, the 4 groups presented distinct clinical and structural pattern of presurgical ventricular restoration ventricular remodeling and significantly different clinical outcome after surgical unloading. During follow-up, 67 patients died or were hospitalized for heart failure (36%). High N-terminal pro-B-type natriuretic peptide levels and RFP, considered individually, were significantly associated with outcome (P < .0001). The combination of both was associated with the highest adjusted hazard of adverse events (hazard ratio, 3.63; 95% CI, 1.73-7.6; P < .0001).

CONCLUSIONS

The simultaneous use of 2 markers, 1 biological and 1 echocardiographic, may allow better prognostic stratification and characterization of the distinct structural and clinical phenotypes in a population of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration. This approach could be useful in the decision-making process to guide treatment choices in patients with ischemic cardiomyopathy.

[Surgical Treatment of Ischemic Cardiomyopathy: Current State of the Problem]

In this article we present discussion of the current state of the problem of surgical treatment of ischemic cardiomyopathy (ICM). The pathophysiological aspects of left ventricular remodeling in patients with ICM are also covered. A detailed characterization of methods for assessing the myocardial viability is given and their role in patients with ICM is shown. The problem of right ventricular dysfunction in ICM is discussed. Main attention is focused on the methods of surgical treatment of ICM. Limitations of the Surgical Treatment for Ischemic Heart Failure (STICH) study are analyzed. The article is intended for cardiologists, general practitioners and cardiac surgeons.

Total Surgical Plication of Left Ventricular Aneurysm Using the BioVentrix Revivent Myocardial Anchoring System

Surgical ventricular reconstruction (SVR) is the therapy of choice for patients with left ventricular dilatation, apical and anterolateral transmural scar, and low ejection fraction. STICH trial did not show that SVR led to improved survival but several observational studies did. However, because of the considerable operative risk, open heart surgery is considered risky in debilitated patients and clinical results are controversial. Alternative less invasive strategies for left ventricular aneurysm repair have been proposed. We present a case of a left ventricular aneurysm repair using the less invasive ventricular enhancement technique (LIVE) with the Revivent TC system (BioVentrix Inc., San Ramon, CA) in a totally surgical approach, instead of a hybrid interventional-surgical one, as previously described.

Myocardial reconstruction in ischaemic cardiomyopathy

An increase in left ventricular volume after a myocardial infarction is a key component of the adverse remodelling process leading to chamber dysfunction, heart failure and an unfavourable outcome. Hence, the therapeutic strategies have been designed to reverse the remodelling process by medical therapy, devices or surgical strategies. Surgical ventricular reconstruction primarily combined with myocardial revascularization has been introduced as an optional intervention aimed to reduce the left ventricle through resection of the scar tissue and is recommended in selected patients with predominant heart failure symptoms, and with myocardial scarring and moderate left ventricular remodelling. This review outlines the rationale and the technique for reconstructing the left ventricle and the possible indications for using that technique, based on experiences from the centre with the largest international experience. The major contributions in the literature are briefly discussed.

Role of surgical ventricular restoration post surgical treatment of heart failure (STICH) trial

Objective

To compare the outcomes of isolated coronary artery bypass grafting (CABG) versus surgical ventricular restoration (SVR) with or without CABG for patients with ischemic cardiomyopathy (ICM).

Methods

Retrospectively, 49 patients with ICM and severe LV dysfunction (LVEF < 35%) who underwent SVR with or without CABG from January 2009 to December 2016 at a single institution was compared with 49 patients who underwent isolated CABG. The two groups were matched for preoperative clinical and echocardiographic parameters including left ventricular end-diastolic diameter (LVIDd), left ventricular end-systolic diameter (LVIDs), left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV). Primary outcomes analyzed included early mortality, late mortality, and major adverse cardiac or cerebrovascular events (MACCE). Secondary outcomes analyzed included echocardiographic parameters of left ventricular volume and function-indexed left ventricular end-diastolic volume (LVEDVi), indexed left ventricular end-systolic volume (LVESVi), and LVEF. Cox and survival analysis was performed.

Results

Early and late mortality in SVR vs. CABG groups were 4 (8.1%) and 6 (12.2%) vs. 1 (2%) and 5 (10.2%) respectively. Mean improvement in LVEF was 3.39 ± 7.51 compared to 4.97 ± 5.45 between the two groups at 3-month follow-up. Mean improvement in LVEF was 5.1 ± 8.3 in the SVR group vs 5.9 ± 7.1 in the CABG group at the last follow-up. There was no statistically significant improvement between the two groups in terms of LVEF at 3 months or the last follow-up. There were statistically significant differences between LVEDVi and LVESVi between the two groups at 3 months and the last follow-up. The 5-year rates of survival were 85 ± 6 and 82 ± 9% for SVR and CABG groups respectively. The 5-year rates of freedom from MACCE were 75 ± 7 and 60 ± 11% for SVR and CABG groups respectively.

Conclusion

Compared with isolated CABG, SVR plus CABG results in equivalent late mortality and better left ventricular reverse remodeling (as evidenced by LV volume reduction) and better freedom from MACCE at 5-year follow-up.

10-Year Outcomes After Left Ventricular Reconstruction: Rethinking the Impact of Mitral Regurgitation

BACKGROUND

Heart failure with reduced ejection fraction due to a post-infarction anteroseptal aneurysm carries a poor prognosis. Patients with refractory heart failure may be considered for advanced surgery, including left ventricular assist device implantation, heart transplantation and left ventricular reconstruction. The aim of this study was to evaluate outcomes after an integrated approach of left ventricular reconstruction with concomitant procedures (mitral/tricuspid valve repair, coronary revascularization), and assess risk factors for event-free survival, focusing on left ventricular geometry/function and presence of functional mitral regurgitation (MR).

METHODS

A total of 159 consecutive heart failure patients who underwent left ventricular reconstruction between 2002 and 2011 were included. Mid-term echocardiographic and long-term clinical outcomes were evaluated. Preoperative risk factors were correlated to event-free survival (freedom from mortality, left ventricular assist device implantation, and heart transplantation).

RESULTS

Mid-term echocardiography demonstrated decreased indexed left ventricular end-systolic volumes (89 ± 42 mL/m² preoperatively; 51 ± 18 at mid-term, p < 0.001), and absence of MR ≥ grade 2. Event-free survival was 83% ± 3% at 1-year, 68% ± 4% at 5-year, and 46% ± 4% at 10-year follow-up. Preoperative wall motion score index (WMSI; hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.7-5.8, p < 0.001) and presence of MR ≥ grade 2 (HR 1.9, 95% CI 1.1-3.1, p = 0.014) were independently associated with adverse event-free survival.

CONCLUSIONS

Event-free survival is favorable in patients with WMSI < 2.5 and significantly worse when WMSI is ≥ 2.5. In both groups, the presence of preoperative MR ≥ grade 2 negatively affects event-free survival, despite successful correction of MR. Risk stratification by preoperative WMSI and MR grade supports the Heart team in choosing the optimal surgical strategy for patients with refractory heart failure.

Long-Term Survival and Echocardiographic Findings After Surgical Ventricular Restoration

BACKGROUND

This study investigates the long-term survival and durability of mitral procedures on patients undergoing surgical ventricular restoration.

METHODS

From 1992 to 2017, 109 patients underwent surgical ventricular restoration. Survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique, and follow-up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival.

RESULTS

The mean age was 61.57 ± 12.81 years. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Concomitant surgeries included mitral valve (MV) repair (n = 40, 37%), MV replacement (n = 5, 5%), tricuspid valve repair (n = 4, 4%), aortic valve replacement (n = 3, 3%), coronary bypass grafting (n = 76, 70%; 1.6 ± 1.3 grafts), and ventricular septal defect closure (n = 5, 5%). Redo-sternotomies were performed in 12 patients (11%). Median duration of echocardiographic follow up was 2.9 years (interquartile range, 9.0) and was obtained in 59 patients (54%). Left ventricular ejection fraction improved from 28% ± 13% to 33% ± 16% (p = 0.011). Median duration of echocardiographic follow-up of MV repair was 3.6 years (interquartile range, 9.5). MV repair led to sustained improvements in mitral regurgitation (MR; p = 0.001) where only 2 (5%) experienced recurrence of moderate to severe MR. For patients who did not undergo an MV procedure there was no difference in preoperative and follow-up MR severity (p = 0.586). Median patient follow-up was 7.1 years (interquartile range, 8.5). Overall 5-, 10-, and 15-year survival rates were 71.9%, 48.1%, and 26.2%, respectively.

CONCLUSIONS

Surgical ventricular restoration was associated with sustained improvement in left ventricular ejection fraction with almost half surviving to 10 years postoperatively. For patients undergoing concomitant MV repair, the improvement in mitral competence is durable.

CABG in patients with left ventricular dysfunction: indications, techniques and outcomes

Ischemic chronic heart failure (CHF) represents one of the cardiovascular diseases with the worst degree of morbidity and mortality in the western world, and with the highest health care costs. Despite several studies demonstrated that surgical revascularization (CABG), especially in the presence of viable myocardium, improve heart function, and therefore, survival, the matter remains unclear and controversial. In the late 1970s, the Coronary Artery Surgery Study showed that a subgroup of patients with coronary artery disease, angina, and reduce LV function had a significant survival benefit after CABG compared to those treated medically. The key concept behind this observation was the presence of viable myocardium, which can resume function following revascularization. In contrary, the surgical treatment for ischemic heart failure (STICH) trial, which randomized patients with CAD and LV dysfunction to evidence-based medical therapy or CABG plus medical therapy, failed to demonstrate at a median follow-up of 56 months a significant difference between the CABG group and the medical therapy group in the rate of death from any cause. However, the results of the STICH extension study (STICHES) at 10 years follow-up demonstrated that CABG is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and readmission for heart compared to optimal medical therapy (OMT) in patients with severe ischemic LV dysfunction. Therefore, this review discusses the available evidences in literature, from observational studies to randomized trials, including operative techniques and controversial issues, in order to better clarify the role of CABG in the current management of ischemic patients with LVD.

Impact of surgical ventricular restoration on early and long-term outcomes of patients with left ventricular aneurysm: A single-center experience

Left ventricular aneurysm (LVA) is a common complication of myocardial infarction. However, the optimal treatment for LVA remains controversial.In this retrospective study, we analyzed the early and long-term clinical consequences of surgical ventricular restoration on 102 patients who had undergone repair between January, 2005 and January, 2015. The LVA repair approaches comprised of patch plasty (n = 28), linear repair (n = 40), and plication repair (n = 34).Patient demographics were 60.8% male, and the mean age was 60.5 ± 7.2 years. The in-hospital mortality rate was 7.8% (8/102), including 6 patients who died from low cardiac output and 2 from multiorgan failure. During the early postoperative period, left ventricular sizes significantly decreased in the patch plasty and linear repair groups compared with the plication group. In addition, all 3 repair techniques greatly ameliorated left ventricular ejection fraction (P < .05), and there was no significant difference in survival rate between groups (P = .25).Surgical ventricular restoration (linear repair, plication repair, and patch plasty) obtained equivalently appreciable outcomes for cardiac function improvement, perioperative mortality, and survival. Selection of a surgical technique for LVA patients should be optimized to individual patient conditions including the morphological characteristics of the aneurysm and ischemic scar.

Ventricular volume and myocardial viability, evaluated using cardiac magnetic resonance imaging, affect long-term results after surgical ventricular reconstruction

OBJECTIVES

We aimed to investigate the outcomes of surgical ventricular reconstruction (SVR) for ischaemic cardiomyopathy and to identify ideal candidates for this procedure using cardiac magnetic resonance imaging (MRI) studies.

METHODS

We retrospectively examined 50 patients who underwent SVR and were preoperatively evaluated using cardiac MRI from 2004 to 2014. Cine MRI and gadolinium-enhanced MRI were performed to evaluate left ventricular (LV) volume and scarring. The midterm (median, 2.5 years) risk factors of cardiac death or major adverse cardiac events (MACEs) were analysed. Patients were divided into three groups-those with preoperative indexed LV end-systolic volume (LVESVI) of ≤100 ml/m² (Group 1), those with LVESVI of >100 and ≤130 ml/m² (Group 2) and those with LVESVI of >130 ml/m² (Group 3)-and examined.

RESULTS

In total, 17 patients exhibited MACEs at follow-up. Kaplan-Meier analysis showed that the 5-year rate of freedom from MACEs was 66%. The Cox hazard model indicated that preoperative LVESVI was the only significant predictor for MACEs (P = 0.006; hazard ratio, 1.02; 95% confidence interval, 1.01-1.04). Moreover, a significant reduction in LVESVI and an increase in LV ejection fraction (LVEF) were observed early after SVR (preoperative versus postoperative: LVESVI, 110 ± 44 vs 68 ± 28 ml/m², P < 0.001; LVEF, 24.3 ± 10.3 vs 32.0 ± 10.4%, P < 0.001) and at follow-up (LVESVI, 61 ± 28 ml/m², P < 0.001; LVEF, 36.5 ± 11.5%, P < 0.001). Although no difference was observed between the groups at follow-up, LVEF and LVESVI primarily improved in Group 2. LVEF improvement was significantly greater in Group 2 than in Group 1 (%increase in LVEF: Group 1, 6%; Group 2, 18%; P = 0.008). In patients with a preoperative LVESVI of >130 ml/m², the number of non-viable segments was a significant risk factor for MACEs.

CONCLUSIONS

Patients with preoperative LVESVI ranging from 100 to 130 ml/m² had fairly better outcomes, and the percentage improvement in LVEF and the percentage reduction in LVESVI were more pronounced in these patients. Hence, accurate preoperative assessments of LV volume and viability testing using cardiac MRI studies are essential for better stratification of the SVR procedure.

Perioperative management of a patient undergoing a novel mini-invasive percutaneous transcatheter left ventricular reconstruction procedure

Survivors of myocardial infarction might have residual damage and higher risks of developing heart failure. This increasing complication encompasses up to 45% of all infarcts. As anesthesiologists we will have to perform anesthesia more frequently in patients with such challenging medical history schedule to undergo mini-invasive surgical procedures. We present the case of a 51-year-old man with severe heart failure post-myocardial infarction with multiple sclerosis undergoing a novel percutaneous transcatheter ventricular reconstruction via a left mini-thoracotomy. To guide the surgeon during the intervention we used a real-time 3D echocardiography, enlightening the fact that guidance is crucial for that kind of procedure. To lower postoperative pain and the inflammatory response we have administered successfully intravenous lidocaine, indicating that it is possible to avoid regional anesthesia in patients with multiple sclerosis scheduled for mini-invasive left ventricular reconstruction requiring a mini-thoracotomy.

Time series analysis of physiologic left ventricular reconstruction in ischemic cardiomyopathy

OBJECTIVE

The history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting.

METHODS

Between May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test.

RESULTS

Hospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees (P = .02) and was still present 4 years after surgery.

CONCLUSIONS

Surgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank-Starling relationship and pressure-volume loop.

Outcome of left ventricular surgical remodelling after the STICH trial

OBJECTIVES

After the publication of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, surgical indications to left ventricular surgical remodelling (LVSR) have become more restrictive. The experience we report reflects the changes in the real world after the publication of STICH trial.

METHODS

From May 2009 to July 2014, 113 patients underwent LVSR, targeted mainly to the left anterior descending territory (89.4%). Of these, 18 patients (15.9%) were operated on an emergency basis. Early and mid-term outcomes were assessed to identify clinical and echocardiographic risk factors.

RESULTS

Most patients (90.3%) had chronic ischaemic mitral regurgitation (CIMR) and were in New York Heart Association (NYHA) class III/IV (77.9%). The median ejection fraction (EF) was 26% [95% confidence interval (CI): 26, 28] and scarred areas were akinetic (86.7%) in most cases. Severe left ventricular diastolic dysfunction (LVDD) was found in 33.6% of patients. Mitral valve surgery was performed in 84.1% of patients. Five patients (4.4%) died while in hospital, all from cardiac causes. Risk factors were abnormal bilirubin and emergency status. After a median follow-up of 12 (95% CI: 6, 18) months, 22 patients died, 17 from cardiac causes. Five-year freedom from death any from cause was 73 ± 5%, emergency status and MR Grade 4 being the only risk factors. Five-year freedom from death from any cause and NYHA class III/IV was 61 ± 6%. Severe LVDD and emergency status were risk factors, along with high bilirubin and diabetes mellitus on insulin. Five-year freedom from death from any cause and non-fatal cardiovascular events (rehospitalization, reoperation and stroke) was 55 ± 6%. LVDD and atrial fibrillation were found to be risk factors. After a median follow-up of 31 (95% CI: 19, 38) months, 91 patients underwent postoperative echocardiography. EF increased by 20%, but stroke volume remained unchanged. Postoperatively, patients with severe LVDD had lower EF and higher end-systolic volumes than patients without LVDD.

CONCLUSIONS

Our findings show that patients, who are candidates for LVSR, have mostly akinetic areas and CIMR requiring surgical correction and are severely symptomatic. Severe LVDD is common and, along with emergency status, is the most important risk factor for early and late outcome.

Mid-term results of coronary bypass graft surgery in patients with ischaemic left ventricular systolic dysfunction and no detected myocardial viability

OBJECTIVES

There are concerns about effects of surgical revascularization on patients with ischaemic systolic dysfunction when no signs of myocardial viability have been detected by nuclear imaging preoperatively. We reviewed our data to determine the efficacy of coronary bypass graft in this special patient cohort.

METHODS

A retrospective review with prospectively collected clinical data was conducted on 87 consecutive patients between 2000 and 2012 whose left ventricular ejection fraction was less than 40%. All patients received positron emission tomography examination before undergoing coronary artery bypass graft and showed no signs of myocardial viability. Improvements in ejection fraction, postoperative re-examination of myocardial viability by nuclear imaging and freedom from major cardiac events were observed. Survival was calculated using Kaplan-Meier analysis.

RESULTS

The 30-day mortality rate was 7%. Ejection fraction improvement (defined as over 5%) was observed in 13 (16%) patients within 6 months postoperatively. Ejection fraction improvement was observed in 46 (58%) patients by the end of the first year and 50 (63%) patients by the second year. It was noted that 25 (32%) and 43 (54%) patients progressed to heart functional class I or II at 1 and 5 years, respectively. Positron emission tomography examination showed enhanced myocardial viability in the non-viable ventricular wall segment in 53 (67%) patients at 1 year. Freedom from major adverse cardiac events was observed in 56 (71%) patients at 1 year and 47 (60%) patients at 5 years. Survival rates were 82 and 66% at 1 and 5 years, respectively.

CONCLUSIONS

Coronary artery bypass graft proved to be a positive choice of treatment for patients with severe ischaemic systolic dysfunction when there was no viable myocardium detected through nuclear imaging.

New Insights in the Diagnosis and Treatment of Heart Failure

Cardiovascular disease is the leading cause of mortality in the US and in westernized countries with ischemic heart disease accounting for the majority of these deaths. Paradoxically, the improvements in the medical and surgical treatments of acute coronary syndrome are leading to an increasing number of “survivors” who are then developing heart failure. Despite considerable advances in its management, the gold standard for the treatment of end-stage heart failure patients remains heart transplantation. Nevertheless, this procedure can be offered only to a small percentage of patients who could benefit from a new heart due to the limited availability of donor organs. The aim of this review is to evaluate the safety and efficacy of innovative approaches in the diagnosis and treatment of patients refractory to standard medical therapy and excluded from cardiac transplantation lists.

Managing Heart Failure Patients with Multivessel Disease - Coronary Artery Bypass Graft versus Percutaneous Coronary Intervention

The foundation of treatment for heart failure with reduced ejection fraction is guideline-directed medical treatment. However, surgical revascularisation offers improved survival and quality of life for patients with more extensive coronary disease and the greatest degree of left ventricular systolic dysfunction and remodelling. The most commonly considered surgical interventions for patients with heart failure with reduced ejection fraction are coronary artery bypass surgery, sometimes combined with surgical ventricular reconstruction and surgery for mitral regurgitation. In this review, the author considers the risks and benefits of coronary artery bypass graft versus percutaneous coronary intervention in the management of heart failure patients with multivessel disease.

Left ventricular reconstruction: update to left ventricular aneurysm/reshaping techniques

The increase in left ventricular (LV) volume after a myocardial infarction (MI) is a component of the remodelling process and is associated with a poor clinical outcome. Hence, the current management strategy for ischaemic LV dysfunction has been aimed at reversing the remodelling process. Surgical LV reconstruction (LVR) has been introduced as an optional therapeutic strategy aimed at reducing LV volumes through the exclusion of the scar tissue, thereby restoring the physiological volume and shape and improving LV function and clinical status. Until recently, several studies have shown that surgical LVR is effective and relatively safe, with a favourable 5-year outcome. However, in spite of the large amount of reports drawn on various data sets, the additional benefit of LVR to CABG remains debated. We briefly discuss the rationale for surgically reversing LV remodelling through LVR, and, more extensively, the technique and the indications to the best of our knowledge.

Residual Stress Impairs Pump Function After Surgical Ventricular Remodeling: A Finite Element Analysis

BACKGROUND

Surgical ventricular restoration (Dor procedure) is generally thought to reduce left ventricular (LV) myofiber stress (FS) but to adversely affect pump function. However, the underlying mechanism is unclear. The goal of this study was to determine the effect of residual stress (RS) on LV FS and pump function after the Dor procedure.

METHODS

Previously described finite element models of the LV based on magnetic resonance imaging data obtained in 5 sheep 16 weeks after anteroapical myocardial infarction were used. Simulated polyethylene terephthalate fiber (Dacron) patches that were elliptical and 25% of the infarct opening area were implanted using a virtual suture technique (VIRTUAL-DOR). In each case, diastole and systole were simulated, and RS, FS, LV volumes, systolic and diastolic function, and pump (Starling) function were calculated.

RESULTS

VIRTUAL-DOR was associated with significant RS that was tensile (2.89 ± 1.31 kPa) in the remote myocardium and compressive (234.15 ± 65.53 kPa) in the border zone. VIRTUAL-DOR+RS (compared with VIRTUAL-DOR-NO-RS) was associated with further reduction in regional diastolic and systolic FS, with the greatest change in the border zone (43.5-fold and 7.1-fold, respectively; p < 0.0001). VIRTUAL-DOR+RS was also associated with further reduction in systolic and diastolic volumes (7.9%; p = 0.0606, and 10.6%; p = 0.0630, respectively). The resultant effect was a further reduction in pump function after VIRTUAL-DOR+RS.

CONCLUSIONS

Residual stress that occurs after the Dor procedure is positive (tensile) in the remote myocardium and negative (compressive) in the border zone and associated with reductions in FS and LV volumes. The resultant effect is a further reduction in LV pump (Starling) function.

Early feasibility evaluation of thoracoscopically assisted transcatheter ventricular reconstruction in an experimental model of ischaemic heart failure with left anteroapical aneurysm

AIMS

To test the feasibility of a thoracoscopically assisted, off-pump, transcatheter ventricular reconstruction (TCVR) approach in an ovine model of left ventricular (LV) anteroapical aneurysm.

METHODS AND RESULTS

Myocardial infarction (MI) was induced by coil occlusion of the middle left anterior descending artery and diagonals. Two months after MI creation, TCVR was performed via a minimal thoracotomy in eight sheep. Under endoscopic and fluoroscopic guidance, trans-interventricular septal puncture was performed from the LV epicardial scar. A guidewire was externalised via a snare placed in the right ventricle from the external jugular vein. An internal anchor was inserted over the wire and positioned on the right ventricular septum and an external anchor was deployed on the LV anterior epicardium. Serial pairs of anchors were placed and plicated together to exclude the scar completely. Immediately after TCVR, echocardiography showed LV end-systolic volume decreased from pre-procedure 58.8±16.6 ml to 25.1±7.6 ml (p<0.01) and the ejection fraction increased from 32.0±7.3% to 52.0±7.5% (p<0.01). LV twist significantly improved (3.83±2.21 vs. pre-procedure -0.41±0.94, p=0.01) and the global peak-systolic longitudinal strain increased from -5.64% to -10.77% (p<0.05).

CONCLUSIONS

TCVR using minimally invasive access techniques on the off-pump beating heart is feasible and resulted in significant improvement in LV performance.