Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

Clinical and hemodynamic outcomes of the Dor procedure in adults with ischemic cardiomyopathy

Ischemic cardiomyopathy continues to be a major contributor to congestive heart failure, which places a significant burden on our healthcare system. Improving medications and different coronary revascularization strategies are the mainstays in the management of ischemic cardiomyopathy. Although medications and mechanical circulatory support are playing an ever-increasing role, cardiac transplantation remains the gold standard for treating advanced heart failure. Given the small number of available and suitable donor hearts, transplantation is limited for the majority of patients. Surgical ventricular restoration has repeatedly been suggested as a viable alternative in managing heart failure in select patients, as it is believed that surgically returning the ventricle to its original dimensions is possible and associated with favorable outcomes. The purpose of this manuscript is to comprehensively review the current literature on various surgical strategies for ventricular restoration. We also contextualize the published data with respect to ventricular function, volume, structure, arrhythmias, mitral regurgitation, and clinical outcomes.

Results of reconstructive interventions in patients with ischemic cardiomyopathy

BACKGROUND

Effective treatment of patients with ischemic cardiomyopathy is one of the most difficult issues in contemporary cardiac surgery. The aim of this study was to evaluate the long-term effectiveness of reconstructive interventions on the left ventricle during chronic heart failure in patients with ischemic cardiomyopathy.

METHODS

Between March 2013 and December 2017, 178 patients underwent surgical treatment for ischemic cardiomyopathy. Isolated coronary artery bypass grafting was compared with coronary artery bypass grafting with left ventricular reconstruction, using propensity score matching analysis. The primary endpoints of the study were hospital mortality and long-term survival.

RESULTS

After propensity score matching, 29 pairs of patients were compared. The 30-day hospital mortality was comparable (6.8% versus 6.8%, p = 0.952), the average follow-up was 37.4 ± 12.6 months, with no statistically significant difference in mortality from all causes (p = 0.352). After coronary artery bypass in combination with left ventricular reconstruction, patients showed a statistically significant decrease in clinical and functional indicators of chronic heart failure compared to those who had coronary artery bypass grafting alone, in terms of peak oxygen consumption (15.3 versus 13.5 mL·kg^-1·min^-1, p = 0.043) and N-terminal pro-brain natriuretic peptide concentrations (298.6 versus 461.1 pg·mL^-1, p = 0.032).

CONCLUSIONS

Compared to isolated coronary artery bypass, coronary artery bypass in combination with left ventricular reconstruction for the treatment of ischemic cardiomyopathy leads to a significant decrease in the clinical and functional parameters of chronic heart failure in the long-term postoperative period.

[Effectiveness of the Cox Maze-IV Procedure in Cardiac Surgery Patients With Atrial Fibrillation]

Aim Analyzing a 5-year experience of surgical treatment of cardiosurgical patients with atrial fibrillation (AF).Material and methods The study analyzed results of surgical treatment with extracorporeal circulation in 132 patients with AF who underwent the Maze-IV procedure using a radiofrequency ablator with transmurality feedback from 2013 through 2018.Results Two fatal outcomes were observed in the study group. These outcomes took place in the early postoperative period and were associated with progressive acute heart failure in patients with repeated surgery for mitral valve restenosis. 61.2% of the patients had no AF. Recurrent AF was observed during the first three years after surgery in association with withdrawal of the antiarrhythmic medication, which confirmed a need for long-term antiarrhythmic therapy. Analysis of risk factors for AF relapse identified significant predictors, including left ventricular dilatation larger than 5.5 cm at baseline and more than two-year duration of a history of arrhythmias.Conclusion The Maze-IV procedure proved an effective and safe method of surgical treatment in AF patients with acquired heart defects and ischemic heart disease, which allowed maintaining sinus rhythm in 61.2% of patients for 5 years. Preventive amiodarone saturation reduced the risk of AF relapse by 24.2 % (p=0.038) and incidence of postoperative arrhythmic complications by 34.9 % (p=0.008) in cardiosurgical patients.

[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.

A single center's experience with total arterial revascularization and spiral aneurysmorrhaphy for ischemic cardiac disease

The restoration of left ventricular (LV) geometry in combination with coronary artery bypass grafting for the treatment of ischemic cardiac disease remains controversial. We hereby present the experience of our center with total arterial myocardial revascularization (TAMR) and spiral aneurysmorrhaphy for ischemic heart disease. A retrospective analysis of 101 patients with advanced cardiovascular disease who underwent TAMR and spiral aneurysmorrhaphy was performed. Spiral aneurysmorrhaphy is a modification of the linear aneurysmorrhaphy and was applied to patients who had a LV aneurysm with a diameter of less than 5 cm. Peri-operative and in-hospital data were retrieved. The majority of the patients were male (87.13%) with a mean age of 63.1 years. Mean pre-operative ejection fraction (EF) was 35.7% ranging between 20 and 65%. An average of 3.23 grafts was required per patient. Early mortality was 6.93% (one intra-operative and six in-hospital deaths). Addition of concomitant valve surgery was associated with prolonged total operative, cardiopulmonary bypass and cross-clamp time (p < 0.001), increased need for blood (p = 0.012) and plasma (p = 0.038), longer intensive care unit (ICU) stay (p = 0.045) and higher rate of post-operative cerebrovascular accident (p = 0.011). Furthermore, patients with a pre-operative EF between 30 and 50% had a shorter ICU stay (p = 0.045) and LoS (p = 0.029) compared with patients with EF <30%. Early mortality and post-operative complication rates following this combined procedure are in consistency with the relevant available data suggesting its feasibility regardless of the EF or addition of concomitant surgeries. Data from the follow-up of these patients are required to examine the long-term efficacy of this surgical modality.

Left ventricular reconstruction surgery in ischemic heart disease: a systematic review of the past two decades

INTRODUCTION

The aim of this paper is to systematically review the existing literature reporting on patients recruited during the past twenty years regarding the role of left ventricular (LV) reconstruction in ischemic cardiomyopathy in terms of efficacy and mortality and provide an updated overview of the current evidence.

EVIDENCE ACQUISITION

The PubMed and Cochrane bibliographical databases were thoroughly searched for the following MeSH terms: "ventricular reconstruction" OR ventriculoplasty OR "ventricular aneurysm" OR "ventricular restoration." Original studies -recruiting patients during the past twenty years- on LV reconstruction surgery in more than five cases and reporting on the associated peri- or postoperative mortality were deemed eligible.

EVIDENCE SYNTHESIS

Twenty-seven studies were included and provided data for 3220 patients with a mean age of 61 years. Angina was present in 66.6% (510/766) of the patients, while nine out of ten (635/699) had a history of myocardial infarction. Average preoperative ejection fraction was 29.9% and end-systolic volume index was 93.6 mL/m2. With respect to complications, low cardiac output syndrome and the need for intra-aortic balloon pump were prevalent in 9.3% (79/850) and 18.8% (334/1773), respectively. Thirty-day mortality was 7.1% (230/3220) and late-mortality (mean follow-up of 36.9 months) was 19.6% (548/2791), while the rate of MACCE was 40.1% (367/915). Five-year mortality was 29% (340/1171).

CONCLUSIONS

Our findings provide a current perspective of the role of LV reconstruction in the treatment of ischemic cardiomyopathy suggesting its benefit in survival. Taking into consideration the existing debate, further studies are required so that a solid conclusion to be made.