Myocardial revascularization in patients with ischemic cardiomyopathy: functional observations

Ischemic cardiomyopathy: midterm survival and its predictors

BACKGROUND

the aim of the study was to analyze all-cause mortality and predictors of long-term survival after myocardial revascularization for ischemic cardiomyopathy.

METHOD

data of 101 patients (mean age, 63.86 years; age range, 30-85 years; 92% male), operated on with stable coronary artery disease and left ventricular ejection fraction <30% between April 2000 and June 2010, were analyzed.

RESULTS

operative mortality was 1.9% (2/101). There was a significant improvement in left ventricular ejection fraction from 25.99% ± 3.8% preoperatively to 34% ± 12% postoperatively (p <0.0001). The mean duration of follow-up was 56.3 ± 33 months, and it was 97% complete (98/101). There were 18/96 (18.75%) late deaths. Overall actuarial survival at 1, 3, 5, and 10 years was 96%, 89%, 83% and 75%, respectively. Univariate predictors of late death were preoperative arrhythmia, cerebrovascular disease, peripheral vascular disease, and logistic EuroSCORE. Multivariate predictors of late death were cerebrovascular disease and preoperative arrhythmia.

CONCLUSION

our study suggests that myocardial revascularization for ischemic cardiomyopathy improves left ventricular ejection fraction and is associated with favorable long-term survival. Patients with cerebrovascular disease and preoperative arrhythmias had poorer outcomes.

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.

Ventricular reconstruction for ischemic cardiomyopathy

Left ventricular surgical reconstruction has been advocated for patients with coronary artery disease, prior myocardial infarction, and poor left ventricular function. The objective of the approach is to resect or exclude all akinetic or dyskinetic nonfunctioning portions of the ventricular cavity and to restore the left ventricle size and shape toward normal as much as possible. We review the pathophysiology of ischemic cardiomyopathy and suggest guidelines for preoperative assessment and patient selection for ventricular reconstruction. Because of the prevalence and prognostic significance of ventricular arrhythmias in this patient population we include in our operative approach a visually directed ablation procedure in those with significant septal scarring. We describe our operative technique and review results achieved with this approach. The procedure results in a significant decrease in ventricular volume, increase in ejection fraction and improvement in apical geometry. We conclude that in selected patients with ischemic cardiomyopathy, left ventricular reconstruction can be accomplished with low operative mortality and results in significant improvement in left ventricular function. During follow up symptom class is decreased in most patients and overall survival at 5 years is 84% and freedom from sudden death is 96%. Ventricular reconstruction should be considered in all patients with coronary artery disease and akinetic or dyskinetic scar.

Left ventricular reconstruction for ischemic cardiomyopathy

An outline of the Toronto General Hospital's philosophy for revascularization and left ventricular reconstruction in patients with ischemic cardiomyopathy. An open beating heart technique with modified linear closure and septoplasty when indicated is used for repair of both akinetic and dyskinetic scar. Patient selection, OR mortality (2.6%), and long-term results are reviewed.

Batista's operation with coronary artery bypass grafting and mitral valve plasty for ischemic dilated cardiomyopathy

A 52-year-old male was admitted for angina pectoris and congestive heart failure classified as New York Heart Association class III. Coronary angiography showed 95% stenosis in the left anterior descending artery, 99% stenosis in the first diagonal branch, total occlusion in the left circumflex artery, and a hypoplastic right coronary artery. Left ventriculography showed a severely dilated left ventricle (ejection fraction 20%) and mild mitral regurgitation. In the myocardial scintigram using 99m-tetrofosmin, there was no viability in the posterolateral wall although the other wall was viable. Partial left ventriculectomy, which is called Batista's operation, coronary artery bypass grafting and Alfieri's mitral valve plasty were performed concomitantly. Postoperatively, the ejection fraction was improved to 39%, and all grafts were patent. The patient was discharged in New York Heart Association class I. We concluded that to succeed in partial left ventriculectomy for ischemic dilated cardiomyopathy, not only should there be no viability in the posterolateral wall to be resected for volume reduction, but the coronary artery which perfuses the residual myocardium with viability should be graftable.

Left ventricular volume reduction and reconstruction in ischemic cardiomyopathy

BACKGROUND

Ischemic cardiomyopathy can be the result of large or small myocardial infarctions or due to myocardial hibernation. Patients with an end-systolic volume index >100 mL¿m2 do not benefit from revascularization alone and require an operation that reduces ventricular volume. Various approaches to reduce ventricular volume have been described. We applied several of these techniques in patients with end-stage ischemic cardiomyopathy.

METHODS

Forty eight patients with end-stage ischemic cardiomyopathy (Class III-IV) underwent left ventricular volume reduction operations with coronary revascularization and mitral valve repair or Alfieri valvoplasty. Fourteen patients underwent interpapillary resections, 22 anterior resections, 4 posterior resections, 2 anterior and posterior resections, and 6 patients reduction of left ventricular volume with endocavitary patches.

RESULTS

All the techniques used improved left ventricular function. Analysis of mortality revealed that extensive resections (interpapillary, anterior, and posterior resection) had a 43% mortality. However, a limited resection or a ventricular reconstruction with an endocavitary patch had only a 12.5% mortality. When we changed our approach to a more conservative one, mortality was reduced from 26% the first 12 months to 13% in the last 15 months of the study.

CONCLUSIONS

Ischemic cardiomyopathy has a poor prognosis if the end-systolic volume index exceeds 100 mL/m2. Various procedures exist to reduce left ventricular volume. Extensive ventricular resections improve ventricular function, but have a high mortality. This led us to use other methods of ventricular volume reduction such as more conservative resections combined with left ventricular reconstructions or ventricular volume reduction with endocavitary patches. Mortality was reduced significantly by this approach. The patients that survived have remained Class I-II in a follow-up that extends up to 30 months. Surgical therapy of Class III-IV ischemic cardiomyopathy is feasible, but aggressive ventricular resections have a high mortality. We advocate a more reconstructive approach with limited or no ventricular resection.