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.

Surgical Restoration of Antero-Apical Left Ventricular Aneurysms: Cardiac Computed Tomography for Therapy Planning

Background

Surgical ventricular restoration (SVR) leads to functional improvement by volume reduction and restoration of left ventricular (LV) geometry. Our purpose was to refine the planning for SVR using cardiac computed tomography (CCT).

Methods

The possibility to anticipate the postoperative residual LV volume was assessed using CCT in 205 patients undergoing SVR combined with coronary artery bypass grafting (77%), mitral valve repair/replacement (19%) and LV thrombectomy (19%). The potential of CCT to guide the procedure was evaluated. Additionally, the predictive value of CCT characteristics on survival was addressed.

Results

30-day, 1- and 5-year survival was 92.6, 82.7, and 72.1%, respectively, with a marked reduction of NYHA class III-IV quota after surgery (95.1% vs. 20.5% in the follow-up). Both pre- and postoperative LV end-systolic volume index (LVESVI) were predictive of all defined endpoints according to the following tertiles: preoperative: <74 ml/m², 74–114 ml/m² and >114 ml/m²; postoperative: <58 ml/m², 58–82 ml/m² and >82 ml/m². On average, a 50 ml/m² increase of preoperative LVESVI was associated with a 35% higher hazard of death (p = 0.043). Aneurysms limited to seven antero-apical segments (1–7) were associated with a lower death risk (n = 60, HR 0.52, CI 0.28–0.96, p = 0.038). LVESVI predicted by CCT was found to correlate significantly with effectively achieved LVESVI (r = 0.87 and r = 0.88, respectively, p < 0.0001).

Conclusions

CCT-guided SVR can be performed with good mid-term survival and significant improvement in HF severity. CCT-based assessment of achievable postoperative LV volume helps estimate the probability of therapeutic success in individual patients.

Minimally invasive transatrial repair of posterior left ventricular aneurysm

Left ventricular aneurysms (LVA) are a complication of myocardial infarction, that rarely involve the posterior wall; surgical repair of posterior LVA poses a technical challenge when associated with concomitant mitral regurgitation. We describe a minimally invasive treatment of ischemic MR and concomitant patch exclusion of posterior LVA through a right minithoracotomy. Using a transatrial approach, the aneurysm is closed with a "U" shaped dacron patch, whose base is anchored to the mitral annulus. Two patients were operated by this method with excellent results.

Results of Left Ventricular Reconstruction With and Without Mitral Valve Surgery

BACKGROUND

This study aims to compare the midterm outcomes of left ventricular reconstruction with those of left ventricular reconstruction plus mitral valve surgery in patients with left ventricular aneurysm due to anterior myocardial infarction and moderate mitral regurgitation.

METHODS

A total of 523 patients (75 who underwent left ventricular reconstruction plus mitral valve surgery and 448 who underwent left ventricular reconstruction) with concomitant moderate mitral regurgitation were included in the study population. All-cause mortality was considered the primary endpoint. Major adverse cardiovascular and cerebrovascular events, including death, myocardial infarction, stroke, and subsequent mitral valve surgery, were considered secondary endpoints. Multivariable proportional hazards Cox regression models were used to assess the associations between groups and outcomes. In the sensitivity analysis we excluded patients who did not undergo coronary artery bypass graft and repeated the statistical analysis above.

RESULTS

The median follow-up time among all patients was 41 months. There was no significant difference between the left ventricular reconstruction plus mitral valve surgery and the left ventricular reconstruction groups with regard to all-cause mortality (P = .208) and major adverse cardiovascular and cerebrovascular events (P = .817) after adjustment for covariates. In the sensitivity analysis there was no significant difference between the left ventricular reconstruction plus mitral valve surgery and left ventricular reconstruction groups with regard to all-cause mortality (P = .158) and major adverse cardiovascular and cerebrovascular events (P = .651) after adjustment for covariates.

CONCLUSIONS

The clinical outcomes of left ventricular reconstruction are comparable with those of left ventricular reconstruction plus mitral valve surgery in patients with left aneurysm and moderate mitral regurgitation.

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.

Surgical ventricular remodeling: should we STICH or not?

PURPOSE OF REVIEW

The surgical management of patients with ischemic cardiomyopathy, especially those with left ventricular ejection fractions less than 20% has historically been controversial. The original trials of surgical revascularization versus medical therapy intentionally excluded those patients with an ejection fraction less than 35%. The significant advances in medical therapy for heart failure over the past 30 years (β-blockade, angiotensin converting enzyme inhibitors, internal cardiac defibrillator and so on) also mandated a reevaluation of the potential benefits of surgical revascularization in this high-risk subset. The purpose of this review is to examine the data from the Surgical Treatment for Ischemic Heart Failure (STICH) trial, initially reported in 2009 and 2011.

RECENT FINDINGS

Recent reports published in 2016 have now clearly defined the role of surgery over medical therapy for these patients. Furthermore, although the benefits of surgical ventricular reconstruction were once questioned by the results of STICH, further analyses identify that an appropriately selected patient who undergoes a technically adequate operation will derive benefit from surgical ventricular reconstruction.

SUMMARY

The conclusions from the various substudies examining STICH trial data now indicate that in surgical candidates with graftable coronary artery disease, surgical revascularization provides a reduction in overall mortality, cardiovascular deaths and hospitalizations, independent of symptoms, baseline left ventricular size or function and surprisingly, regardless of any viability or evidence of inducible ischemia.

High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure

OBJECTIVE

Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure.

METHODS

We identified patients with left ventricular ejection fraction <20% and VO₂ max <14 mL/min/m², who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era.

RESULTS

A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12%. Actuarial survival at 5 and 10 years was 72% ± 4% and 39% ± 8%, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95% confidence interval, 0.66-3.2], P = .34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95% confidence interval, 0.16-1.50], P = .21).

CONCLUSIONS

Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.

Multislice computed tomography-guided surgical repair of acquired posterior left ventricular aneurysms: demonstration of mitral valve and left ventricular reverse remodelling

OBJECTIVES

Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms.

METHODS

Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD).

RESULTS

Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD.

CONCLUSIONS

MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms.