Safety and Efficacy of Surgical Ventricular Restoration in Unstable Patients With Recent Anterior Myocardial Infarction

Interventionelle LV-Modulation in der Herzinsuffizienztherapie

Trotz großer Fortschritte in der Akutversorgung des Myokardinfarkts entwickelt ein relevanter Teil der Patienten eine chronische Herzinsuffizienz. Der durch den Infarkt verursachte myokardiale Schaden kann pathologische Umbauprozesse im Herzen wie linksventrikuläre Dilatation, Veränderung der ventrikulären Geometrie und die Ausbildung von Narbengewebe initiieren, die in einer progredienten Herzinsuffizienzsymptomatik und -letalität resultieren können. Verschiedene chirurgische und interventionelle Therapieverfahren zur Modulation der pathologischen Umbauprozesse im Herzmuskel wurden entwickelt. Sie erwiesen sich als sicher und effektiv in der Reduktion linksventrikulärer Volumina, einer Steigerung der linksventrikulären Ejektionsfraktion sowie im Hinblick auf klinische Parameter. Randomisierte prospektive Studien, die einen Überlebensvorteil durch interventionelle oder chirurgische linksventrikuläre Modulation nachweisen, liegen zurzeit nicht vor.

An image of mitral valve repair

Mitral regurgitation is a severe problem of the mitral valve mechanism caused by many factors, including ischemic and nonischemic cardiomyopathy, inflammation, degeneration and others. Regardless of the cause of valve dysfunction, many changes in surgical approach have been undertaken. The pioneering work of Carpentier led to the era of mitral valve reconstruction a few decades ago. Understanding the different techniques applied in several pathoanatomic settings is of major interest. This review summarizes the indications and results of this specific surgical procedure in the setting of ventricular dysfunction by different causes.

LEFT VENTRICULAR REMODELLING AND MITRAL VALVE REMODELLING IN CORONARY HEART DISEASE PATIENTS WITH POST-SURGERY PROGRESSION OF MITRAL REGURGITATION

The progression of ischemic mitral regurgitation (MR) after coronary arty bypass graft (CABG) surgery remains one of the most complex and still unresolved problems in the treatment of coronary heart disease (CHD).

Aim. To study myocardial function, left ventricular (LV) remodelling, and mitral valve (MV) remodelling in CHD patients with MR progression after isolated CABG or CABG combined with LV reconstructive surgery.

Material and methods. In total, 101 CHD patients after CABG were included in the analysis.

Results. The mechanisms of MR progression after isolated CABG differ from those after CABG and LV reconstructive surgery. After the former, LV remodelling progresses both locally and globally, while after the latter, the LV remodelling progression is predominantly global. The patients with post-surgery MR progression differ from their peers without MR in terms of all key parameters of MV geometry.

Conclusion. The leading mechanism of MR progression is local and global LV remodelling, which leads to papillary muscle dislocation and MV leaflet tension and restricted motion. The categories of patients with a high risk of post-surgery MR progression are defined. 

Left anterior descending artery occlusion secondary to blunt chest trauma diagnosed by comprehensive echocardiography and coronary angiography

Blunt chest trauma can cause serious complications, but coronary artery occlusion is rare. In a 19-year-old man, 40 days after a motorcycle accident, comprehensive echocardiography detected left anterior descending artery occlusion and left ventricular dysfunction, which was confirmed by coronary angiography and ventriculography. Echocardiography was also able to confirm restored left anterior descending artery flow and improved left ventricular function after coronary artery bypass grafting.

Surgical Ventricular Restoration: An Operation to Reverse Remodeling - Clinical Application (Part II)

The first part of the article dealt with the basic science behind the evolution of ventricular restoration procedures and the rationale for the use of novel surgical techniques. The second part describes the preoperative workup of patients in advanced heart failure, the core information required to determine the surgical approach and the essential principles and techniques of ventricular restoration. It then examines the effects of ventricular restorative procedures on pump function and clinical outcomes, the results of the worldwide experience with ventricular restoration and concludes with more recent advances in this field.

Outcomes Following Surgical Ventricular Restoration for Patients With Clinically Advanced Congestive Heart Failure (New York Heart Association Class IV)

BACKGROUND

It has been well documented that survival in patients with advanced congestive heart failure (CHF) receiving medical therapy is worse with advancing stages of disease (New York Heart Association [NYHA] IV versus NYHA III). However, such comparisons are rare in the surgical treatments for CHF. Surgical ventricular restoration (SVR) is an accepted therapy for patients with ischemic cardiomyopathy after anterior wall myocardial infarction. We evaluated the impact of advanced stage of CHF (NYHA IV) on survival after SVR.

METHODS AND RESULTS

A retrospective review was conducted of SVR patients at our institution between January 2002 and December 2005. Seventy-eight patients underwent SVR during the study period; 34 patients were NYHA IV and 44 patients were NYHA II/III before surgery. NYHA IV patients had significantly worse preoperative ejection fraction (EF), left ventricular end systolic volume index (LVESVI), and stroke volume index (SVI). Both groups demonstrated significant improvement in EF and LVESVI after SVR, and there were no differences between the groups with regard to postoperative EF, LVESVI, or SVI. There were 3 operative deaths in each group (P = 1.00). Sixty-five percent (P < .0001) of NYHA IV patients and 82% (P < .0001) of NYHA II/III patients improved to NYHA class I or II at follow-up. NYHA IV patients trended toward reduced Kaplan-Meier survival at 32 months (68% versus 88%, P = .08), although NYHA IV was not a significant predictor of mortality.

CONCLUSIONS

NYHA IV patients demonstrate similar improvements in cardiac function with acceptable, although decreased, survival after SVR when compared with those with less severe clinical disease. These outcomes are superior to those reported for medical management, indicating that patients with clinically advanced CHF who are appropriate candidates should be considered for SVR irrespective of preoperative NYHA class.

Contemporary performance of surgical ventricular restoration procedures: data from the Society of Thoracic Surgeons' National Cardiac Database

BACKGROUND

Surgical ventricular restoration (SVR) is an operation that demonstrates promise to improve outcomes for patients with left ventricular dysfunction. Current use and operative outcomes of SVR have come from centers of expertise, and operative risks of SVR in community practice are unknown. We sought to characterize the performance of SVR nationally and describe the acute risks of mortality and major morbidity plus predictors of adverse outcomes.

METHODS

We identified patients undergoing an SVR procedure at US hospitals participating in the Society of Thoracic Surgeons (STS) National Cardiac Database from January 2002 to June 2004. Baseline characteristics, operative characteristics, clinical outcomes, and predictors of adverse procedural outcomes were analyzed.

RESULTS

There were 731 patients who underwent SVR at 141 of STS's 576 hospitals, and 20 centers performed 10 SVR procedures or more. The operative mortality was 9.3%; reoperation in 14.1%, stroke in 3.3%, renal failure in 8.1%, and prolonged ventilation in 21.5%. Combined death or major complications occurred in 33.5%. Major predictors of this combined end point were age, female sex, creatinine > or = 2 mg/dL, insulin-dependent diabetes, myocardial infarction within 1 week, history of congestive heart failure, 3-vessel coronary disease, severe mitral insufficiency, and status of surgery.

CONCLUSION

This study provides a first look at use and outcomes of SVR in a national sample. Although a quarter of STS sites are performing SVR, most have limited experience and perioperative events are somewhat higher than prior selected series. Further studies of SVR are needed to improve patient selection and procedural performance.