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Ann Thorac Surg 1998;65:434-438
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Left Ventricular Volume Predicts Postoperative Course in Patients With Ischemic Cardiomyopathy

Department of Cardiovascular Surgery, Omiya Medical Center, Jichi Medical School, Omiya, Japan

Accepted for publication August 7, 1997.

Dr Yamaguchi, Department of Cardiothoracic Surgery, Stanford University, CV-096, Falk Medical Research Center, Stanford, CA 94305-5247 (e-mail: atsushiy@leland.stanford.edu).

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The left ventricular end-systolic volume index (LVESVI) helps to predict postoperative left ventricular function in patients with ischemic cardiomyopathy.

Methods. We retrospectively assessed the ability of preoperative variables to predict death and the development of postoperative congestive heart failure in 41 patients with a preoperative ejection fraction of less than 0.30.

Results. A preoperative LVESVI of greater than 100 mL/m² was identified as an independent predictor of death by Cox’s proportional hazards model. Diabetes and a preoperative LVESVI of greater than 100 mL/m² were independent predictive risk factors for the development of postoperative congestive heart failure. Postoperative congestive heart failure developed in 2 of the 23 patients (8.7%) who had a preoperative LVESVI of less than 100 mL/m² and in 10 of the 16 patients (62.5%) who had a preoperative LVESVI of greater than 100 mL/m². The actuarial survival rate during follow-up in patients who had a preoperative LVESVI of less than 100 mL/m² was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m². The actuarial rate of freedom from congestive heart failure during the follow-up period also was greater in patients who had a preoperative LVESVI of less than 100 mL/m².

Conclusions. Our results suggest that the preoperative LVESVI predicts the development of postoperative congestive heart failure and the actuarial survival rate in patients with ischemic cardiomyopathy.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The presence of left ventricular dysfunction, as defined by an ejection fraction (EF) of less than 0.30, is a major risk factor for postoperative complications and late death after coronary artery bypass grafting (CABG) [1] [2]. However, recent studies have shown that early postoperative survival after CABG has improved as a result of advances in surgical techniques, myocardial protection strategies, anesthesia, and postoperative pharmacologic and mechanical support [3] [4] [5]. Although perioperative surgical management has lowered operative mortality rates after CABG in patients with severe left ventricular dysfunction, a major concern remains as to whether coronary revascularization improves ventricular function and provides long-term survival.

It has been reported that CABG is an effective therapy for congestive heart failure (CHF) in certain subsets of patients [6], but specific selection criteria for myocardial revascularization have not been established for patients with severe left ventricular dysfunction. In our previous study [7], we reported that the left ventricular end-systolic volume index (LVESVI) in patients with ischemic cardiomyopathy helps to detect the presence of hibernating myocardium and to predict postoperative left ventricular function. In this retrospective study, we determined whether LVESVI predicts the occurrence of postoperative cardiac events and the rate of long-term survival.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Of the 443 patients who underwent isolated CABG at Omiya Medical Center between January 1990 and December 1995, 41 (9.3%) had left ventricular dysfunction (a preoperative EF of less than 0.30) as a result of ischemic cardiomyopathy. Among these 41 patients, there were 2 operative deaths. We assessed preoperative and postoperative left ventricular systolic and diastolic volumes in the 39 remaining patients by biplane cineventriculography during left heart catheterization. We retrospectively assessed preoperative variables as predictors of death and the development of postoperative CHF using univariate and multivariate analysis. The clinical data and cardiac risk factors for the 41 patients in this series are shown in Table 1.

Coronary artery bypass grafting was performed using moderate systemic hypothermia (28°C), topical surface cooling with cold saline solution (4°C), and a membrane oxygenator. All patients underwent aortic cross-clamping, antegrade blood cardioplegia (16°C), and complete myocardial revascularization. Treatment with inotropic agents was initiated before the discontinuation of cardiopulmonary bypass in all patients.

Preoperative and postoperative cardiac catheterizations were performed in 39 patients. Postoperative studies were performed a mean of 28 days (range, 7 to 60 days) after CABG. Biplane left cineventriculography was performed in the 30-degree right anterior oblique and 60-degree left anterior oblique projections at the time of catheterization. The left ventricular end-systolic volume was defined as the volume of blood remaining in the left ventricle at the end of contraction. The left ventricular end-diastolic volume was defined as the maximum left ventricular volume for a given cardiac cycle. These measurements commonly are normalized to body surface area, and expressed as left ventricular volume indexes. Left cineventriculograms were projected onto a video monitor and the left ventricular silhouette at both end-diastole and end-systole was traced using a commercial computer system (Cardio 500; Kontron, MA). The images were digitized to obtain the left ventricular volume. The LVESVI, left ventricular end-diastolic volume index, and EF were calculated from the biplane data [8]. This method of calculation has been found to be superior to the area-length method [9] for evaluating left ventricular volume.

Perioperative information was obtained from hospital records. Operative death was defined as death that occurred within 30 days of operation or during the hospital stay. Follow-up information was obtained during patient visits to an outpatient facility at our medical center or by telephone interviews. The mean duration of follow-up was 1,330 ± 550 days. Complete follow-up data were obtained for all 41 patients. Congestive heart failure, ventricular arrhythmias, and recurrent angina that required rehospitalization after CABG were defined as postoperative cardiac events.

Continuous variables are expressed as the mean plus or minus standard deviation. Continuous data were analyzed using the Student’s t test. Predictors of the development of postoperative CHF were determined by univariate and multivariate analyses. To determine independent risk factors for postoperative CHF, discrete data were analyzed using Fisher’s exact test or ² test. The analyzed variables are summarized in Table 1. Cox’s proportional hazards models then were used to identify independent predictors. Variables that had a value of p < 0.1 by univariate analysis are included in the multivariate analysis. Results of the multivariate analysis are presented with estimates of the ß coefficient as well as the odds ratio (with 95% confidence intervals) and the p value for each variable. Actuarial survival analysis and event-free analysis were done by the Kaplan-Meier method. In the actuarial survival analysis, both operative death and long-term death were taken into consideration. A value of p less than 0.05 was considered statistically significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Among the 41 patients, there were two operative deaths and six late deaths during follow-up. The causes of the operative deaths were low output syndrome and stroke, respectively. The causes of the late deaths included progressive CHF (3 patients), ventricular tachycardia/ventricular fibrillation (2 patients), and cerebrovascular disease (1 patient). Two patients who had a preoperative LVESVI of less than 100 mL/m² and 6 patients who had a preoperative LVESVI of greater than 100 mL/m² died after CABG. The risk factors that predicted operative death and late death by univariate analysis were diabetes (p = 0.0326) and a preoperative LVESVI of greater than 100 mL/m² (p = 0.0211). In this group of patients, Cox’s proportional hazards model identified a preoperative LVESVI of greater than 100 mL/m² as an independent predictor of death (Table 2). The actuarial survival during follow-up in patients who had a preoperative LVESVI of less than 100 mL/m² was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m² (85.0% versus 53.5%; p < 0.05) (Fig 1).

View larger version (15K): [in this window] [in a new window]   Actuarial survival curve. Numbers above the time axis indicate the numbers of patients at risk 0, 1, 3, and 5 years after operation. The actuarial survival rate during follow-up for patients who had a preoperative left ventricular end-systolic volume index (LVESVI) of less than 100 mL/m2 was significantly greater than that for patients who had a preoperative LVESVI of greater than 100 mL/m2 (85.0% versus 53.5%; p < 0.05).

The mean EF increased significantly from 0.25 ± 0.06 to 0.35 ± 0.09 (p < 0.01) in patients who did not have postoperative CHF. However, the EF did not change in patients who had postoperative CHF (0.24 ± 0.06 versus 0.25 ± 0.06). Although there was no significant difference in the preoperative EF between patients who did and did not have CHF, the postoperative EF was significantly greater in patients who did not have CHF than in those who did (p < 0.01). The preoperative LVESVI was significantly greater in patients who had CHF than in those who did not (114.9 ± 21.4 mL/m² versus 84.1 ± 20.4 mL/m²; p < 0.01). The mean LVESVI decreased significantly from 84.1 ± 20.4 mL/m² to 71.5 ± 26.2 mL/m² after CABG in patients who did not have postoperative CHF (p < 0.05). In contrast, the mean LVESVI did not change in patients who had postoperative CHF (114.9 ± 21.4 mL/m² versus 112.4 ± 26.9 mL/m²). The preoperative mean left ventricular end-diastolic volume index in patients who had postoperative CHF (150.6 ± 25.6 mL/m²) also was significantly greater than that in patients who did not have postoperative CHF (112.8 ± 26.4 mL/m²). Fig 1Fig 2 demonstrates that the postoperative EF was greater than 0.30 in 22 of the 23 patients who had a preoperative LVESVI of less than 100 mL/m², but in only 3 of the 16 patients who had a preoperative LVESVI of greater than 100 mL/m². Congestive heart failure exacerbation requiring rehospitalization occurred in 2 of the 23 patients (8.7%) who had a preoperative LVESVI of less than 100 mL/m². In contrast, 10 of the 16 patients (62.5%) who had a preoperative LVESVI of greater than 100 mL/m² had CHF requiring rehospitalization during the follow-up period (Fig 2). In patients who had a preoperative LVESVI of less than 100 mL/m², the rate of freedom from CHF during follow-up was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m² (85.0% versus 31.4%; p < 0.01) (Fig 3).

View larger version (24K): [in this window] [in a new window]   Relation between the preoperative left ventricular end-systolic volume index (LVESVI) and the postoperative ejection fraction (EF). The closed circles indicate patients who were free of congestive heart failure (CHF) after operation, and the open circles indicate patients in whom CHF developed after operation.

View larger version (17K): [in this window] [in a new window]   Freedom from congestive heart failure. Numbers above the time axis indicate the numbers of patients at risk 0, 1, 3, and 5 years after operation. The rate of freedom from congestive heart failure during follow-up was significantly greater for patients who had a preoperative left ventricular end-systolic volume index (LVESVI) of less than 100 mL/m2 than for patients who had a preoperative LVESVI of greater than 100 mL/m2 (85.0% versus 31.4%; p < 0.01).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Because perioperative surgical management has lowered the operative mortality rate after CABG in patients with severe left ventricular dysfunction, the question arises as to whether coronary revascularization improves ventricular function and provides long-term survival benefits. Pigott and colleagues [11] found that the 7-year mortality rate was 66% in 133 patients who received medical treatment and 37% in 77 patients who underwent CABG. Further, Kron and associates [15] reported a 3-year surgical mortality rate of 17% in 39 patients who had ischemic cardiomyopathy and a left ventricular EF of less than 0.20. In patients with ischemic cardiomyopathy who are awaiting heart transplantation, the 5-year actuarial survival rate is almost 80% for those who undergo CABG, compared with 28% for those who receive medical therapy alone [4] [5]. The Coronary Artery Surgery Study group [12] found that the survival rates in patients who had severe ventricular dysfunction (an EF of 0.25 or less), were 86% at 1 year and 69% at 5 years for those who underwent operation, compared with 62% and 32%, respectively, for those who were treated medically. It was concluded that CABG provided greater long-term survival in patients with ischemic cardiomyopathy compared with medical therapy or catheter-based interventions. Therefore, although left ventricular dysfunction has been identified as a risk factor for early death, CABG may improve survival substantially in many patients.

A number of parameters have been proposed to measure left ventricular function and predict prognosis after myocardial revascularization in patients with ischemic cardiomyopathy [16] [17]. Left ventricular function usually is evaluated in terms of the EF, but it is not clear that the EF differentiates between myocardium that is dysfunctional because of reversible ischemia, termed "hibernating myocardium" [18], and myocardium that is dysfunctional because of fibrosis from a previous infarction. Furthermore, these two conditions may coexist in the same patient. In a previous study [7], we found no relation between the preoperative and postoperative EF in patients with ischemic cardiomyopathy. The present results also demonstrate that there is no relation between the preoperative EF and the development of postoperative CHF after CABG. These findings indicate that the preoperative EF alone is not sufficient to predict postoperative morbidity or mortality after revascularization in patients with left ventricular dysfunction.

Previous studies [19] [20] have suggested that patients who have ischemic cardiomyopathy and a preoperative left ventricular end-diastolic dimension of greater than 70 mm are poor candidates for CABG and perhaps are treated better by cardiomyoplasty or heart transplantation. Pigott and colleagues [11] found that the late survival rate was lower in surgically treated patients who had an elevated left ventricular end-diastolic volume (greater than 100 mL/m²) than in those who had a normal end-diastolic volume. White and co-workers [21] suggested that determination of the left ventricular end-systolic volume by quantitative left cineventriculography was more specific for distinguishing between hypertrophic and dilated cardiomegaly, and that an end-systolic volume of greater than 100 mL was a better predictor of death after myocardial infarction than was an increased end-diastolic volume. Thus, an increase in the left ventricular volume may be a more specific indicator of the presence of myocardial fibrosis than the resting EF in patients who have ischemic cardiomyopathy.

In the present study, Cox’s proportional hazards model identified a preoperative LVESVI of greater than 100 mL/m² as an independent predictor of the development of postoperative CHF. The actuarial survival rate after operation in patients who had a preoperative LVESVI of less than 100 mL/m² was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m². Further, there was a lower incidence of CHF in patients who had a preoperative LVESVI of less than 100 mL/m². Because the left ventricular end-diastolic volume index also can reflect changes in left ventricular volume, it also may be a good predictor of postoperative morbidity and mortality. We conclude that the larger the hearts are, in both their diastolic and systolic dimensions, the poorer the predicted response will be to CABG. It is possible that for patients who have end-stage ischemic cardiomyopathy, the preoperative LVESVI will become one of the criteria used to decide whether myocardial revascularization or heart transplantation will be performed. On the other hand, an LVESVI of less than 100 mL/m² in patients who had a left ventricular EF of less than 0.30 was associated with a significant improvement in the postoperative actuarial survival rate, and with a striking decrease in the incidence of CHF during the follow-up period. In conclusion, our results suggest that preoperative evaluation of left ventricular volume using biplane cineventriculography may be useful for determining which patients with ischemic cardiomyopathy are likely to benefit from CABG.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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