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Ann Thorac Surg 2005;79:456-461
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Left Ventricular Reconstruction Benefits Patients With Dilated Ischemic Cardiomyopathy

Atsushi Yamaguchi, MD*, Hideo Adachi, MD, Koji Kawahito, MD, Seiichiro Murata, MD, Takashi Ino, MD

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

Accepted for publication July 19, 2004.

Abbreviations and Acronyms CABG = coronary artery bypass grafting; CHF = congestive heart failure; CM = cardiomyopathy; CRF = chronic renal failure; EVCPP = endoventricular circular patch plasty; MVP = mitral valve annuloplasty; NYHA = New York Heart Association; LV = left ventricle; LVEF = left ventricular ejection fraction; LVEDVI = left ventricular end-diastolic volume index; LVESVI = left ventricular end-systolic volume index; LVR = left ventricular reconstruction; SAVER = surgical anterior ventricular endocardial restoration

22

* Address reprint requests to Dr Yamaguchi, 1–847 Amanuma, Omiya-ku, Saitama, Japan 330–8503 (E-mail: yamaatsu{at}omiya.jichi.ac.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Since the preoperative left ventricular end-systolic volume index (LVESVI) of greater than 100 mL/m2 was demonstrated to be an independent predictor of long-term mortality following isolated coronary artery bypass grafting (CABG), LV reconstruction (LVR) has been concomitantly performed in patients with a dilated LV due to ischemic cardiomyopathy.

METHODS: We retrospectively assessed the ability of preoperative and intraoperative variables to affect the actuarial survival in 48 patients with a preoperative LV ejection fraction (EF) of less than 0.30 and a preoperative LVESVI of greater than 100 mL/m2. Mean preoperative LVEF was 0.22 ± 0.07, and preoperative LVESVI was 121 ± 28 mL/m2. Coronary artery bypass grafting was performed in all patients. Mean number of grafted vessels was 2.8. The LVR was concomitantly performed in 20 patients and mitral valve plasty in 11. Preoperative and intraoperative variables were exposed to univariate and multivariate analyses.

RESULTS: There were 3 hospital deaths and 17 late deaths during the follow-up period. Causes of deaths were pump failure (9), myocardial infarction (2), ventricular arrhythmia (4), cerebral infarction (2), and cancer (2). Cox’s proportional hazards model identified LVR and renal failure as independent factors, which affected the actuarial survival with odds ratios of 0.28 and 3.64 (p < 0.05). The 5-year actuarial survival (Kaplan-Meier) was significantly greater following LVR (90% ± 11%) compared to isolated CABG (53% ± 17%).

CONCLUSIONS: Left ventricular reconstruction contributed to improve the actuarial survival in patients with dilated ischemic cardiomyopathy, which could not be achieved by isolated CABG. The LVR can be an alternative to heart transplantation for the treatment of ischemic cardiomyopathy.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The metaanalysis study [1, 2] and randomized study [3, 4] have demonstrated that coronary artery bypass surgery (CABG) prolonged the actuarial survival and decreased late cardiac events for patients with abnormal left ventricular (LV) function, and have emphasized that the surgical strategy of complete revascularization is important for patients with ischemic cardiomyopathy [5]. Patients with reversible ischemia are most likely to show significant improvement in ventricular function with revascularization alone, even if the preoperative left ventricular function is deeply depressed [6].

However, recent studies [7, 8] have pointed out that the benefits of revascularization may be limited if left ventricular volumes are grossly increased. It is well established that patients with impaired LV systolic function represent a high risk group with significantly greater annual mortality following revascularization than those with preserved LV function, and that survival rates decline in proportion to the severity of LV function [8]. White and colleagues [9] and Gaudron and colleagues [10] demonstrated LV volume to be a sensitive marker of postinfarction ventricular dysfunction and a very important predictor of prognosis after myocardial infarction. Vanoverschelde and colleagues [11] also reported that patients with an improved function after revascularization alone had lower LV end-diastolic and end-systolic volumes before revascularization than patients with persistent dysfunction. Our previous report [12] demonstrated preoperative LV volume as an additional predictor of outcome at 5 years following isolated CABG. Patients with EF of less than 0.30 had a 5-year survival of only 54% if the left ventricular end-systolic volume index (LVESVI) was greater than 100 mL/m2, compared with 85% if the LVs were smaller. Congestive heart failure (CHF) was also more common among those with the larger hearts (69% vs 15%). Postinfarction LV aneurysm, either akinetic or dyskinetic, is an extreme example of adverse remodeling that leads to progressive deterioration of function with symptoms and signs of CHF [13].

Since the technical surgical modifications proposed in the 1980s by Jatene [14] and Dor and colleagues [15], the resection of LV aneurysms and the endoventricular patch plasty have reduced LV volume and tended toward a more physiologic reorganization of the ventricular cavity. We speculated that those who have a large LV would benefit most from ventricular reconstruction. The aim of this study was to clarify whether LV reconstruction (LVR), in addition to CABG, was beneficial in LV function and long-term survival of patients with LVESVI of greater than 100 mL/m2 associated with postinfarction dilated ischemic cardiomyopathy.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Of 1,600 patients who underwent CABG at Omiya Medical Center between February 1990 and March 2004, 118 (7.9%) had LV dysfunction with a left ventricular ejection fraction (LVEF) of less than 0.30 as a result of ischemic cardiomyopathy. Forty-eight (3.0%) patients who had an enlarged LV with a LVESVI of greater than 100 mL/m2 and LVEF of less than 0.30, were retrospectively analyzed. Eighteen of them were the subjects in our previous paper [12]. The clinical data and cardiac risk factors for the 48 patients in this series are shown in Table 1. The mean age was 62.4 ± 8.5 years. Every patient had historical and electrocardiographic evidence of a previous transmural wall myocardial infarction. The majority of patients had New York Heart Association class III or IV CHF symptoms on maximal medical therapy. Forty patients (83%) who had anginal symptoms or evidence of reversible ischemia on stress perfusion imaging were offered CABG. The remaining 6 patients were found to have severe coronary artery disease requiring CABG in the presence of minimal or no angina. Moderate mitral regurgitation was preoperatively documented in 11 patients and ventricular arrhythmia in 9.


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  		Table 1. Preoperative and Operative Variables
 
Every patient underwent CABG. Sixteen patients underwent CABG and LVR concomitantly. Seven patients underwent CABG and mitral valve annuloplasty (MVP) for treatment of ischemic mitral insufficiency. Four patients underwent CABG, LVR, and MVP. Before 1998, isolated CABG was performed in patients with preoperative LVEF of less than 0.30 and LVESVI of greater than 100 mL/m2. Our previous report in 1998 [12] demonstrated that those patients with dilated ischemic cardiomyopathy had almost 50% of 5-year survival following isolated CABG. On the basis of the report, LVR was mainly performed in addition to CABG in patients with preoperative LVESVI of greater than 100 mL/m2 since 1998. Every patient involved in this study had a dilated LV with either a large akinetic scar or a large dyskinetic scar. Regardless of homogeneous akinetic scar or discrete dyskinetic aneurysm, patients with LVESVI of less than mL/m2 were excluded from this study.

There were three hospital deaths. Causes of hospital deaths were low output syndrome in 2 patients and cerebral infarction in one patient. Preoperative and postoperative left ventricular volumes in the remaining 45 patients were assessed by biplane cineventriculography with a 30 degree right anterior oblique and a 60 degree left anterior oblique projection. The LVESVI, left ventricular end-diastolic volume index (LVEDVI), and LVEF were calculated from the biplane data [16]. This method of calculation has been found to be superior to the area-length method [17] for evaluating LV volume. Perioperative information was obtained from hospital records. Follow-up information was obtained during patient visits to an outpatient facility at our medical center or by telephone interview. The mean duration of follow-up was 1,608 days. Complete follow-up data were obtained for all patients.

Surgical Technique
The procedure was performed under total cardiac arrest with tepid cold blood cardioplegia. In two cases the whole procedure was performed under ventricular fibrillation, because the ascending aorta was porcelain and unfeasible for cross-clamping. Coronary revascularization was first performed using one or two internal mammary arteries, saphenous veins, and the right gastroepiploic artery. Eleven patients underwent mitral annuloplasty using a rigid Carpentier-Edwards ring (Baxter Healthcare Corp, Irvine, CA), because moderate mitral regurgitation associated with ischemic tethering was preoperatively noted by an echocardiogram.

In 20 cases, the LV reconstructive portion of the operation was then carried out. The principle of the procedure was described as endoventricular circular patch plasty (EVCPP) by Dor and colleagues [18]. The LV was opened at the center of the scar and the endocardial scar was resected. In case the infarct segment was located in anteroapical and septal regions, the incision was parallel to the left anterior ascending artery following the description of the surgical anterior ventricular endocardial restoration (SAVER) procedure [19]. An encircling 2 to 0 monofilament suture was then passed around the endocardial fibrous scar to cinch the area and restore the normal internal ventricular curvature. The resulting orifice excluded the ventricular scar and became the platform for patch insertion. A Dacron circular (3 x 3 cm) or hemicircular (2 x 3 cm) patch was then anchored to the fibrotic tissue to close the orifice and reconstruct the internal cavity. The excluded external tissue was then folded over the patch to reinforce the suture line and provide additional hemostasis.

Statistical Analysis
Continuous variables are expressed as the mean plus or minus standard deviation. Continuous data were analyzed using the Student’s t test. Factors affecting long-term mortality were determined by univariate and multivariate analyses. To determine independent risk factors for long-term mortality, discrete data were analyzed using Fisher’s exact test or {chi}2 test. The analyzed variables are summarized in Table 1. Cox’s proportional hazards models then were used to identify independent factors. Variables that had a value of p less than 0.20 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 was done by the Kaplan-Meier method. In the actuarial survival analysis, both operative mortality and long-term mortality were taken into consideration. A log-rank test was used to evaluate differences in the survival between subgroups. A value of p less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The mean number of grafted vessels was 2.8 ± 1.2. The preoperative LVEF, LVESVI, and LVEDVI were 0.22 ± 0.06, 121 ± 28 mL/m2, and 156 ± 34 mL/m2, respectively. The postoperative LVEF, LVESVI, and LVEDVI were 0.33 ± 0.11, 83 ± 28 mL/m2, and 121 ± 27 mL/m2, respectively.

There were 3 hospital deaths and 17 late deaths during the follow-up period. Causes of hospital deaths were pump failure in 2 patients and cerebral infarction in 1 patient. Causes of late deaths were pump failure in 7 patients, de novo myocardial infarction in 2, ventricular arrhythmia in 5, cancer in 2, and cerebral infarction in 1 patient. Table 1 shows the preoperative and operative variables with the p values obtained by univariate analyses demonstrating independent risk factors for operative and late mortality. Table 2 demonstrates the results of Cox’s proportional hazards models identifying the LVR procedure as an independent factor which significantly prolonged the long-term survival. The models identified chronic renal failure as another independent factor, which significantly worsened the survival. The MVP did not significantly improve the survival. The 5-year actuarial survival shown in Figure 1 was significantly greater (p less than 0.05) following LVR (90% ± 11%) compared to isolated CABG (53% ± 17%). The LVR procedure significantly improved the 5-year survival in patients with ischemic cardiomyopathy, even though preoperative LVEF was less than 0.30 and preoperative LVESVI was greater than 100 mL/m2.


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  		Table 2. Risk Factors for Operative and Late Death
 


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  		Fig 1. The figure demonstrates the actuarial survival curves following left ventricular reconstruction (LVR) and isolated coronary artery bypass grafting (CABG). Numbers above the time axis indicate the numbers of patients at risk 0, 1, 3, and 5 years following operation. The survival following LVR was significantly greater compared to isolated CABG analyzed using the Kaplan-Meier method and a log rank test (p <0.05).

 
Table 3 shows perioperative changes of left ventricular dimension. When LVR was performed in addition to CABG with or without MVP, the postoperative LVEF (0.42 ± 0.09) showed significantly greater than that following isolated CABG (0.28 ± 0.07), although there was no significant difference in the preoperative LVEF between groups (0.21 ± 0.06 in isolated CABG patients vs 0.24 ± 0.07 in LVR patients). The preoperative LVEDVI (140 ± 19 mL/m2) and LVESVI (112 ± 21 mL/m2) in isolated CABG patients were significantly smaller than LVEDVI (178 ± 41 mL/m2) and LVESVI (137 ± 24 mL/m2) in LVR patients. The postoperative LVEDVI (111 ± 22 mL/m2) and LVESVI (65 ± 19 mL/m2) following LVR were significantly smaller than the LVEDVI (128 ± 30 mL/m2) and LVESVI (94 ± 28 mL/m2) following isolated CABG, although the preoperative LVEDVI and LVESVI in LVR patients were significantly larger than those in isolated CABG patients. The LVR procedure remarkably reduced LVESVI postoperatively, which was almost half of the preoperative LVESVI.


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  		Table 3. Preoperative and Postoperative Left Ventricular Dimension
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Postinfarction left ventricular remodeling is characterized by chamber dilatation and abnormal shape leading to systolic and diastolic dysfunction [20, 21]. After myocardial infarction, necrotic muscle is replaced by fibrous tissue. To compensate for loss of contractile function of the infracted segment the ventricular chamber dilates. It results in increased wall tension based on Laplace’ law, decreased systolic shortening, and increased oxygen consumption in areas remote from the original infarct. In some cases the infarct area shows little infarct expansion and it may take many years for adverse ventricular remodeling to occur. In other cases there is rapid development of an obvious dyskinetic aneurysm and heart failure symptoms. Recently, surgical approaches [18, 19] have been designed to abort and reverse remodeling, diminish heart failure, and improve survival. Surgical therapy achieves the following: relieves ischemia by coronary artery revascularization, diminishes ventricular volume, restores the ventricle to more normal geometry, and further diminishes volume overload by mitral valve repair.

According to the description by Dor and colleagues in 1985 [15], the EVCPP technique excludes akinetic or dyskinetic portions of the LV, reshapes the LV with a stitch that encircles the transitional zone between contractile and noncontractile myocardium, and uses a small patch to reestablish ventricular wall continuity at the level of the pursestring suture. The concept of EVCPP and geometric reconstruction is now more fully understood [18]. The LVR itself will improve LV performances for several reasons: (1) septal scar exclusion to decrease cavity size; (2) reorganization of angular architecture of the LV wall to reduce wall tension in remote myocardial areas, the resultant improved contraction of previously stretched viable muscle is clearly defined by analysis of pressure volume curves [22], associated with reduction of myocardial oxygen consumption and further enhances diastolic coronary flow; and (3) patch placement to avoid excessive reduction of volume that causes a restrictive defect; the rebuilt cavity will be of adequate size to maintain the appropriate diastolic capacity for functional activity.

In our previous report [12], a 5-year actuarial survival rate was only 53% following isolated CABG in patients with LVEF of less than 0.30 and LVESVI of greater than 100 mL/m2. The present study demonstrated 90% of a 5-year survival rate following LVR combined with CABG, even though all patients had an enlarged LV with EF of less than 0.30 and ESVI of greater than 100 mL/m2. The late result of LVR surpasses the result following isolated CABG and was comparable to the results reported by Dor and colleagues [18] and Mickleborough and colleagues [23]. Dor and colleagues [18] reported 7.3% of hospital mortality rate, 75% of a 5-year actuarial survival, and greater than 50% of a 10-year actuarial survival of the cohort of 870 patients with ischemic cardiomyopathy following the EVCPP procedure. Mickleborough and colleagues [23] also reported 2.6% of hospital mortality and 84% of a 5-year actuarial survival of greater than 200 patients following ventricular reconstruction using modified linear closure technique. Those reports demonstrated that LVR could be used with a 5-year mortality of approximately 20% in patients with end-stage ischemic cardiomyopathy with preoperative EF of less than 0.30 and CHF refractory to complete medical therapy. Dor and colleagues [24] and DiDonato and colleagues [25] emphasized that patients who benefited most from the EVCPP procedure were those with more severe preoperative ventricular dysfunction and larger LV volume, while a 5-year mortality of approximately 50% in those patients undergoing isolated CABG was reported.

Preoperative poor systolic function of LV has been demonstrated to be an independent predictor of late mortality following LVR as well as isolated CABG. DiDonato and colleagues [26] demonstrated preoperative LVESVI as a significant predictor of late mortality following LVR. Patients with LVESVI of greater than 120 mL/m2 had approximately 70% of a 5-year survival rate, which was significantly poorer compared to patients with LVESVI of below 120 mL/m2. Dor and colleagues [18] also demonstrated that greater than 80% of patients were alive at 10 years when preoperative LVESVI was below 90 mL/m2; however, survival percentage fell toward 50% in patients with preoperative LVESVI of greater than 120 mL/m2. In the present study, the 5-year survival was 90% following LVR, although the mean value of LVESVI in the series was 121 mL/m2. The results suggested that LV reconstruction, in addition to CABG, was beneficial in long-term survival of patients with LVESVI of greater than 100 mL/m2, despite the present study having an extremely smaller volume compared to the study by Athanasuleas and colleagues [27] with an entire volume of almost 800 patients. As shown in the results, LVR procedure remarkably reduced LVESVI postoperatively, likely to lead to the improvement in LV systolic function. The LVR procedure provided significantly smaller postoperative LV volume compared to isolated CABG, although the preoperative LV volume in LVR patients was significantly larger compared to isolated CABG patients.

Some disappointing late results occurred in this category of patients with large LV. In the series reported by DiDonato and colleagues [28], a tendency to increase the pulmonary pressure was noted in approximately 25% of patients following LVR surgery, associated with secondary progression of mitral insufficiency. They also reported that patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation. In the present series, four of the LVR patients underwent mitral surgery using a rigid annuloplasty ring. There was no recurrence or progression of mitral insufficiency in LVR patients. Another disappointing late cardiac-related event that has concerned many surgeons is ventricular arrhythmia. DiDonato and colleagues [29] initiated electrophysiologic preoperative and postoperative studies in an attempt to induce sustained ventricular tachycardia in candidates for LVR, and supplemented the surgical procedure with endocardiectomy and cryoablation. Their surgical management resulted in marked reduction of inducible ventricular tachycardia from 41% to 8%. In the present study, 9 patients had sustained ventricular arrhythmia refractory to medical therapy. Sudden death due to ventricular arrhythmia was documented in 5 patients following isolated CABG. Since capacity of revascularization alone to prevent recurrent ventricular tachycardia in dilated hearts is uncertain [30], in the next series of patients who preoperatively develop sustained ventricular arrhythmia with dilated heart we will adopt adequate endocardium resection and large encircling cryoablation during aneurysmectomy in addition to coronary revascularization.

We conclude that LVR contributed to improve the actuarial survival in those who had dilated ischemic cardiomyopathy with LVEF of less than 0.30 and LVESVI of greater than 100 mL/m2.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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