Volume reduction rate by surgical ventricular restoration determines late outcome in ischaemic cardiomyopathy

Abstract

AimsSurgical ventricular restoration (SVR) effectively reduces left ventricular (LV) volume in ischaemic cardiomyopathy (ICM), but the recent Surgical Treatment of Ischemic Heart Failure (STICH) Trial questions its importance. We report 8-year SVR experience in patients with ICM. Methods and resultsBetween 2000 and 2008, 135 patients underwent SVR for ICM. This report analyses data from 90 patients who underwent accurate pre-and post-operative assessment of LV volumes by left ventriculogram or scintigram. All patients also had echocardiograms. Pre-operative LV end-systolic volume index (ESVI) was 123.5 + 53.2 mL/m 2 (range 92-310). Overall, 63 patients were in NHYA class III and 27 were in class IV. The SVR procedure was endoventricular circular patch plasty in 33 patients, septal-anterior ventricular exclusion in 43, and 14 patients had posterior exclusion. Coronary artery bypass grafting was performed in 78 patients (87%) and 50 underwent mitral procedures. Eighteen follow-up late deaths occurred owing to chronic heart failure (n ¼ 12) and sudden death (n ¼ 6). Post-operative ESVI was ,90 mL/m 2 (Group-S) in 54 patients, 90 -120 mL/m 2 (Group-M) in 16, and.120 mL/m 2 (Group-L) in 20 patients. The 8-year survival rate was 82.4% in group-S following a .33% LV volume reduction. In contrast, in Group-M and Group-L, the volume reduction was 15%, and 100% of patients died within 7 years following the SVR procedure (or 0% 8-year survival). ConclusionsSVR is most effective when a .33% volume reduction rate achieves an ESVI of ,90 mL/m 2 . No long-term benefits occur when SVR induces an LV volume reduction of ,15% leaving a residual ESVI .90 mL/m 2 . This database contradicts the STICH trial findings.--

Surgical Ventricular Restoration for Ischemic Cardiomyopathy with Functional Mitral Regurgitation

“…More recently, we have suggested the effectiveness of SVR for patients with ICM 51) . According to our results, SVR is most effective when a >33% volume reduction rate achieves an LVESVI of <90 ml/m 2 .…”

The Ultimate Goals of Surgical Ventricular Reconstruction

“…However, in the Surgical Treatment for Ischemic Heart Failure (STICH) trial, adding surgical ventricular restoration (SVR) to coronary artery bypass grafting (CABG) did not result in any improvement in survival or ventricular function, even though SVR achieved greater LV end-systolic volume index (LVESVI) reduction, by 19% as a whole, as compared to the 6% achieved with CABG alone 2) . As a benchmark 30% post-SVR volume reduction, which could impact the prognosis, has been reported 3) , a 19% volume reduction seems to be modest. Many subanalyses of the STICH results have been performed, and it has become clear which patient group has benefitted the most from SVR.…”

“…Isomura et al 3) performed a retrospective analysis of 135 ischemic cardiomyopathy patients who underwent SVR. They concluded that SVR is most effective when a >33% volume reduction rate achieves an LVESVI of <90 ml/m 2 , and no long-term benefits occur when SVR induces an LV volume reduction of <15%, leaving a residual LVESVI >90 ml/m 2 .…”

Estimating postoperative left ventricular volume: Identification of responders to surgical ventricular reconstruction

“…2 In fact, the postoperative LV end-systolic volume index (ESVI) <60 ml/m 2 , a >30% ESVI reduction, and >33% ESVI reduction with a resultant postoperative ESVI <90 ml/m 2 are considered to be desired goals of SVR, since these are associated with lower mortality rates after SVR. [3][4][5] On the other hand, the postoperative ESVI <70 ml/m 2 could demarcate candidates for SVR, because this is associated with a higher survival rate for those with CABG plus SVR than those with CABG alone. 4 However, the volume reduction effect by SVR has limits.…”