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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector RESULTS AFTER PARTIAL LEFT VENTRICULECTOMY VERSUS HEART TRANSPLANTATION FOR IDIOPATHIC CARDIOMYOPATHY Steven W. Etoch, MD Objective: Partial left ventriculectomy has been introduced as an alterna- Steven C. Koenig, PhD tive surgical therapy to heart transplantation. We performed a single- Mary Ann Laureano, RN center, retrospective analysis of all patients with idiopathic dilated car- Pat Cerrito, PhD diomyopathy who underwent partial left ventriculectomy or heart Laman A. Gray, MD Robert D. Dowling, MD transplantation or who were listed for transplantation to determine operative mortality rate, 12-month survival, freedom from death on the heart transplantation waiting list, and freedom from death or need for relisting for heart transplantation. Methods: Patients who had partial left ventriculectomy (October 1996 to April 1998) were retrospectively com- pared with patients who were listed for heart transplantation (January 1995 to April 1998). Survival was assessed after the surgical procedure (partial left ventriculectomy vs heart transplantation) and from time of listing for heart transplantation to assess the additional impact of wait- ing list deaths. Freedom from death or relisting for heart transplanta- tion was also compared. Results: There was no difference in age or United Network for Organ Sharing status between the 2 groups. Twenty-nine patients with idiopathic dilated cardiomyopathy were listed for heart transplantation; 17 patients underwent transplantation, 6 patients died while on the waiting list, and 6 patients remain listed. One patient died after heart transplantation, and 1 patient required relisting. Sixteen patients had partial left ventriculectomy; 10 patients are in improved condition, 2 patients died (1 death early from sepsis and 1 death from progressive heart failure), and 4 patients required relisting for heart transplantation. Operative survival was 94% after partial left ven- triculectomy and 94% after heart transplantation (P = .92). Post- operative 12-month Kaplan-Meier survival was 86% after partial left ventriculectomy and 93% after heart transplantation (P = .90). Twelve- month Kaplan-Meier survival after listing for heart transplantation was 75% due to death while on the waiting list (P = .76). Freedom from death or need for relisting for heart transplantation was 56% after partial left ventriculectomy and 86% after transplantation (P = .063). Conclusion: Operative and 12-month survival after partial left ventriculectomy and heart transplantation were comparable. However, despite their initial improvement, many patients who underwent partial left ventriculectomy required relisting for transplantation. Although partial left ventriculec- tomy is associated with acceptable operative and 12-month survival, it may prove to serve better as a bridge to transplantation in patients with idiopathic dilated cardiomyopathy rather than definitive therapy, given the number of patients who required relisting for transplantation. (J Thorac Cardiovasc Surg 1999;117:952-9) From the Department of Surgery, Division of Cardiothoracic Surgery, Address for reprints: Steven W. Etoch, MD, Division of University of Louisville, Louisville, Ky. Cardiothoracic Surgery, 201 Abraham Flexner Way, Suite 1200, Read at the Twenty-fourth Annual Meeting of The Western Thoracic Louisville, KY 40202. Surgical Association, Whistler, British Columbia, June 24-27, 1998. Received for publication July 15, 1998; revisions requested Aug 17, Copyright © 1999 by Mosby, Inc. 1998; revisions received Jan 12, 1999; accepted for publication Jan 13, 1999. 0022-5223/99 $8.00 + 0 12/6/97227 952 The Journal of Thoracic and Etoch et al 953 Cardiovascular Surgery Volume 117, Number 5 rthotopic heart transplantation (OHT) remains the Cox regression were used to compare the postoperative PLV O standard with which all other alternative surgical and OHT groups statistically (SAS Institute, Cary NC), therapies for the treatment of end-stage cardiomy- where the initial time (t = 0 days) was defined as the date of opathies are compared. Today with the current prac- the procedure (PLV or OHT). A secondary objective was to tices of immunosuppression and the use of surveillance compare postoperative survival after PLV with survival from the time of listing for OHT. The Kaplan-Meier method was endomyocardial biopsy, survival after OHT is 84% at 1 2 1 used to estimate survival. Log-rank statistics and Cox year and 74.5% at 3 years in the United States. Despite regression were used to compare the PLV and OHT groups, these appealing results, only a small percentage of where the initial time (t = 0 days) was defined as the date of patients who could potentially benefit will receive OHT the procedure (PLV) and the date of listing for OHT. A third because of the shortage of donor supply, the strict objective was to compare postoperative survival and freedom selection criteria, and the substantial financial consid- from relisting for OHT between patients who had a PLV or erations. Recently, partial left ventriculectomy (PLV) OHT surgical procedure. The Kaplan-Meier method was was introduced by R. J. V. Batista, MD, of Curitiba, used to estimate postoperative survival and freedom from Brazil, as an alternative surgical therapy for the treat- relisting rates for the PLV and OHT groups.2 Log-rank statis- ment of patients with end-stage dilated cardiomyopa- tics and Cox regression were used to compare the postopera- thy. To date, little is known about the potential benefits tive survival and freedom from relisting for OHT for the PLV and OHT groups, where the initial time (t = 0 days) was or the long-term results of this procedure. We therefore defined as the date of the procedure (PLV or OHT). performed a single-center, retrospective analysis of all Our operative technique for PLV has previously been de- patients with idiopathic dilated cardiomyopathy scribed and is reviewed here for completeness.3 Echo- (IDCM) who underwent OHT or PLV to determine cardiographic assessment of LVEDD was determined before operative mortality rates, 12-month survival, and free- the operation with a transgastric short axis view for assess- dom from death or need for relisting for OHT. ment of the interpapillary muscle distance to determine whether resection of the lateral wall between the papillary muscles would be adequate to decrease the LVEDD to Methods approximately 6 cm or less. If resection of the interpapillary From October 1996 to April 1998, all patients evaluated muscle would not result in adequate decrease in LVEDD, a with end-stage heart failure as the result of IDCM were con- decision was made to proceed with either mitral valve sidered potential candidates for PLV. All of these patients replacement or mitral valve repair with reimplantation of the underwent a complete heart transplantation evaluation, which papillary muscle. There were no strict guidelines for deciding included exercise oxygen consumption, dobutamine echocar- between repair and replacement. However, if we planned to diography, and quality of life questionnaire. Patients with resect more than 3 cm posterior to the posterior papillary IDCM, left ventricular end-diastolic diameter (LVEDD) muscle, mitral valve replacement was performed through the greater than 7 cm, New York Heart Association (NYHA) class left ventriculotomy. Tricuspid valve annuloplasty was per- IV symptoms despite maximal medical therapy, and severely formed for significant (>2+) regurgitation. impaired exercise oxygen consumption were considered can- A median sternotomy was performed with standard aortic didates for PLV. Patients were not excluded from PLV on the and bicaval cannulation, and cardiopulmonary bypass was basis of right ventricular dysfunction, elevated transpul- initiated. The tricuspid valve was repaired on the beating monary gradient, presence of incidental coronary disease, heart. For patients who required mitral valve repair, the mitral need for inotropic agents, or an intra-aortic balloon pump. valve was exposed through a standard left atriotomy after Patients who met all criteria for both OHT and PLV were arrest of the heart with antegrade and retrograde cardioplegia. given both options. Patients who did not meet the require- Standard annuloplasty with a Physio ring (Baxter Carpentier- ments for transplantation were given the option of PLV or Edwards; Baxter Health Care Corp, Irvine Calif) was per- continued maximal medical management. This study was formed by downsizing the ring by 1 or 2 sizes to ensure ade- approved by the Institutional Review Boards of the quate leaflet coaptation and thereby prevent central University of Louisville and Jewish Hospital, Louisville, regurgitation. After completion of the mitral valve repair, a Kentucky. All of the follow-up studies were performed at warm dose of cardioplegic solution was given, and the aortic Jewish Hospital, Louisville, Kentucky.3 crossclamp was released. An incision was then made in the Patients who had PLV were retrospectively compared with left ventricle to the left of the left anterior descending artery all patients with IDCM who were listed for OHT from and 3 cm proximal to the apex. The position of the papillary January 1995 to April 1998. Age, gender, United Network for muscles was determined, and an incision was extended along Organ Sharing (UNOS) status, and death were identified for the base of the anterior papillary muscle to within
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