View metadata, citation and similar papers at core.ac.uk brought to you by CORE Ferrazzi et al Surgery for Acquired Cardiovascular Disease provided by Elsevier - Publisher Connector Surgical ventricular reverse remodeling in severe ischemic dilated cardiomyopathy: The relevance of the left ventricular equator as a prognostic factor Paolo Ferrazzi, MD, FETCS,a Marco L. S. Matteucci, MD,a Maurizio Merlo, MD,a Attilio Iacovoni, MD,a Giuseppe Rescigno, MD,a Matteo Bottai, PhD,b Piervirgilio Parrella, ScD,a Luca Lorini, MD,a Michele Senni, MD, FESC,a and Antonello Gavazzi, MD, FESCa Objectives: Surgical ventricular reverse remodeling has been shown to possibly improve hemodynamics and symptoms, but effects on long-term mortality are not established. No consistent data are available on which patients will benefit most from this procedure. This study was designed to analyze the predictors of long-term survival after surgical ventricular reverse remodeling in patients with ischemic cardiomyopathy. Methods: Eighty-five patients who underwent surgical ventricular reverse remod- eling between May 1991 and October 2003 were retrospectively analyzed. Left ventricular wall motion and left ventricular equatorial diameter were assessed by M. Senni, A. Iacovoni, M. Merlo, A. Gavazzi, P. Ferrazzi, L. Lorini (front), M. Matteucci means of angioventriculography. Left ventricular ejection fraction and volumes (back) (left to right) were measured by means of echocardiography. Cox regression analysis was used in several combinations to create a final model for identifying predictors of death. Supplemental material is available online. ACD Results: Actuarial survival after 1, 3, 5, and 10 years was 89%, 79%, 75%, and 75%, respectively. New York Heart Association class improved from 2.9 Ϯ 1.0 to 1.3 Ϯ 0.5 (P Ͻ .0001), left ventricular ejection fraction increased from 27.6% Ϯ 6.3% to 43.0% Ϯ 10.1% (P Ͻ .0001), and left ventricular end-systolic volume index decreased from 89.6 Ϯ 27.6 mL/m2 to 56.5 Ϯ 34.5 mL/m2 (P Ͻ .0001). Multivariate analysis identified left ventricular equatorial diameter of 70 mm or greater (hazard ratio, 5.28; 95% confidence interval, 1.79-11.71; P ϭ .020) and segmental akinesia (hazard ratio, 4.46; 95% confidence interval, 1.23-17.12; P ϭ .024) as the only independent predictors of death. Conclusions: In this analysis of a single cohort of patients, surgical ventricular reverse remodeling improves the symptoms of ischemic cardiomyopathy, as well as left ventricular function, shape, and volume, with encouraging long-term outcomes, particularly in patients with dyskinesia. A left ventricular equatorial diameter of 70 mm or greater appears to be an important independent prognostic factor, which From the Dipartimento Cardiovascolare suggests the relevance of the left ventricular equatorial region for effective surgical Clinico e di Ricerca,a Ospedali Riuniti Ber- gamo, Italy, and the Department of Epide- reverse remodeling. miology and Biostatistics,b Arnold School of Public Health, University of South Caro- lina, Columbia, SC. Address for reprints: Paolo Ferrazzi, MD, Dipartimento Cardiovascolare Clinico e di oronary artery disease is the most frequent cause of heart failure (HF) in Ricerca, Ospedali Riuniti, Largo Barozzi 1, Western countries.1 Despite improvements with medical treatment, the 24100 Bergamo, Italy (E-mail: pferrazzi@ 2 ospedaliriuniti.bergamo.it). Cprognosis of patients with end-stage HF remains poor. Although heart J Thorac Cardiovasc Surg 2006;131:357-63 transplantation is the best option for end-stage cardiomyopathy, this treatment is 0022-5223/$32.00 limited by a shortage of donors. Furthermore, in the subgroup with ischemic cardiomyopathy, both mortality on the waiting list and long-term results of heart Copyright © 2006 by The American Asso- 3,4 ciation for Thoracic Surgery transplantation are worse than in patients with idiopathic dilated cardiomyopathy. doi:10.1016/j.jtcvs.2005.10.008 These factors contributed to the development of surgical techniques with the aim of improving the function of the left ventricle. Left ventricular (LV) surgical reverse The Journal of Thoracic and Cardiovascular Surgery ● Volume 131, Number 2 357 Surgery for Acquired Cardiovascular Disease Ferrazzi et al fied on the basis of the available information (hospital records, Abbreviations and Acronyms death certificates, and statements from witnesses). Death was con- ACE ϭ angiotensin-converting enzyme sidered caused by progressive HF in cases of onset and progression HF ϭ heart failure of symptoms of definite HF. Sudden death was defined as death LV ϭ left ventricular within 1 hour of new symptoms or witnessed death without new LVEF ϭ left ventricular ejection fraction symptoms in the 72 hours preceding death. In-hospital mortality LVEqD ϭ left ventricular end-diastolic equatorial included any death occurring during hospitalization. diameter LVESVI ϭ left ventricular end-systolic volume index Echocardiography MLHF ϭ Minnesota Living With Heart Failure Echocardiographic studies were performed with a 2.5- or 3.5-MHz NYHA ϭ New York Heart Association transducer. Mitral regurgitation was assessed semiquantitatively as SVR ϭ surgical ventricular reverse remodeling grade 1ϩ to 4ϩ by means of color flow Doppler scanning. LVEF and LV volumes were calculated by using a modified version of Simpson’s rule.11 Preoperative data were obtained by reviewing reports. Follow-up assessment consisted of a complete 2-dimensional and Doppler echocardiographic study performed by a single operator restoration (surgical ventricular reverse remodeling [SVR]; who had no knowledge of the patients’ clinical status. surgical remodeling and ventricular reshaping) or surgical ventricular restoration5 has been found to improve symp- Cardiac Catheterization toms and ventricular function in patients with ischemic 6,7 All patients underwent preoperative ventricular angiography in the cardiomyopathy. This operative method benefits patients standard 30° right anterior oblique projection with injection of 0.7 with akinesia or dyskinesia of anterior LV segments and mL/kgϪ1 nonionic contrast medium at a rate of 12 mLsϪ1 filmed decreased LV function by reducing ventricular wall stress at 50 framessϪ1. Ventricular volumes were calculated by using the and restoring the spherical left ventricle to a more physio- Chapman monoplane method,12 and anterior regional wall motion logic elliptical shape.8 A recent registry of 1198 SVR pro- was analyzed with the centerline method13 to distinguish akinetic cedures performed in 13 centers worldwide indicates en- and dyskinetic segments. Regional wall motion was defined as couraging results.9 In this study different surgical teams dyskinetic if the absolute motion of contiguous chords was less used a variety of surgical techniques, and follow-up time than zero and akinetic if it was equal to zero. The LV end-diastolic was limited to 5 years. The ongoing Surgical Treatment for equatorial diameter (LVEqD) was measured as the LV transversal diameter at the midpoint of the longitudinal axis between the Ischemic Heart Failure trial was designed to address open 10 mitral plane and the LV apex on end-diastolic angioventriculo- and controversial issues about SVR in patients with HF. graphic frames. The mean of 3 measurements obtained during 3 We thought it would be worth reviewing our series of SVR different cardiac cycles was calculated for each patient and used before we entered this trial in November 2003 to identify for the subsequent statistical analysis. any factors that could help in predicting outcomes. Because this series represents our whole 12-year experience with Operative Technique SVR, it might also provide some useful long-term follow-up The aim of the operation was to exclude all asynergic areas of the information. ventricle, restoring a more physiologic elliptical geometry and LV volume. All patients underwent SVR either through the Dor pro- Methods cedure or a modified Dor-type technique (without the Dacron Patient Population patch).14-16 Between May 1991 and October 2003, 122 patients with LV Coronary artery bypass grafting, mitral valve repair or replace- dysfunction caused by coronary artery disease underwent SVR. ment, biventricular pacing, and/or automatic cardioverter device Excluded from the analysis were patients with posterior akinetic or implantation were carried out as necessary. A single surgeon dyskinetic LV segments (n ϭ 18), patients with an LV ejection performed most (82%) of the operations. fraction (LVEF) of greater than 35% (n ϭ 10), patients undergoing the Batista procedure (n ϭ 4), patients with an associated aortic Statistical Analysis valve replacement (n ϭ 2), patients with postinfarction ventricular Results are presented as mean values Ϯ standard deviation or septal defect closure (n ϭ 2), and a child previously operated on frequency percentages. Baseline and follow-up findings were com- for arterial switch repair for transposition of the great arteries with pared by using the Wilcoxon signed-rank nonparametric test for a postischemic LV aneurysmectomy. The remaining 85 patients continuous variables and the Fisher exact test for categoric vari- were the subjects of the study. ables. Because of the relatively small size of the sample and few Functional status was evaluated by using the New York Heart events, we estimated several Cox proportional hazard models of Association (NYHA) classification, and quality of life was as- analysis (no more than 6 variables at a time), removing and adding sessed through a self-administered