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Published on: April 8, 2013
Left ventricular volume reduction and reconstruction in ischemic cardiomyopathy
R García-Rinaldi1, E R Soltero, J Carballido
1The Pavia Heart Institute, San Juan, Puerto Rico, USA. garciarinald@isla.net
Insights
Surgical reduction of left ventricular volume improves function in end-stage ischemic cardiomyopathy. Conservative approaches, unlike extensive resections, significantly reduce mortality, leading to better patient outcomes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Ischemic cardiomyopathy results from myocardial infarctions or hibernation.
- Patients with end-systolic volume index >100 mL/m² require ventricular volume reduction surgery.
- Various surgical techniques exist for ventricular volume reduction.
Purpose of the Study:
- To evaluate the efficacy and safety of different left ventricular volume reduction techniques.
- To compare mortality rates associated with extensive versus conservative resection methods.
- To assess long-term outcomes in patients with end-stage ischemic cardiomyopathy undergoing these procedures.
Main Methods:
- Forty-eight patients with end-stage ischemic cardiomyopathy (Class III-IV) underwent surgery.
- Procedures included coronary revascularization, mitral valve repair/valvoplasty, and various left ventricular volume reduction techniques.
- Techniques comprised interpapillary, anterior, posterior resections, and endocavitary patch reconstruction.
Main Results:
- All techniques improved left ventricular function.
- Extensive resections (interpapillary, anterior, posterior) showed a 43% mortality rate.
- Limited resection or endocavitary patch reconstruction resulted in a 12.5% mortality rate.
- A shift to conservative approaches reduced mortality from 26% to 13%.
Conclusions:
- Ischemic cardiomyopathy with end-systolic volume index >100 mL/m² has a poor prognosis without intervention.
- Aggressive ventricular resections improve function but carry high mortality.
- Conservative resections and endocavitary patches significantly reduce mortality.
- Surgical therapy is feasible, with survivors remaining in functional Class I-II up to 30 months post-surgery.
Background:
Ischemic cardiomyopathy can be the result of large or small myocardial infarctions or due to myocardial hibernation. Patients with an end-systolic volume index >100 mL¿m2 do not benefit from revascularization alone and require an operation that reduces ventricular volume. Various approaches to reduce ventricular volume have been described. We applied several of these techniques in patients with end-stage ischemic cardiomyopathy.
Methods:
Forty eight patients with end-stage ischemic cardiomyopathy (Class III-IV) underwent left ventricular volume reduction operations with coronary revascularization and mitral valve repair or Alfieri valvoplasty. Fourteen patients underwent interpapillary resections, 22 anterior resections, 4 posterior resections, 2 anterior and posterior resections, and 6 patients reduction of left ventricular volume with endocavitary patches.
Results:
All the techniques used improved left ventricular function. Analysis of mortality revealed that extensive resections (interpapillary, anterior, and posterior resection) had a 43% mortality. However, a limited resection or a ventricular reconstruction with an endocavitary patch had only a 12.5% mortality. When we changed our approach to a more conservative one, mortality was reduced from 26% the first 12 months to 13% in the last 15 months of the study.
Conclusions:
Ischemic cardiomyopathy has a poor prognosis if the end-systolic volume index exceeds 100 mL/m2. Various procedures exist to reduce left ventricular volume. Extensive ventricular resections improve ventricular function, but have a high mortality. This led us to use other methods of ventricular volume reduction such as more conservative resections combined with left ventricular reconstructions or ventricular volume reduction with endocavitary patches. Mortality was reduced significantly by this approach. The patients that survived have remained Class I-II in a follow-up that extends up to 30 months. Surgical therapy of Class III-IV ischemic cardiomyopathy is feasible, but aggressive ventricular resections have a high mortality. We advocate a more reconstructive approach with limited or no ventricular resection.
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