Surgical ventricular remodeling for multiterritory myocardial infarction: defining a new patient population
Nishant D Patel1, Jason A Williams, Christopher J Barreiro
1Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md, USA.
Insights
Surgical ventricular remodeling improved cardiac function and functional status in patients with multiterritory myocardial infarction. This procedure offers a promising option for high-risk heart failure patients, expanding treatment possibilities.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Limited options exist for end-stage congestive heart failure.
- Multiterritory myocardial infarction (MI) patients were historically high-risk.
- Surgical ventricular remodeling (SVR) criteria were expanded to include these patients.
Purpose of the Study:
- To evaluate the efficacy of SVR in patients with multiterritory MI.
- To propose a new patient population benefiting from SVR.
- To assess outcomes and identify risk factors in this cohort.
Main Methods:
- Retrospective analysis of 51 consecutive SVR patients (Jan 2002-June 2004).
- Defined three left ventricular vascular territories for infarction assessment.
- Used MRI and intraoperative findings to assess infarction extent.
Main Results:
- 64.7% of patients had multiterritory MI (33/51), with 61% in all three territories.
- SVR significantly improved left ventricular volumes and ejection fraction.
- Operative mortality (6.1%) did not differ from single-territory MI patients; 69% improved NYHA class.
Conclusions:
- SVR improves cardiac function and functional status in multiterritory MI patients.
- Initial results are promising for expanding SVR inclusion criteria.
- Further studies are warranted to confirm these findings and broaden patient selection.
Objective:
Because of limited medical and surgical options for patients with end-stage congestive heart failure, we expanded the criteria for surgical ventricular remodeling to include patients with multiterritory myocardial infarction, a group historically considered high-risk candidates. We present our series of patients with multiterritory myocardial infarction who underwent surgical ventricular remodeling and propose a new patient population who may benefit from this procedure.
Methods:
Data were analyzed for 51 consecutive patients undergoing surgical ventricular remodeling from January 2002 to June 2004, with 100% follow-up. Three left ventricular vascular territories were defined: anteroapicoseptal (left anterior descending), lateral (circumflex), and inferior (right coronary artery). Infarction was assessed with magnetic resonance imaging and intraoperative findings.
Results:
Multiterritory myocardial infarction was found in 64.7% of patients (33/51) undergoing surgical ventricular remodeling. Mean age was 61.6 +/- 11.1 years (range 40-81 years). Sixty-one percent (20/33) demonstrated evidence of myocardial infarction in all three territories. Five patients underwent concomitant mitral valve repair or replacement. Operative mortality was 6.1% (2/33) and did not differ from that of patients with single-territory infarction (11.1%, P = .61). Surgical ventricular remodeling significantly improved left ventricular volumes and ejection fraction in patients with multiterritory myocardial infarction. Three patients required assist device implantation, and 2 patients required defibrillator placement. Sixty-nine percent of patients in preoperative New York Heart Association functional class III or IV (22/32) had improvement to class I or II at follow-up (P < .01). Cox regression analysis discriminated a preoperative left ventricular end-systolic volume index greater than 100 mL/m(2) as a significant risk factor for mortality (odds ratio 12.1, 95% confidence interval 1.27-114.51, P = .03). Thirty-month survival of patients with multiterritory myocardial infarction (73.5% +/- 8.3%) did not differ statistically from that of patients with single-territory infarction (n = 18).
Conclusion:
Surgical ventricular remodeling improves cardiac function and New York Heart Association functional status in patients with multiterritory myocardial infarction. Our initial results are promising and should prompt further studies to confirm our results and potentially expand the surgical ventricular remodeling inclusion criteria to include patients with multiterritory myocardial infarction.
