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Left ventricular reconstruction benefits patients with ischemic cardiomyopathy and non-viable myocardium
Gustavo Aguiar Ribeiro1, Cledicyon Eloy da Costa, Mauricio M Lopes
1Clinic of Cardio-Surgery at Campinas, Rua Jose Teodoro de Lima 77, ap 62, Cambuí, 130150-150 Campinas, Brazil. gcar@hotmail.com
Insights
Coronary artery bypass grafting plus ventricular restoration significantly improves outcomes in patients with ischemic cardiomyopathy and large left ventricles compared to bypass surgery alone. This combined approach enhances ejection fraction and reduces heart failure symptoms.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Ischemic cardiomyopathy presents complex treatment challenges, particularly regarding optimal surgical strategies for subsets of patients.
- Left ventricular dysfunction, characterized by reduced ejection fraction and increased end-systolic volume, significantly impacts patient prognosis.
Purpose of the Study:
- To compare clinical outcomes of coronary artery bypass graft (CABG) alone versus CABG with additional ventricular restoration in patients with ischemic cardiomyopathy.
- To evaluate the impact of myocardial viability on treatment outcomes in patients undergoing surgical intervention.
Main Methods:
- A cohort of 137 patients with anterior myocardial infarction, ejection fraction <50%, and left ventricle end-systolic volume index >80 ml/m² were analyzed.
- Patients were stratified into viable and non-viable myocardium groups based on thallium-201 testing.
- Viable myocardium groups were randomized to CABG alone (Group 1a) or CABG plus ventricular restoration (Group 1b); non-viable groups underwent CABG plus ventricular reconstruction (Group 2).
Main Results:
- At 2-year follow-up, ejection fraction improvement was significantly greater in Group 1b (CABG + ventricular restoration) compared to Group 1a (CABG alone).
- Group 1b demonstrated significantly smaller end-systolic volumes and reduced mitral regurgitation compared to Group 1a.
- Heart failure symptoms (NYHA class) decreased in all groups, with better outcomes in patients with end-systolic volume <120 ml/m².
Conclusions:
- Coronary artery bypass surgery combined with ventricular restoration yields superior short-term and mid-term clinical outcomes compared to coronary artery bypass surgery alone in patients with large left ventricles.
- Ventricular restoration is a valuable adjunct to CABG in selected patients with ischemic cardiomyopathy, improving ventricular remodeling and functional status.
Objective:
There are subsets of patients with ischemic cardiomyopathy for whom the optimal treatment strategies are not clear. The objective of this study was to delineate the relationship between clinical outcomes and surgical procedure in patients who were treated either with a coronary artery bypass graft or with a coronary artery bypass graft and additional ventricular restoration.
Methods:
The study population comprised 137 consecutive patients with anterior myocardial infarction. All patients had an ejection fraction <50% and left ventricle end-systolic volume index >80 ml/m(2). The patients were divided into a viable and a non-viable group according to anterior myocardium viability, which was determined by a thallium-201 test. The viable group underwent a revascularization and was randomized into two groups for additional ventricular reconstruction. Group 1a comprised 35 patients with viable anterior wall who underwent surgical revascularization. Group 1b comprised 39 patients with viable anterior wall who underwent surgical revascularization and ventricular restoration. Group 2 comprised 69 patients with non-viable anterior wall who underwent revascularization and ventricular reconstruction. The preoperative and postoperative ejection fractions, end-systolic volume, mitral regurgitation, mortality, and heart failure symptoms were compared among groups.
Results:
Complete 2-year follow-up was achieved in 127 (92.7%) patients. Ejection fraction improved in all groups compared with preoperative values and it was greater in group 1b than in group 1a (p<0.001) at 2 years. There were no postoperative deaths in group 1a, one in group 1b, and two in group 2. After 2 years, group 1b was significantly smaller than group 1a (p<0.01) in relation to mitral regurgitation of grades 1 to 2+. End-systolic volume was significantly smaller in group 1b than in group 1a (p<0.001), it was smaller in group 1a than in group 2 (p<0.001), and it was smaller in group 1b than in group 2 (p<0.001). Heart failure class (NYHA) was reduced in all groups and events were significantly smaller in patients with end-systolic volume lesser than 120 ml/m(2) (p<0.05).
Conclusion:
We have demonstrated that the short-term and mid-term outcomes of coronary artery surgery alone in patients with a large left ventricle are inferior to coronary artery surgery plus ventricular restoration.
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