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Published on: July 14, 2021
Outcome of left ventricular surgical remodelling after the STICH trial
Antonio M Calafiore1, Angela L Iaco'2, Hatim Kheirallah2
1Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia am.calafiore@gmail.com.
Insights
Left ventricular surgical remodelling (LVSR) is indicated for patients with akinetic areas and chronic ischaemic mitral regurgitation (CIMR). Severe left ventricular diastolic dysfunction (LVDD) and emergency surgery are key risk factors for adverse outcomes.
Area of Science:
- Cardiovascular Surgery
- Heart Failure Management
- Clinical Outcomes Research
Background:
- The Surgical Treatment for Ischaemic Heart Failure (STICH) trial led to more restrictive indications for left ventricular surgical remodelling (LVSR).
- Real-world clinical practice has adapted to these changes, necessitating an evaluation of current LVSR outcomes.
- Understanding patient profiles and risk factors is crucial for optimizing surgical decision-making.
Purpose of the Study:
- To assess the outcomes of left ventricular surgical remodelling (LVSR) in the post-STICH trial era.
- To identify clinical and echocardiographic risk factors associated with early and mid-term outcomes after LVSR.
- To evaluate the impact of LVSR on ejection fraction and ventricular function.
Main Methods:
- A cohort of 113 patients undergoing LVSR between May 2009 and July 2014 was retrospectively analyzed.
- Data collected included patient demographics, preoperative clinical status, echocardiographic findings, and surgical procedures.
- Early and mid-term outcomes, including mortality and cardiovascular events, were assessed, with risk factor analysis performed.
Main Results:
- Most patients presented with chronic ischaemic mitral regurgitation (CIMR), severe symptoms (NYHA class III/IV), reduced ejection fraction (EF 26%), and akinetic areas.
- Severe left ventricular diastolic dysfunction (LVDD) was present in 33.6% of patients; 84.1% underwent concomitant mitral valve surgery.
- In-hospital mortality was 4.4%. Key risk factors for adverse outcomes included emergency surgery, severe LVDD, high bilirubin, and diabetes mellitus.
- At a median follow-up of 31 months, EF improved by 20%, but stroke volume remained unchanged. Severe LVDD was associated with poorer postoperative EF and higher end-systolic volumes.
Conclusions:
- Patients undergoing LVSR typically have akinetic areas and CIMR, requiring surgical correction due to severe symptoms.
- Severe LVDD and emergency surgical status are significant risk factors impacting both early and late outcomes after LVSR.
- LVSR can improve ejection fraction, but careful patient selection considering LVDD and emergency status is critical for optimizing results.
Objectives:
After the publication of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, surgical indications to left ventricular surgical remodelling (LVSR) have become more restrictive. The experience we report reflects the changes in the real world after the publication of STICH trial.
Methods:
From May 2009 to July 2014, 113 patients underwent LVSR, targeted mainly to the left anterior descending territory (89.4%). Of these, 18 patients (15.9%) were operated on an emergency basis. Early and mid-term outcomes were assessed to identify clinical and echocardiographic risk factors.
Results:
Most patients (90.3%) had chronic ischaemic mitral regurgitation (CIMR) and were in New York Heart Association (NYHA) class III/IV (77.9%). The median ejection fraction (EF) was 26% [95% confidence interval (CI): 26, 28] and scarred areas were akinetic (86.7%) in most cases. Severe left ventricular diastolic dysfunction (LVDD) was found in 33.6% of patients. Mitral valve surgery was performed in 84.1% of patients. Five patients (4.4%) died while in hospital, all from cardiac causes. Risk factors were abnormal bilirubin and emergency status. After a median follow-up of 12 (95% CI: 6, 18) months, 22 patients died, 17 from cardiac causes. Five-year freedom from death any from cause was 73 ± 5%, emergency status and MR Grade 4 being the only risk factors. Five-year freedom from death from any cause and NYHA class III/IV was 61 ± 6%. Severe LVDD and emergency status were risk factors, along with high bilirubin and diabetes mellitus on insulin. Five-year freedom from death from any cause and non-fatal cardiovascular events (rehospitalization, reoperation and stroke) was 55 ± 6%. LVDD and atrial fibrillation were found to be risk factors. After a median follow-up of 31 (95% CI: 19, 38) months, 91 patients underwent postoperative echocardiography. EF increased by 20%, but stroke volume remained unchanged. Postoperatively, patients with severe LVDD had lower EF and higher end-systolic volumes than patients without LVDD.
Conclusions:
Our findings show that patients, who are candidates for LVSR, have mostly akinetic areas and CIMR requiring surgical correction and are severely symptomatic. Severe LVDD is common and, along with emergency status, is the most important risk factor for early and late outcome.
