Severe ischemic cardiomyopathy with mechanical complications: Still a surgical disease

Surgical treatment of ischemic cardiomyopathy (ICM) with mechanical complications has been limited in favor of suboptimal treatments because of the perception of poor outcome.

From May 2009 till June 2014 115 patients with severe ICM (ejection fraction, EF, ≤25%) and mechanical complications were operated on. Median EF was 24% (19, 24), mean end-systolic volume index (ESVi) was 86±27ml/m² and all patients had an MR grade of 2 or more. The right ventricle (RV) was hypokinetic in 33 patients. All of them underwent mitral valve surgery. Left ventricular (LV) surgical remodeling was performed in 60 patients (52.2%) and tricuspid surgery in 58 (50.4%). In-hospital mortality was 4.3% (5 patients). Six-year freedom from death any cause and from death any cause and NYHA class III/IV were, respectively, 70.5±4.9% and 66.4±4.8%. Cox regression analysis showed that risk factors were lower EF (cutpoint≤20%) and RV hypokinesia. Eighty-six patients had a follow up echocardiogram after a median of 31 (19, 51) months. EF increased by 60%, from 24 (19, 24) to 35 (27 ,46) (p=0.00), and ESVi decreased by 32%, from 87±29 to 59±27ml/m² (p=0.00). SVi increased by 32%, from 23±7 to 32±12ml/m². MR grade was ≥2 only in 6 patients (7%) and was not severe in any of them.

Surgery for severe ICM with MR can be performed with low surgical risk and good midterm survival. These findings have to be taken into account while abandoning a clear surgical indication in favor of suboptimal alternative therapies.