Severe ischemic cardiomyopathy with mechanical complications: Still a surgical disease.

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

Outcome of left ventricular surgical remodelling after the STICH trial.

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.

Bilateral internal mammary artery grafting: in situ versus Y-graft. Similar 20-year outcome.

OBJECTIVE: The aim of this study was to evaluate the 20-year clinical outcome of patients undergoing coronary artery bypass grafting with bilateral internal mammary arteries (BIMAs) using two different configurations, in situ versus Y-graft. METHODS: From September 1991 to December 2002, 2150 patients with multivessel coronary artery disease underwent isolated myocardial revascularization with BIMA grafting. BIMA was used as an in situ or Y-configuration in 1332 and 818 cases, respectively. A propensity score model was applied to calculate a standardized difference of ≤10% between groups (BIMA in situ vs BIMA Y-graft), and a cohort of 1468 matched patients was identified (734 in each group). Death, non-fatal myocardial infarction and the need for repeat revascularization were defined as 'major adverse cardiac events'. RESULTS: Late mortality was 24.3% (n = 357) [BIMA in situ vs BIMA Y-graft: 26.9% (n = 197) vs 21.8% (n = 160)]; in 11.6% (n = 170) of cases death was due to cardiac causes [11.9% (n = 87) vs 11.3% (n = 83)]. The rate of major adverse cardiac events was 37.1% (n = 545) [40.8% (n = 299) vs 33.5% (n = 246)]. The 20-year survival was 59 ± 6% and the event-free survival was 45 ± 7%. CONCLUSIONS: The clinical outcome of BIMA grafting is independent of surgical configuration. Y-grafting increases the flexibility of BIMA grafting and should be taken into account when a surgical strategy for myocardial revascularization needs to be planned.

A giant pseudoaneurysm of the left anterior descending coronary artery related to Behçet disease.

We report the case of a young patient with a recent diagnosis of Behçet disease, in whom the left anterior descending coronary artery was found fully open into a giant pseudoaneurysm, with occlusion of the distal segment. Surgical treatment included opening of the pseudoaneurysm with clot and fibrous tissue removal, proximal left anterior descending coronary artery closure, and distal left anterior descending coronary artery grafting. In patients with Behçet disease, it is advisable to perform computed tomography coronary angiography to rule out the presence of coronary artery disease and the occurrence of a rare but potentially life-threatening complication.

Left ventricular surgical remodelling: is it a matter of shape or volume?.

OBJECTIVE: Left ventricular surgical remodelling (LVSR) can be targeted to volume reduction (VR), (independently of the final shape) or to conical shape (CS). The aim of this study was to evaluate the long-term clinical and echocardiographic results of these two surgical strategies. METHODS: From January 1988 to December 2012, 401 patients underwent LVSR: 107 in Group VR (1988-2001) and 294 in Group CS (1998-2012). The latter group of patients had lower ejection fraction (EF) and higher mitral and tricuspid regurgitation grade, with higher incidence of pulmonary hypertension. A propensity score model was built to adjust long-term results for preoperative and operative profiles. RESULTS: Thirty-day mortality was 6.0%. Median follow-up interval time was 100 (3-300) months. Overall 20-year and event-free survival were 36.1 ± 7.8 and 19.4 ± 7.2, respectively. No differences were found regarding 10-year survival (Group VR: 55.1 ± 4.8 vs Group CS: 64.2 ± 4.2, P = 0.16) and event-free survival (Group VR: 41.1 ± 4.8 vs Group CS: 50.5 ± 4.8, P = 0.12). However, Group CS provided better 10-year freedom from cardiac deaths (74.5 ± 3.7 vs 60.4 ± 4.8, P = 0.03) and from cardiac events (55.6 ± 5.0 vs 45.0 ± 4.9, P = 0.04). After propensity score adjustment, all the main outcomes were significantly better in Group CS. Multivariate Cox analysis confirmed this result; furthermore, to avoid any bias related to improved experience, 30-day mortality being higher in Group VR, we excluded the first month from Cox analysis: left ventricle VR (independently of the final shape) was still confirmed as the wrong approach. At the follow-up, Group CS showed significant improvement in EF (+18 vs +8%), end-systolic volume index (-35 vs -20%) and sphericity index (-6 vs +9%). CONCLUSIONS: LVSR should aim to provide a more physiological shape (conical) rather than simple VR.

Bilateral internal mammary artery for multi-territory myocardial revascularization: long-term follow-up of pedicled versus skeletonized conduits.

OBJECTIVES: The aim of this study was to evaluate 17-year actual clinical outcomes of patients undergoing coronary artery bypass graft (CABG) using skeletonized versus pedicled bilateral internal mammary arteries (BIMAs). METHODS: From September 1991 to June 1996, 548 consecutive patients underwent CABG for multivessel disease using BIMA. After propensity matching, 350 patients were enrolled: 175 patients with skeletonized BIMA (Group S) and 175 with pedicled BIMA (Group P). The two groups were adequately comparable. Composite end-point: deaths, new revascularization and new myocardial infarctions were defined as 'events'. RESULTS: Group S provided a higher rate of total arterial myocardial revascularization (94.3 vs 82.9%, P 0.001) with a higher average number of arterial anastomoses (3.1 ± 0.8 vs 2.7 ± 0.8, P < 0.001) and BIMA anastomoses (2.5 ± 0.3 vs 2.1 ± 0.3, P < 0.001). In Group S, the incidence of sequential grafts was higher (37.7 vs 17.7%, P < 0.001). The rate of sternal wound healing problems was lower (1.7 vs 7.4%, P = 0.010). Thirty-day mortality and morbidity were similar. The median survival time of survivors was 17.8 years (min-max = 17.0-21.5); 17.3 (17.0-18.0) in Group S vs 19.1 (18.1-21.5) in Group P, P < 0.001. Seventeen-year actual outcomes were better in Group S: deaths (8.7 vs 27.9%, P < 0.001), cardiac deaths (4.7 vs 13.4%, P = 0.005), cardiac events (10.5 vs 22.1%, P = 0.003), new revascularization (2.9 vs 8.7%, P = 0.021) and events (15.1 vs 36.1%, P < 0.001). CONCLUSIONS: Skeletonization of BIMA allows one to achieve a higher rate of arterial grafting and better outcome if compared with pedicled BIMA.

A novel and simple technique for correction of posterior leaflet prolapse due to chordal elongation or rupture.

OBJECTIVE: The study objective was to evaluate the midterm results of a technique for correction of posterior leaflet prolapse without resection or use of artificial chordae. METHODS: From May 2009 to October 2013, 96 patients with isolated posterior leaflet prolapse (n=36) or bileaflet prolapse (n=60) with or without chordal rupture underwent posterior leaflet repair at the Prince Sultan Cardiac Center. The novel Uniscallop ("U") technique was used in 46 patients (group U), based only on scallop suture without resection or artificial chordae application. A conventional approach (quadrangular or triangular resection, focal sliding, artificial chordae) was adopted in the remaining 50 patients (group C). In both groups, the annulus was reshaped using a 40- or 50-mm-long band. Postoperative echocardiography was performed in all patients after a mean follow-up of 18±13 months in group U and 20±9 months in group C. RESULTS: There were no early or late deaths. No patients in either group showed systolic anterior motion. Both surgical strategies were successful in obtaining a significant reduction in mitral regurgitation grade. Left ventricular function was maintained, and tricuspid regurgitation grade was reduced overall. Moderate mitral regurgitation during follow-up developed in only 1 patient in group C, as the result of dehiscence of a plication stitch. CONCLUSIONS: Although the rationale for the use of the U technique is different from what is generally accepted, the midterm results of this approach are comparable to those obtained with more conventional techniques, remaining stable after a mean follow-up of 18 months.

Chordal cutting in ischemic mitral regurgitation: a propensity-matched study.

OBJECTIVE: The optimal surgical treatment of ischemic mitral regurgitation (MR) has not been well defined. Second-order chordal cutting (CC), in selected patients, can improve surgical outcomes. METHODS: From 2007 to 2011, 31 patients underwent CC for ischemic MR. The indication was the presence of increased tethering of the anterior leaflet, with a bending angle (BA) <145°. Patients with same echocardiographic characteristics were identified and propensity matched for age, ejection fraction (EF), MR grade, diameters, and BA. Only patients with preoperative and follow-up echocardiograms were included and divided into 2 groups of 26 patients each, CC and no-CC. RESULTS: Preoperatively, in the CC and no-CC groups, the age was 61 ± 9 and 62 ± 10 years, EF was 31% ± 5% and 29% ± 8%, MR grade (0-4) was 3.6 ± 0.6 and 3.3 ± 0.8, and diastolic and systolic dimension was 56 ± 7 and 43 ± 8 mm and 57 ± 11 and 44 ± 11 mm, respectively. The New York Heart Association class and BA was 2.7 ± 0.6 and 2.6 ± 0.7 and 137° ± 4° and 137° ± 6°, respectively. All patients underwent overreductive annuloplasty. In the CC group, second-order chords were cut using aortotomy. After a mean of 33 ± 15 months, the MR grade was 0.6 ± 0.6 and 1.1 ± 0.8 (P = .014) and the EF was 40% ± 5% and 35% ± 7% (P = .005) in the CC and no-CC groups, respectively. The corresponding diastolic and systolic diameters were 52 ± 5 and 38 ± 8 mm and 53 ± 11 and 41 ± 12 mm (P = NS). The modifications were significant only in the CC group (P = .022 and P = .029 for the diastolic and systolic dimensions, respectively). The corresponding New York Heart Association class decreased to 1.1 ± 0.3 and 1.5 ± 0.6 (P = .004). The BA increased to 182° ± 4° in the CC (P < .001) and remained unchanged (137° ± 6°) in the no-CC group. CONCLUSIONS: In selected patients with a BA <145° and coaptation depth ≤10 mm, CC is related to less MR return or persistence, improved EF, and lower New York Heart Association class.

Intermittent tethering of second-order chords after mitral valve repair for bileaflet prolapse.

Mitral valve regurgitation which occurs immediately after repair can be due to anatomic (failure of repair) or functional (systolic anterior motion) reasons. We report a case where a patient with bileaflet prolapse showed, after surgical correction of the disease, moderate to severe regurgitation after cardiopulmonary bypass was stopped. The regurgitation was due to second-order tethering and was successfully treated with second-order chordal cutting.

Cold reperfusion before rewarming reduces neurological events after deep hypothermic circulatory arrest.

OBJECTIVES: To identify a safety threshold of deep hypothermic circulatory arrest (DHCA) duration; to determine which protection offers the best outcome and whether a 10-min period of cold perfusion (20°C) preceding rewarming can reduce neurological events (NE). METHODS: From January 1988 to April 2009, 456 patients underwent aortic surgery using DHCA: for chronic disease in 239 and acute in 217. Cerebral protection was obtained by straight DHCA (sDHCA) in 69 cases, retrograde perfusion (RCP) in 198 and antegrade perfusion (ACP) in 189. In 247 subjects, a 10-min period of cold perfusion (20°C) preceded rewarming; in 209 rewarming was restarted without this preliminary. RESULTS: Fifty-eight patients (13%) experienced NE. Twenty-two (5%) suffered temporary neurological dysfunction (TND) and 36 (8%) suffered stroke. DHCA duration >30 min was predictive for higher rate of NE (25.2% vs. 2.0%, P 0.001); after this value, only ACP was able to reduce incidence of NE (16.5% vs. 30.5%, P = 0.035). Cold reperfusion before rewarming significantly reduced incidence of NE (7.7% vs. 18.7%, P < 0.001) and extended the safe period to 40 min. Thirty-day mortality was 16.0%. Predictors of higher early mortality were acute aortic disease, longer DHCA, lack of ACP or prompt rewarming when DHCA >30 min and postoperative stroke. CONCLUSIONS: sDHCA remains a safe and easy tool for cerebral protection when DHCA duration is expected to be less than 30 min. When aortic surgery requires a longer period, ACP should be instituted. Before rewarming, a 10-min period of cold perfusion significantly reduces incidence of NE.

Surgical treatment of functional mitral regurgitation.

Incidence of functional mitral regurgitation (FMR) is increasing due to aging and better survival after acute myocardial infarction, the most frequent cause of FMR. At the basis of FMR there is a displacement of one of both papillary muscle(s) and/or annular enlargement, which can be primitive or, more often, secondary. There is general agreement that its natural history is unfavorable, as witnessed by a considerable body of evidences. However, even if there is no clear evidence that surgical treatment of FMR changes consistently the outcome of patients with this disease, at least in terms of survival, there are some studies which show that function improves, as well as the global quality of life. The guidelines reflect this uncertainty, providing no clear indications, even in the gradation of severity of the FMR. Surgical techniques are variable and are mainly addressed to the annulus (restrictive annuloplasty), which is only a part of the anatomic problem related to FMR. Insertion of a prosthesis inside the native valve is appearing more and more a valuable option rather than a bail out procedure. On the other side, techniques addressed to modify the position of the papillary muscles appear to be still under investigation and not yet in the armamentarium of surgical treatment of FMR. Even after many years, rules are not established and results are fluctuating, but how and when to treat FMR is becoming more and more a topic of interest in cardiac surgery.

Echocardiographically based treatment of chronic ischemic mitral regurgitation.

OBJECTIVES: We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. METHODS: From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm(2), and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. RESULTS: Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm(2) to 2.3 ± 0.4 mm(2) (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm(2). Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P < .001), improving in 47, remaining unchanged in 63, and worsening in 7. CONCLUSIONS: Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥ 10 mm(2) in 7.7% of cases, with no patients showing effective regurgitant orifice ≥ 20 mm(2)). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

Echocardiographic-based treatment of functional tricuspid regurgitation.

OBJECTIVES: Functional tricuspid regurgitation (FTR) worsens over time, and its natural history is unfavorable. An aggressive surgical strategy, using the echocardiographic systolic dimensions of the tricuspid annulus (sysTA), can be helpful to reduce the detrimental late effects of FTR. METHODS: From March 2006 to February 2008, 298 patients, with at least FTR grade 1+, underwent mitral valve surgery. Of these 298 patients, 167 underwent tricuspid repair (treated group [T], moderate-or-greater FTR in 108 and mild in 59, with sysTA > 24 mm) and 137 did not (untreated group [UT], moderate-or-greater FTR in 16 and mild in 115; 81 with sysTA > 24 mm and 34 with sysTA of ≤ 24 mm). The 256 survivors underwent echocardiographic examination at a mean follow-up of 13 ± 8 months. RESULTS: Preoperatively, at discharge, and at the follow-up examination, the mean FTR grade was 1.11 ± 0.32, 0.87 ± 0.49, and 1.03 ± 0.57 (P = NS) in the UT group and 2.11 ± 0.92, 0.45 ± 0.36, and 0.48 ± 0.32 (P < .001) in the T group. A total of 24 patients had FTR grade 2 or greater, 16 (14.5%) in the UT group and 8 (5.5%) in the T group (P = .026). In the UT group, 10 of 16 patients had sysTA of 25 to 28 mm and 6 of 10 had sysTA greater than 28 mm. No patient with mild FTR and sysTA of 24 mm or less had an increased FTR grade. Globally, 12 patients (10.9%) had an increased FTR grade in the UT group versus none in the T group (P < .001). Patients with postoperative atrial fibrillation had less residual FTR if annuloplasty had been performed (1.6 ± 0.7 vs 0.91 ± 0.63, P = .005). CONCLUSIONS: An aggressive strategy for FTR correction, using the sysTA, was able to reduce the FTR grade 1 year after surgery, but mitral surgery alone could not.

Left ventricular surgical restoration for anteroseptal scars: volume versus shape.

OBJECTIVE: We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target. METHODS: From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V). RESULTS: Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2). CONCLUSIONS: When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

Distortion of the proximal circumflex artery during mitral valve repair.

A 74-year-old woman showed electrocardiographic signs of severe lateral ischemia with no hemodynamic consequence after mitral valve repair for severe mitral regurgitation. An angiogram showed interruption of the proximal circumflex artery. The patients then underwent an on-pump beating heart marginal branch revascularization. A new angiogram performed before discharge showed a widely patent graft.

Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.

OBJECTIVE: This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. METHODS: From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. RESULTS: Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. CONCLUSIONS: In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.