Left ventricular reconstruction: Early and late results.

OBJECTIVES: In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning. METHODS: Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% +/- 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%). RESULTS: Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 +/- 48 months, 8 patients required transplantation (interval of 49 +/- 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 +/- 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% +/- 9%. CONCLUSIONS: Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Gender differences in quality of distal vessels: effect on results of coronary artery bypass grafting.

OBJECTIVE: The quality of target vessels may affect gender differences in outcome after coronary artery bypass grafting. This prospective study compares preoperative angiographic assessment of vessel quality with intraoperative visual assessment of size and presence or absence of diffuse disease. The effect of vessel quality on operative mortality and late survival is examined. METHODS: Data were prospectively collected on 1939 consecutive patients undergoing isolated coronary artery bypass grafting by a single surgeon. Quality of target vessels was assessed preoperatively (angiogram) and intraoperatively by inspection and probe calibration. RESULTS: Vessels were poorly visualized in 29% of female patients and 37% of male patients (P =.004), although all but 1.6% of target vessels were grafted. Women were no more likely than men to have small vessels (<1.5 mm) (57% vs 59%, P =.449) and were less likely to have distal disease (45% vs 53%, P =.005). Operative mortality was low, not statistically different in women versus men (1.3% vs 0.7%, P =.237), and increased in patients with distal disease (1.3% vs.03%, P =.021). Late survival was decreased in patients with poor left ventricle function, congestive heart failure, and peripheral vascular disease. Late survival was decreased in men with increased age, class IV symptoms, small size, and no left internal thoracic artery graft, and in women with recent myocardial infarction and preoperative cerebrovascular accident. CONCLUSION: We conclude that in most patients with poorly visualized vessels in the preoperative angiogram, complete revascularization can be achieved if one is willing to graft small or diffusely diseased vessels. Women are no more likely than men to have vessels less than 1.5 mm in size and are less likely to have diffuse disease. Such an approach is associated with a low operative mortality and good long-term survival. Predictors of late survival were different for men and women. Neither small vessel size nor diffuse disease was an independent predictors of poor late outcome.

Mild to moderate mitral regurgitation in patients undergoing coronary bypass grafting: effects on operative mortality and long-term significance.

BACKGROUND: Patients undergoing bypass grafting (CABG) often present with mitral regurgitation (MR). While surgical strategy for patients with either trace or severe MR is well established, the need for a valve procedure with mild (2) to moderate (3+) mitral regurgitation is controversial. METHODS: We reviewed 1,939 consecutive CABG patients (1987 to 1999). A preoperative echocardiogram performed when clinically indicated graded MR from 1 to 4+. Patient characteristics, hospital mortality, and long-term survival were compared between 167 patients with grade 2 to 3+ MR and controls. A multivariate analysis identified independent predictors for long-term mortality. RESULTS: The MR patients were more often female and older; had increased comorbidities including hypertension, diabetes, and heart failure; had more extensive coronary disease and worse left ventricular (LV) function; and required urgent surgery more often. Operative mortality was 0.8% in no MR patients and 1.8% in MR patients (p not significant). Long-term survival for MR patients with poor LV function (LV grade 3 to 4) was significantly lower (53% versus 75% at 10 years, p = 0.001). Independent predictors of poor long-term survival were advanced age, LV dysfunction, heart failure, diabetes, prior cerebrovascular accident, peripheral vascular disease, and no left internal mammary artery use. CONCLUSIONS: Coronary artery bypass graft patients with mild or moderate MR have worse baseline characteristics but operative mortality with CABG alone is not significantly increased. Long-term prognosis for MR patients with poor LV function is worse compared with patients with no MR but MR was not an independent predictor of long-term mortality. To determine whether surgical correction of MR would improve results, a prospective randomized trial seems warranted.

Ventricular reconstruction for ischemic cardiomyopathy.

Left ventricular surgical reconstruction has been advocated for patients with coronary artery disease, prior myocardial infarction, and poor left ventricular function. The objective of the approach is to resect or exclude all akinetic or dyskinetic nonfunctioning portions of the ventricular cavity and to restore the left ventricle size and shape toward normal as much as possible. We review the pathophysiology of ischemic cardiomyopathy and suggest guidelines for preoperative assessment and patient selection for ventricular reconstruction. Because of the prevalence and prognostic significance of ventricular arrhythmias in this patient population we include in our operative approach a visually directed ablation procedure in those with significant septal scarring. We describe our operative technique and review results achieved with this approach. The procedure results in a significant decrease in ventricular volume, increase in ejection fraction and improvement in apical geometry. We conclude that in selected patients with ischemic cardiomyopathy, left ventricular reconstruction can be accomplished with low operative mortality and results in significant improvement in left ventricular function. During follow up symptom class is decreased in most patients and overall survival at 5 years is 84% and freedom from sudden death is 96%. Ventricular reconstruction should be considered in all patients with coronary artery disease and akinetic or dyskinetic scar.

Left ventricular reconstruction for ischemic cardiomyopathy.

An outline of the Toronto General Hospital's philosophy for revascularization and left ventricular reconstruction in patients with ischemic cardiomyopathy. An open beating heart technique with modified linear closure and septoplasty when indicated is used for repair of both akinetic and dyskinetic scar. Patient selection, OR mortality (2.6%), and long-term results are reviewed.