title: Surgical ventricular remodeling for multiterritory myocardial infarction: defining a new patient population.
abstract: OBJECTIVE
  Because of limited medical and surgical options for patients with end-stage congestive heart failure, we expanded the criteria for surgical ventricular remodeling to include patients with multiterritory myocardial infarction, a group historically considered high-risk candidates. We present our series of patients with multiterritory myocardial infarction who underwent surgical ventricular remodeling and propose a new patient population who may benefit from this procedure.
  
  
  METHODS
  Data were analyzed for 51 consecutive patients undergoing surgical ventricular remodeling from January 2002 to June 2004, with 100% follow-up. Three left ventricular vascular territories were defined: anteroapicoseptal (left anterior descending), lateral (circumflex), and inferior (right coronary artery). Infarction was assessed with magnetic resonance imaging and intraoperative findings.
  
  
  RESULTS
  Multiterritory myocardial infarction was found in 64.7% of patients (33/51) undergoing surgical ventricular remodeling. Mean age was 61.6 +/- 11.1 years (range 40-81 years). Sixty-one percent (20/33) demonstrated evidence of myocardial infarction in all three territories. Five patients underwent concomitant mitral valve repair or replacement. Operative mortality was 6.1% (2/33) and did not differ from that of patients with single-territory infarction (11.1%, P = .61). Surgical ventricular remodeling significantly improved left ventricular volumes and ejection fraction in patients with multiterritory myocardial infarction. Three patients required assist device implantation, and 2 patients required defibrillator placement. Sixty-nine percent of patients in preoperative New York Heart Association functional class III or IV (22/32) had improvement to class I or II at follow-up (P < .01). Cox regression analysis discriminated a preoperative left ventricular end-systolic volume index greater than 100 mL/m(2) as a significant risk factor for mortality (odds ratio 12.1, 95% confidence interval 1.27-114.51, P = .03). Thirty-month survival of patients with multiterritory myocardial infarction (73.5% +/- 8.3%) did not differ statistically from that of patients with single-territory infarction (n = 18).
  
  
  CONCLUSIONS
  Surgical ventricular remodeling improves cardiac function and New York Heart Association functional status in patients with multiterritory myocardial infarction. Our initial results are promising and should prompt further studies to confirm our results and potentially expand the surgical ventricular remodeling inclusion criteria to include patients with multiterritory myocardial infarction.
authors.affiliation: Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md, USA.
authors.forename: Nishant D
authors.initials: ND
authors.lastname: Patel
authors.forename: Jason A
authors.initials: JA
authors.lastname: Williams
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Barreiro
authors.forename: Pramod N
authors.initials: PN
authors.lastname: Bonde
authors.forename: Michele M
authors.initials: MM
authors.lastname: Waldron
authors.forename: David C
authors.initials: DC
authors.lastname: Chang
authors.forename: David A
authors.initials: DA
authors.lastname: Bluemke
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000145:classification / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors