Surgical ventricular restoration for advanced congestive heart failure: should pulmonary hypertension be a contraindication?
BACKGROUND
Surgical ventricular restoration (SVR) is an established therapy for congestive heart failure due to ischemic cardiomyopathy. Pulmonary hypertension (PHTN) has been considered a contraindication for SVR owing to a presumed increase in operative risk. However, outcomes in these patients and the impact of SVR on PHTN have not been specifically evaluated.


METHODS
We retrospectively reviewed SVR patients between January 2002 and June 2005. Patients were classified as PHTN (mean pulmonary artery pressure > or = 25 mm Hg) and no PHTN (mPAP < 25 mm Hg) based on preoperative cardiac catheterization. Cardiac function was assessed using magnetic resonance imaging and echocardiography. Follow-up was 100%.


RESULTS
Sixty-nine patients underwent SVR for congestive heart failure. Thirty-six percent (25 of 69) had preoperative PHTN. Preoperatively, PHTN patients had significantly lower ejection fraction (21.1% versus 30.0%; p = 0.005) and larger left ventricular end-systolic volume index (119.0 versus 88.7 mL/m2; p = 0.04) than patients without PHTN. All PHTN patients and 95.5% (42 of 44) of the no PHTN group were New York Heart Association (NYHA) class III/IV preoperatively. There was 1 operative death in the PHTN group. Surgical ventricular restoration significantly improved cardiac function and pulmonary pressures for PHTN patients. Both groups had similar cardiac function postoperatively. Seventy-two percent (18 of 25) of PHTN patients and 69.0% (29 of 42) of patients without PHTN improved to NYHA class I/II at follow-up. Kaplan-Meier survival of PHTN patients was 68.1% at 3 years, which was lower than patients without PHTN (81.4%; p = 0.44), but not statistically significant. Kaplan-Meier 3-year survival for all SVR patients was 76.6%.


CONCLUSIONS
Surgical ventricular restoration is a good treatment option in patients with advanced congestive heart failure and PHTN. Our early results are promising and should prompt further studies to confirm these findings.
Patel
Nishant D
ND
Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
Williams
Jason A
JA
Nwakanma
Lois U
LU
Waldron
Michele M
MM
Bluemke
David A
DA
Conte
John V
JV
D000368:Aged; D006348:Cardiac Surgical Procedures; D015897:Comorbidity; D000075202:Contraindications; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000601:surgery*; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk; D013318:Stroke Volume; D016896:Treatment Outcome