Surgical ventricular restoration combined with mitral valve procedure for endstage ischemic cardiomyopathy.
OBJECTIVE
A poor functioning dilated left ventricle with mitral regurgitation is the worst condition in chronic ischemic heart failure. Our 7-year experience in combined mitral valve and left ventricular reconstruction was evaluated.


METHODS
Among 246 patients having undergone a left ventriculoplasty for postinfarction left ventricular dysfunction in our experience, there were 76 patients with advanced heart failure due to dilated ischemic cardiomyopathy with mitral regurgitation (70 males and 6 females with a mean age of 60 years). All patients had NYHA class III (n = 41) or IV (n = 35) heart failure, including 26 patients (34%) with inotropic support before the operation. All patients had a mitral regurgitation of more than 2+ and 46 patients (61%) had 3+ or more. Mitral reconstruction (61 repairs, 15 replacements) and left ventriculoplasty (Dor 34, SAVE 36, PLV 6) were undergone in combination with CABG (74%).


RESULTS
Operative mortality was 7.9% (5.0% in 60 elective and 18.8% in 16 emergency operations). The ejection fraction and cardiac index increased from 24.9 +/- 7.0% to 33.3 +/- 8.7%, and 2.0 +/- 0.4 l/min/m2 to 2.6 +/- 0.4 l/min/m2, respectively (p < 0.001). The endodiastolic and endosystolic volume indices, and diastolic dimension decreased from 165.9 +/- 43.2 ml/m2 to 121.2 +/- 31.1 ml/m2, 123.3 +/- 38.9 ml/m2 to 74.0 +/- 27.5 ml/m2, and 69.5 +/- 7.7 mm to 61.2 +/- 7.1 mm, respectively (p < 0.001). Late deaths were noted in 13 patients (17.1%), with 10 cardiac deaths. One- and 5-year survival rates were 80.2% and 67.7%, respectively. The mean NYHA class improved from 3.5 to 1.4 among the survivors. Multivariate analysis showed that patients with a mitral regurgitation of 3+ or more and preoperative endosystolic volume index were significant predictors for postoperative mortality. However, age, preoperative inotropes and pulmonary hypertension did not show any significant differences.


CONCLUSIONS
Combined mitral and left ventricular reconstruction is effective in treating advanced heart failure with endstage ischemic cardiomyopathy associated with a dilated left ventricle and mitral regurgitation.
Suma
Hisayoshi
H
The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan. sumah@cvi.or.jp
Tanabe
Hiroaki
H
Uejima
Tokuhisa
T
Isomura
Tadashi
T
Horii
Taiko
T
D000368:Aged; D002311:Cardiomyopathy, Dilated / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D004812:Epidemiologic Methods; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006352:Heart Ventricles / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome