Restrictive mitral annuloplasty with or without surgical ventricular reconstruction in ischaemic cardiomyopathy: impacts on neurohormonal activation, reverse left ventricular remodelling and survival.
OBJECTIVE
In the STICH trial, adding surgical ventricular reconstruction (SVR) to coronary artery bypass grafting (CABG) reduced LV end-systolic volume index (LVESVI) by 19%, as compared with 6% with CABG alone, providing no survival or functional benefits. Herein, we compared the efficacy of restrictive mitral annuloplasty (RMA) alone with that of RMA combined with SVR in patients with functional mitral regurgitation (MR).


RESULTS
One hundred and six patients with ischaemic cardiomyopathy underwent RMA with (n = 52) or without SVR (n = 54) for functional MR. Pre- and post-operative (1 month) left ventriculography and longitudinal measurements of plasma BNP were performed. Pre-operatively, patients who underwent RMA plus SVR had a larger LVESVI (126 ± 26 vs. 100 ± 24 mL/m(2) , P < 0.0001). After surgery, RMA plus SVR reduced LVESVI more than RMA alone (43% vs. 22%, P <0.0001), yielding a nearly identical post-operative LVESVI (71 ± 17 vs. 78 ± 26 mL/m(2) ). Survival rate was not different between the groups (4-year survival, 62% vs. 62%, P = 0.99), though among patients with pre-operative LVESVI ranging from 105 to 150 mL/m(2) , that was higher in the RMA plus SVR group (73% vs. 40%, P = 0.046), accompanied by a larger percentage reduction in plasma BNP from baseline to the latest follow-up examination (63 ± 34% vs. 34 ± 46%, P = 0.012). After propensity score adjustment, patients with LVESVI ranging from 105 to 150 mL/m(2) who underwent RMA alone showed a greater association with mortality (hazard ratio 7.5, 95% confidence interval 2.1-27, P = 0.010), as compared with those with LVESVI <105 mL/m(2) who underwent RMA alone.


CONCLUSIONS
RMA plus SVR reduced LVESVI to a greater degree than RMA alone, neutralizing anticipated worse prognosis. Selected patients with functional MR and advanced LV remodelling may benefit by adding SVR to RMA.
Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Osaka, Japan; Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
Satoshi
S
Kainuma
Kazuhiro
K
Taniguchi
Koichi
K
Toda
Toshihiro
T
Funatsu
Shigeru
S
Miyagawa
Haruhiko
H
Kondoh
Takafumi
T
Masai
Shigeaki
S
Otake
Yasushi
Y
Yoshikawa
Hiroyuki
H
Nishi
Taichi
T
Sakaguchi
Takayoshi
T
Ueno
Toru
T
Kuratani
Takashi
T
Daimon
Yoshiki
Y
Sawa
D000368:Aged; D056988:Anterior Wall Myocardial Infarction / Q000150:complications*; D009202:Cardiomyopathies / Q000209:etiology / Q000601:surgery*; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000601:surgery*; D005260:Female; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D013318:Stroke Volume; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling
Functional mitral regurgitation; Ischaemic cardiomyopathy; Restrictive mitral annuloplasty; Surgical ventricular reconstruction