title: Non-heart transplant surgical approaches with left ventricular restoration and mitral valve operation for advanced ischaemic cardiomyopathy.
abstract: OBJECTIVE
  The aim of this study was to assess long-term outcomes of non-heart transplant surgical approaches to advanced ischaemic cardiomyopathy (ICM), including left ventricular restoration (LVR) and mitral valve operation.
  
  
  METHODS
  Since September 2002, 102 consecutive patients (mean age 65, 18 females) with advanced ICM [ejection fraction (EF) <40%, left ventricular end-systolic volume index (LVESVI) > 60 ml/m(2)] were treated using non-heart transplant procedures. A total of 84 patients with asynergy of large scar exceeding 35% of left ventricular (LV) perimeter underwent LVR, and 30 patients with greater than or equal to moderate mitral regurgitation (MR) underwent mitral valve operation such as annuloplasty (n = 23) and valve replacement (n = 7). Patients were divided into four groups according to their interagency registry for mechanically assisted circulatory support (INTERMACS) profiles: Profile 1-2 (the highest levels of clinical compromise; n = 9), Profile 3-4 (n = 40), Profile 5-6 (n = 32) and Profile ≥ 7 (n = 21). We compared the four groups, looking at survival, major adverse cardiac and cerebrovascular event (MACCE), New York Heart Association (NYHA) status, LV volume and function.
  
  
  RESULTS
  The overall 8-year survival including 3 hospital deaths (2.9%) was 64.3% without sudden death due to arrhythmia. Ninety-nine survivors showed significant improvement in the mean NYHA status, from 2.9 to 1.4, and the mean EF (33.2-41.7%) (P < 0.0001). The mean LVESVI was significantly reduced from 104.1 to 61.4 ml/m(2) (41% volume reduction) (P < 0.0001). Seven-year survival in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 50.0, 57.2, 60.3 and 95.2%, respectively (P = 0.13). Freedom from MACCE at 5 years in patients with Profiles 1-2, 3-4, 5-6 and ≥ 7 were 29.6, 47.0, 67.2 and 95.2%, respectively (P = 0.0067). The improvements in NYHA status were significantly greater in patients with higher levels of clinical compromise (P < 0.0001), although, there was no significant difference in LV volume reduction and functional improvement among the four groups. Patients with Profile ≥ 7 had significantly better survival at 7 years (hazard ratio (HR): 0.11, P = 0.046) and freedom from MACCE at 5 years (HR: 0.053, P = 0.0066) compared with patients with Profiles 1-2.
  
  
  CONCLUSIONS
  Our non-heart transplant surgical approaches using LVR and mitral valve operation for advanced ICM yielded excellent long-term outcomes in terms of survival and NYHA status, even in patients who are potential candidates for heart transplantation or LV assist devices; and are encouraging in a very particular situation where heart transplantation is limited due to organ storage.
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan ynoricho@tokai-u.jp.
authors.forename: Yasunori
authors.initials: Y
authors.lastname: Cho
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Shinichiro
authors.initials: S
authors.lastname: Shimura
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Aki
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Hidekazu
authors.initials: H
authors.lastname: Furuya
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Shigeto
authors.initials: S
authors.lastname: Odagiri
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Kimiaki
authors.initials: K
authors.lastname: Okada
authors.affiliation: Department of Cardiovascular Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
authors.forename: Toshihiko
authors.initials: T
authors.lastname: Ueda
mesh_terms: D000368:Aged; D005260:Female; D006304:Health Status; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D017202:Myocardial Ischemia / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: INTERMACS profiles; Left ventricular restoration; Long-term outcomes; Mitral valve operation; Non-heart transplant approaches