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Surgical ventricular restoration combined with mitral valve procedure for endstage ischemic cardiomyopathy

^a The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
^b Hayama Heart Center, Kanagawa, Japan
^c Kagawa University, Kagawa, Japan

Received 20 August 2008; received in revised form 3 March 2009; accepted 10 March 2009.

^_* Corresponding author. (Email: sumah{at}cvi.or.jp).

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. Materials and 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. Conclusion: 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.

Key Words: Heart failure • Myocardial infarction • Cardiomyopathy • Mitral regurgitation • Ventriculoplasty