Eur J Cardiothorac Surg 2006;29:196-201
© 2006 Elsevier Science NL
Left ventricular reconstruction benefits patients with ischemic cardiomyopathy and non-viable myocardium
Gustavo Aguiar Ribeiro
*
,
Cledicyon Eloy da Costa,
Mauricio M. Lopes,
Ana Nunes Albuquerque,
Fernando Antoniali,
Gleice Agnes A. Reinert,
Kleber G. Franchini
Clinic of Cardio-Surgery at Campinas, Rua Jose Teodoro de Lima 77, ap 62, Cambuí, 130150-150 Campinas, Brazil
Received 1 August 2005;
received in revised form 16 November 2005;
accepted 22 November 2005.
* Corresponding author. Tel.: +55 19 3232 3856; fax: +55 19 3232 3856. (Email: gcar{at}hotmail.com).
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Abstract
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Objective: There are subsets of patients with ischemic cardiomyopathy for whom the optimal treatment strategies are not clear. The objective of this study was to delineate the relationship between clinical outcomes and surgical procedure in patients who were treated either with a coronary artery bypass graft or with a coronary artery bypass graft and additional ventricular restoration. Methods: The study population comprised 137 consecutive patients with anterior myocardial infarction. All patients had an ejection fraction <50% and left ventricle end-systolic volume index >80 ml/m2. The patients were divided into a viable and a non-viable group according to anterior myocardium viability, which was determined by a thallium-201 test. The viable group underwent a revascularization and was randomized into two groups for additional ventricular reconstruction. Group 1a comprised 35 patients with viable anterior wall who underwent surgical revascularization. Group 1b comprised 39 patients with viable anterior wall who underwent surgical revascularization and ventricular restoration. Group 2 comprised 69 patients with non-viable anterior wall who underwent revascularization and ventricular reconstruction. The preoperative and postoperative ejection fractions, end-systolic volume, mitral regurgitation, mortality, and heart failure symptoms were compared among groups. Results: Complete 2-year follow-up was achieved in 127 (92.7%) patients. Ejection fraction improved in all groups compared with preoperative values and it was greater in group 1b than in group 1a (p
< 0.001) at 2 years. There were no postoperative deaths in group 1a, one in group 1b, and two in group 2. After 2 years, group 1b was significantly smaller than group 1a (p
< 0.01) in relation to mitral regurgitation of grades 1 to 2+. End-systolic volume was significantly smaller in group 1b than in group 1a (p
< 0.001), it was smaller in group 1a than in group 2 (p
< 0.001), and it was smaller in group 1b than in group 2 (p
< 0.001). Heart failure class (NYHA) was reduced in all groups and events were significantly smaller in patients with end-systolic volume lesser than 120 ml/m2 (p
< 0.05). Conclusion: We have demonstrated that the short-term and mid-term outcomes of coronary artery surgery alone in patients with a large left ventricle are inferior to coronary artery surgery plus ventricular restoration.
Key Words: Myocardial viability • Ventricular reconstruction • Surgical revascularization
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1. Introduction
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Myocardial infarctions (MI) are associated with increased short-term and long-term mortalities. Multiple prognostic factors, including the patient's baseline characteristics, the extent and complications of MI, and the use of medications and procedures, have been shown to influence the risk of death [1]. After acute MI, early infarct expansion predicts late, generalized ventricular dilatation, reduced longevity, and progressive loss of cardiac function [2]. The development of heart failure (HF) postinfarction is particularly serious because patients manifesting HF have a several-fold increase in the risk of death compared with other MI survivors.
Yamaguchi et al. [3] clearly demonstrated that overall mortality in patients who underwent coronary artery bypass is related to preoperative left ventricle (LV) volume.
There are subsets of patients with ischemic cardiomyopathy for whom the optimal treatment strategies are not as clear. Akinetic areas create less of a mechanical problem than true aneurysm, as the scar and muscle are heterogeneous and the clinical results are more equivocal [4]. Ventricular volume-reduction surgery for an ischemic dilated left ventricle has recently become an interesting new field for cardiac surgeons [5]. Recently, Maxey et al. [6] showed that ventricular restoration results in significant improvement in ejection fraction compared to coronary artery bypass alone. The aim of this study was to clarify whether LV reconstruction (VR), in addition to coronary artery bypass surgery, benefits patients with viable myocardium.
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2. Methods
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2.1 Patient selection, study protocol
The study population comprised 137 consecutive and prospective patients with anterior myocardial infarction. The decision regarding revascularization was based on clinical grounds (symptoms, presence/absence of ischemia/viability, and angiographic findings). The indications for surgery were multiple and included angina alone (13.1%), heart failure (62.0%), or both (25%). The patients’ diagnosis was primary ischemic cardiomyopathy. The inclusion criteria were ejection fraction <40% and left ventricle end-systolic volume index >80 ml/m2 measured by echocardiography.
Significant valvular heart disease was not included, except mitral regurgitation (MR) of grades 1 to 2+. MR of more than 2+ were also excluded. Patients with akinetic anterior wall motion as evaluated by angiography exam were included, and those who showed dyskinetic motion were excluded. Detailed wall motion analysis was performed, following the centerline method. The extent of asynergy was calculated as a percentage length of the LV perimeter showing a fractional shortening of standard deviation (SD) below 2 from normal mean values [7]. In all cases, myocardium viability was assessed using the thallium-201 radionuclide method. Patients were divided according to anterior wall viability. Patients who had a viable anterior wall were randomized for two different approaches: group 1a, 35 (25.7%) patients, underwent a coronary artery bypass graft (CABG); group 1b, 39 (28.4%) patients, underwent CABG and ventricular reconstruction (VR). Group 2 included 63 (45.9%) patients who presented with a non-viable anterior wall and underwent CABG and VR. Thirty-five patients underwent CABG alone and 102 patients underwent CABG and VR, all of which were performed by two staff surgeons (G.C.A.R and C.E.C)
Comparative follow-up was done during the first 2 years for outcomes, and left ventricular function was assessed by echocardiogram (before surgery and 6, 12, 18, and 24 months after surgery). Each patient gave informed consent to the study, which was approved by the local ethics committee. The randomized patients were assigned to CABG or CABG plus VR in a ratio 1:1. Allocations were generated by a card system and concealed in sealed opaque envelopes. Both the patients and the surgeons were aware of the result of randomization.
2.2 Echocardiograph studies
All echocardiograms were performed with a Vivid 3 device (General Electric) equipped with a second-harmonic 1.8- to 3.6-MHz transducer. Standard views of the LV were obtained from the resting echocardiography (before and sequentially after surgery for at least 2 years). LV volumes were measured using the biplane Simpson's rule. The end-systolic volumes were indexed (LVESVI) according to the body surface area.
2.3 Myocardial viability
All patients underwent pharmacological stress testing with dipyridamole. Thallium-201 chloride (111 MBq) was injected intravenously and images were obtained. Redistribution images were obtained 3–4 h after the injection. Twenty-four hours later, the delayed resting images were obtained and medication was restarted. Single photon emission computed tomography (SPECT) images were obtained using a wide-field-of-view rotating gamma camera. They were divided into 20 segments: 6 basal segments, 6 mid-ventricular segments, and 6 apical segments; the apex was represented by 2 segments. Both ischemia and viability were evaluated. Segments (from the time points of the stress test, the 3–4-h redistribution, and the 24-h-delayed polar maps) were classified as having normal thallium-201 uptake (>75% of maximum uptake), moderately reduced thallium-201 uptake (50–75% of maximum uptake), or severely reduced uptake (<50% of maximum uptake). Segments were classified as ischemic when a perfusion defect was present on the stress images and significant redistribution occurred on the 3–4-h redistribution images (>10% increase in activity). Segments were classified as viable when the activity in the late images was normal (>75% tracer uptake) or moderately reduced (>50% tracer uptake), or when significant redistribution was present (>10% increase in activity from the 3–4-h redistribution images to the 24-h-delayed images). Therefore, segments were classified as ischemic and/or viable (jeopardized). Segments with a fixed-perfusion defect and activity of <50% were classified as scar tissue [8].
2.4 Assessment of functional status and mid-term follow-up
Functional status was assessed according to the New York Heart Association (NYHA) criteria (for symptoms of heart failure) and the Canadian Cardiovascular Society (CCS) classification (for angina pectoris). Symptoms were evaluated before revascularization and at 6 months. Clinical follow-up was conducted through interviews. Events included all causes of death, MI, recurrent heart failure, lack of improvement of ejection fraction, and lack of decrease in end-systolic volume, including worsening or development of new mitral regurgitation.
2.5 Operative procedure
With the patient supported by cardiopulmonary bypass, myocardial protection was achieved with antegrade and retrograde blood cardioplegia. After complete coronary revascularization, in all patients in groups 1b and 2, we declamped the aorta and with the heart beating, performed ventricular restoration using the technique described as endoventricular reconstruction by Dor et al. [9].
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3. Statistical analysis
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All continuous data were expressed as mean ± SD and compared using unpaired and paired Student's t-test and one-way analysis of variance data as appropriate. Comparisons of categorical data were performed using 
2 and Fisher's exact tests. Survival was evaluated using the Kaplan–Meier method, and mortality and other events were taken into consideration. Differences among survival curves were tested with the log-rank test. For all tests, a probability value of p
< 0.05 was considered significant.
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4. Results
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Baseline clinical data are summarized in Table 1
and operative data are presented in Table 2
. Group 1a consisted of 35 patients with viable anterior walls who underwent a CABG; group 1b consisted of 39 patients with viable anterior wall who underwent a CABG plus VR, and group 2 consisted of 63 patients with non-viable anterior wall who underwent a CABG plus VR. There were no significant differences between groups 1a and 1b with regard to age, gender, clinical variables, and amount of viable or scarred segments. The LV ejection fraction (LVEF) in group 1a was 32 ± 7.6 (range 18–48%), and in group 1b it was 34.5 ± 6.3 (range 17–45%) (p
= 0.12). There were no postoperative deaths in group 1a, one in group 1b (from sepsis), and two in group 2 (due to low cardiac output and intestinal complications).
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Table 1. Preoperative patient characteristics and cardiac performance (values in number and in percentage unless indicated otherwise)
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A comparison of groups 1a and 1b revealed no difference in preoperative mitral regurgitation (Table 2). Postoperatively, there was no significant difference in the development of mitral regurgitation of grade >2+ (p
= 0.19) although there was a significant difference in mitral regurgitation of grades 1 to 2+ between groups 1a and 1b (p
= 0.02). There was an important reduction in the number of patients with mitral regurgitation of grades 1 to 2+ postoperatively in group 1b compared to the preoperative number (22 vs 5 patients, p
= 0.01). The cross-clamp time, mammary artery used, distal anastomosis, and grafted left descending artery were similar between the groups, but the cardiopulmonary bypass time was greater in group 1b than in group 1a (p
< 0.001). After surgery, groups 1a and 1b exhibited a significant improvement in LV function as determined by echocardiography; in group 1a, LVEF changed from 32.0 ± 7.6 to 40.1 ± 8.3 (p
< 0.001) and in group 1b, LVEF changed from 34.5 ± 6.3 to 44.2 ± 5.2 (p
< 0.001). The postoperative LVEF was greater in group 1b (44.2 ± 5.2%) than it was in the patients with isolated CABG, group 1a (40.1 ± 8.3%; p
= 0.012). After 2 years, there was a significant difference in LVEF between groups 1a and 1b (41.0 ± 6.3 vs 49.5 ± 4.3, respectively; p
< 0.001). At mid-term follow-up, one patient in group 1a died (of heart failure), one patient in group 1b died (of a non-cardiac cause), and one patient in group 2 died (of myocardial infarction or had sudden death). Complete follow-up was achieved in 127 (92.7%) patients. Data were incomplete for three patients (one in each group), one patient (in group 1a) could not be located, and there were the six (4.3%) above-mentioned deaths. LV volumes decreased significantly compared with preoperative volumes. In group 1a, the LV volume dropped from 112 ± 24 ml/m2 to 96 ± 32 ml/m2 (p
= 0.02), and in group 1b, from 107 ± 19 ml/m2 to 63 ± 17 ml/m2 (p
< 0.001). The postoperative LVESVI (63 ± 17 ml/m2) in group 1b was smaller than the LVESVI in group 1a (96 ± 32 ml/m2) (p
< 0.001). After 2 years, the LVESVI was smaller in group 1b than in group 1a (p
< 0.001; Table 3
). The number of patients whose injection fraction increased more than 10 units was greater in group 1b than in group 1a (p
< 0.001). Heart failure class (NYHA) was reduced in all groups although it decreased more in group 1b than in group 1a (p
< 0.001). There was no significant difference in the rate of recurrence of heart failure. The preoperative LVEF of group 2 was smaller than that of all patients in group 1. After 2 years, the LVEF of group 2 had improved relative to the preoperative LVEF (p
< 0.001), but it was smaller than that of group 1b (p
< 0.001). At mid-term follow-up, the LVESVI of group 2 following VR was significantly smaller than the LVESVI of group 1a following isolated CABG (73 ± 17 vs 98 ± 23, p
< 0.001; Table 3). The VR procedure remarkably reduced LVESVI postoperatively. The 2-year actuarial survival shown in Fig. 1 was not significant in comparison with all patients. Comparison of the percentage of patients in groups 1a and 1b free of events after 2 years is presented in Fig. 2
. For this comparison, patients were divided according to preoperative LVESVI: 80–100 ml/m2, 100–120 ml/m2, and >120 ml/m2. The following were considered as events: all causes of death, recurrent heart failure, lack of improvement of ejection fraction, lack of decreased systolic volume, and the aggravation (or worsening) or development of new mitral regurgitation. In group 1a, patients with preoperative LVESVI > 120 ml/m2 had more events than the patients with preoperative LVESVI < 120 ml/m2. There was no difference when we compared patients with preoperative LVESVI < 100 ml/m2 versus preoperative LVESVI 100–120 ml/m2. Events were significantly more in group 1b when preoperative LVESVI was greater than 120 ml/m2 when compared with patients with LVESVI < 120 ml/m2. Between groups 1a and 1b, events were more frequent in group 1a when preoperative LVESVI was greater than 100 ml/m2 (p
= 0.0016). Fig. 3
shows the percentage of patients’ freedom from heart failure: recurrence of symptoms, worsening NYHA functional class, and rehospitalization. Group 1b had significantly improved freedom from heart failure compared with group 1a (p
= 0.016).
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Fig. 1. Percentage of patients after 2 years free of mortality. Curve free of mortality. Log-rank test, p
= 0.6.
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Fig. 2. Percentage of patients after 2 years free of events, comparison group 1a versus 1b, dividing left ventricle end-systolic volume: 80–100 ml/m2; 100–120 ml/m2, and >120 ml/m2. The following were considered as events: all causes of death, recurrent heart failure, lack of improvement of ejection fraction, lack of decreased systolic volume, and the aggravation (or worsening) or the development of new mitral regurgitation. Log-rank test p
< 0.05. Group 1a: preoperative LVESVI < 100 ml/m2 versus 100–120 ml/m2, p
= 0.4; preoperative LVESVI < 120 ml/m2 versus >120 ml/m2, p
= 0.002*; preoperative LVESVI > 120 ml/m2 versus 100–120 ml/m2, p
= 0.004*. Group 1b: preoperative LVESVI < 100 ml/m2 versus 100–120 ml/m2, p
= 0.31; preoperative LVESVI < 120 ml/m2 versus >120 ml/m2, p
= 0.038*; preoperative LVESVI 100–120 ml/m2 versus >120 ml/m2, p
= 0.13. Group 1a versus group 1b: preoperative LVESVI < 100 ml/m2, p
= 0.56; preoperative LVESVI > 100 ml/m2, p
= 0.0016* (*
p
< 0.05, log-rank test was significantly different).
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Fig. 3. Percentage of patients’ freedom from heart failure in comparison of group 1a and group 1b. Heart failure was considered: recurrence of symptoms, worsening NYHA functional class, rehospitalization. Group 1b had improvement of freedom from heart failure more than group 1a (p
< 0.016).
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5. Discussion
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Many variables affect ventricular remodeling after acute MI. Size, transmurality, and infarct location are major variables. Loading conditions, previous scarring, and revascularization of occluded vessels are among other important variables [10]. Myocardial viability tests are very important in deciding which therapy to use, but more large series and randomized studies are needed. Studies have indicated that the longer the duration of hibernation, the more severe the ultrastructural damage will be. This ultrastructural damage may vary extensively, and the severity of damage has been related to the time needed for complete recovery of function [11]. In clinical practice, not all patients with a substantial amount of dysfunction but viable myocardium improve after revascularization. The absence of recovery in patients with considerable amounts of viable tissue may be related to an increased left ventricular volume due to extensive ventricular remodeling. Surgical procedures [6,12] have been designed to reverse the remodeling process, diminish heart failure, and improve survival. In patients with previous anterior infarction, surgical anterior ventricular restoration achieves diminished ventricular volume, restores ventricular geometry, and further diminishes volume overload by mitral valve repair [13]. Yamaguchi et al. [13] showed that overall mortality is related to preoperative left ventricular volume. In our series for this prospective study, the patients were consecutive, and patients with a viable anterior wall were randomized for two different approaches. The number of patients was small and we had only a mid-term follow-up. Dor et al. [14] demonstrated that more than 80% of patients who underwent an endoventricular restoration were alive at 10 years if the preoperative end-systolic LV volume was below 90 ml/m2. Yamaguchi et al. [13] also demonstrated that the 5-year survival rate was 90% following ventricular restoration. There is little evidence that either the size or function of the ventricle stabilizes, or that the remodeling process ends until regional expansion ends [15]. Jackson et al. [15] demonstrated that an expanding regional infarction can initiate a myopathic process that spreads beyond the immediate per-infarct region and might involve the entire ventricle. Surgery may interrupt the development of non-ischemic infarct extension by reducing border zone stress. Athanasulaes et al. [16] found that 5-year freedom from hospital readmission for heart failure was 78%. Furthermore, preoperatively, 67% of patients were in NYHA functional class III or IV and postoperatively, 85% were in class I or II. We found a remarkable reduction in symptoms, and in group 1b this benefit was more prominent. Nishina et al. [17], in an experimental study, showed that there was initial improvement in LV function and neurohormonal status after volume-repair surgery. Di Donato et al. [18] have reported some disappointing results for mitral regurgitation. In the series reported by Maxey et al. [6], mitral regurgitation of grades 
2+ was very common preoperatively, occurring in 56.4% of the CABG group and in 53.7% of the VR group. In our series, we excluded patients with mitral regurgitation of grades 3+; nevertheless, 72 (52.5%) had trivial MR, and 15 (10.9%) had mild MR. At the end of 2 years, 55 (43.3%) patients showed trivial and mild MR; however, we found 10 (7.8%) with MR that was moderate or severe. Progressive ventricular dilation often distorts critical elements of the mitral apparatus and can result in functional MR. Group 1b included 22 (56.4%) patients with preoperative MR and 6 (16.6%) at the end of 2 years, only one being moderate. Group 1a had 5 patients (15.6%) with moderate or severe MR and group 2 had 4 (6.7%) such patients. Maxey et al. [6] demonstrated that a reduction in ventricular volume is a central feature of improvement and they suggested that the clinical effect of restoring elliptical ventricular shape and re-establishing normality to the mitral apparatus cannot be ignored. In this series, we compared patients with anterior MI, anterior wall viability, and large LV, and we found a remarkable reduction in heart failure symptoms. The VR approach provided significantly smaller postoperative LV volumes when compared with isolated revascularization, and this result persisted at 2 years. Although these patients were consecutive, prospective, and randomized for two different approaches, the number of patients was small and we had a short follow-up. Recurrence of heart failure is likely to occur at higher rates after more time has passed. In general, small LV volumes should lead to a good outcome unless ventricular volumes are so low that diastolic dysfunction is produced or mitral regurgitation is increased by distortion of the papillary muscles [17]. The RESTORE group results have been promising although any conclusion about the incremental efficacy of ventricular restoration relative to CABG must be made with caution [19]. First, it is not clear whether VR provides a survival benefit over CABG alone. Second, it is unknown whether a reduction in the volume of dilated ventricle improves survival, and it is not clear whether the reconstruction can revert or stop the remodeling processes after the infarct [20]. Further studies are needed to determine the value of these additional surgical procedures in patients with a substantial amount of viable tissue.
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6. Conclusion
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We have demonstrated that the short-term and mid-term outcomes of coronary artery surgery alone in patients with large left ventricles are inferior to coronary artery surgery plus ventricular restoration.
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Abstract
1. Introduction
