Factors affecting late survival after surgical remodeling of left ventricular aneurysms

OBJECTIVES: Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods. METHODS: From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch. RESULTS: Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04). CONCLUSIONS: Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.     

Surgery for left ventricular aneurysm: early and late survival after simple linear repair and endoventricular patch plasty

OBJECTIVE: Simple linear resection and endoventricular patch plasty are alternative techniques to repair postinfarction left ventricular aneurysm. The aim of the study was to compare these 2 methods with regard to early mortality and long-term survival. METHODS: We retrospectively reviewed 159 patients undergoing operations between 1989 and 2003. The epidemiologic design was of an exposed (simple linear repair, n = 74) versus nonexposed (endoventricular patch plasty, n = 85) cohort with 2 endpoints: early mortality and long-term survival. The crude effect of aneurysm repair technique versus endpoint was estimated by odds ratio, rate ratio, or relative risk and their 95% confidence intervals. Stratification analysis by using the Mantel-Haenszel method was done to quantify confounders and pinpoint effect modifiers. Adjustment for multiconfounders was performed by using logistic regression and Cox regression analysis. Survival curves were analyzed with the Breslow test and the log-rank test. RESULTS: Early mortality was 8.2% for all patients, 13.5% after linear repair and 3.5% after endoventricular patch plasty. When adjusted for multiconfounders, the risk of early mortality was significantly higher after simple linear repair than after endoventricular patch plasty (odds ratio, 4.4; 95% confidence interval, 1.1-17.8). Mean follow-up was 5.8 +/- 3.8 years (range, 0-14.0 years). Overall 5-year cumulative survival was 78%, 70.1% after linear repair and 91.4% after endoventricular patch plasty. The risk of total mortality was significantly higher after linear repair than after endoventricular patch plasty when controlled for multiconfounders (relative risk, 4.5; 95% confidence interval, 2.0-9.7). Linear repair dominated early in the series and patch plasty dominated later, giving a possible learning-curve bias in favor of patch plasty that could not be adjusted for in the regression analysis. CONCLUSIONS: Postinfarction left ventricular aneurysm can be repaired with satisfactory early and late results. Surgical risk was lower and long-term survival was higher after endoventricular patch plasty than simple linear repair. Differences in outcome should be interpreted with care because of the retrospective study design and the chronology of the 2 repair methods.     

Determinants of mid- and long-term results in patients after surgical revascularization for ischemic cardiomyopathy

BACKGROUND: The revascularization of patients suffering from ischemic cardiomyopathy is possible with acceptable perioperative mortality and morbidity. Many publications have discussed the problem of predicting myocardial viability, whereas the quality of the peripheral coronary vessels has been focused on less frequently. METHODS: We studied 908 consecutive patients with ischemic cardiomyopathy revascularized between January 1, 1988 and April 30, 2000. Death, recurrent heart failure, hospitalization due to cardiac causes, ventricular assist device implantation, heart transplantation, and ventricular arrhythmias were defined as adverse events. To analyze the importance of pre- and perioperative variables (state of the coronary arteries, myocardial viability, complete vs incomplete revascularization, urgency of the operation, previous operations, gender, diabetes, preoperative New York Heart Association class, age, number of grafts, and ischemic time), a proportional hazards model was used. RESULTS: The most important predictors of short- and long-term event-free survival were the quality of the coronary arteries, followed by myocardial viability, complete revascularization, number of bypass grafts, and an elective operation. CONCLUSIONS: The coronary vascular system can be described by means of a simple scoring system. A good or at least moderate coronary artery perfusing an area of dysfunctional yet viable myocardium is the main predictor of a successful perioperative course and an event-free survival. Patients with a poor coronary vasculature regardless of myocardial viability should not be considered suitable for revascularization.