Long-Term Outcomes of Left Ventricular Restoration in Patients Ineligible for Concomitant Coronary Artery Bypass Grafting
DOI:
https://doi.org/10.1532/hsf.4683Keywords:
left ventricular restoration, left ventricular aneurysm, severe coronary artery disease, coronary artery bypass grafting, left ventricular ejection fractionAbstract
Background: The prognosis of severe coronary artery disease (CAD) patients undergoing left ventricular restoration (LVR) and ineligible for concomitant coronary artery bypass grafting (CABG) is unclear. This study illustrates the clinical characteristics and the long-term survival of these patients in a retrospective cohort.
Methods: From January 1999 to March 2021, a total of 78 patients underwent surgical left ventricular restoration without concomitant CABG at our center. The primary endpoint was the major adverse cardiovascular and cerebrovascular events (MACCE). Kaplan–Meier analysis was performed to calculate survival, and compared by log-rank test, followed by multiple adjustments using Cox regression.
Results: The mean age was 55.3 ± 11.4 years. There were 76 (97.4%) true and 2 (2.6%) pseudo-aneurysms. Forty-six (59.0%) patients presented NYHA functional class III or IV. The mean EuroSCORE was 10.6 ± 3.2. Concomitant surgeries included mitral valve repair (N = 3), mitral valve replacement (N = 2), tricuspid valve repair (N = 2), ventricular septal defect closure (N = 18), maze procedure (N = 1), and appendage ligation (N = 1). Reoperation for bleeding was performed in one patient (1.3%). Prolonged ventilation was observed in 21 (26.9%) patients. Fourteen (17.9%) patients presented with low cardiac output and were supported with IABP. Operative death occurred in one (1.3%) patient. The median duration of echocardiographic follow-up was 53 months (interquartile range, 81.5) and was obtained in 46 (59.0%) patients. Left ventricular ejection fraction (LVEF) improved from 41.1% ± 10.5% to 45.6% ± 7.9% (P < 0.001), and the left ventricular end-diastolic dimension (LVEDD) fell from 57.8 ± 6.6 mm to 52.0 ± 6.2 mm (P < 0.001). The median patient follow-up time was 79.5 months (interquartile range, 53.5). Overall, 1-, 5-, and 10-year survival rates were 98.7%, 95.5% and 82.3%, respectively.
Conclusions: Patients with severe CAD and ineligible for concomitant CABG are in critical condition, and LVR could be a reliable approach to improving cardiac function with satisfactory early and long-term outcomes
References
Bakaeen FG, Gaudino M, Whitman G, Doenst T, Ruel M, Taggart DP, Stulak JM, Benedetto U, Anyanwu A, Chikwe J, et al. 2021. 2021: The American Association for Thoracic Surgery Expert Consensus Document: Coronary artery bypass grafting in patients with ischemic cardiomyopathy and heart failure. J Thorac Cardiovasc Surg. 162(3):829-850.e821.
Barratt-Boyes BG, White HD, Agnew TM, Pemberton JR, Wild CJ. 1984. The results of surgical treatment of left ventricular aneurysms. An assessment of the risk factors affecting early and late mortality. J Thorac Cardiovasc Surg. 87(1):87-98.
Cooley DA. 1989. Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm. J Card Surg. 4(3):200-205.
Cooley DA, Collins HA, Morris GC, Jr., Chapman DW. 1958. Ventricular aneurysm after myocardial infarction; surgical excision with use of temporary cardiopulmonary bypass. J Am Med Assoc. 167(5):557-560.
Di Donato M, Sabatier M, Montiglio F, Maioli M, Toso A, Fantini F, Dor V. 1995. Outcome of left ventricular aneurysmectomy with patch repair in patients with severely depressed pump function. Am J Cardiol. 76(8):557-561.
Dor V, Sabatier M, Di Donato M, Maioli M, Toso A, Montiglio F. 1995. Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle. J Thorac Cardiovasc Surg. 110(5):1291-1299; discussion 1300-1291.
Grondin P, Kretz JG, Bical O, Donzeau-Gouge P, Petitclerc R, Campeau L. 1979. Natural history of saccular aneurysms of the left ventricle. J Thorac Cardiovasc Surg. 77(1):57-64.
Gupta S, Pressman GS, Morris DL, Figueredo VM. 2010. Distribution of left ventricular ejection fraction in angina patients with severe coronary artery disease not amenable to revascularization. Coron Artery Dis. 21(5):278-280.
Henry TD, Satran D, Hodges JS, Johnson RK, Poulose AK, Campbell AR, Garberich RF, Bart BA, Olson RE, Boisjolie CR, et al. 2013. Long-term survival in patients with refractory angina. Eur Heart J. 34(34):2683-2688.
Jolicoeur EM, Cartier R, Henry TD, Barsness GW, Bourassa MG, McGillion M, L'Allier PL. 2012. Patients with coronary artery disease unsuitable for revascularization: definition, general principles, and a classification. Can J Cardiol. 28(2 Suppl):S50-59.
Koilpillai C, Quiñones MA, Greenberg B, Limacher MC, Shindler D, Pratt CM, Benedict CR, Kopelen H, Shelton B. 1996. Relation of ventricular size and function to heart failure status and ventricular dysrhythmia in patients with severe left ventricular dysfunction. Am J Cardiol. 77(8):606-611.
Komeda M, David TE, Malik A, Ivanov J, Sun Z. 1992. Operative risks and long-term results of operation for left ventricular aneurysm. Ann Thorac Surg. 53(1):22-28; discussion 28-29.
Lundblad R, Abdelnoor M, Svennevig JL. 2003. Repair of left ventricular aneurysm: surgical risk and long-term survival. Ann Thorac Surg. 76(3):719-725.
Mukherjee D, Comella K, Bhatt DL, Roe MT, Patel V, Ellis SG. 2001. Clinical outcome of a cohort of patients eligible for therapeutic angiogenesis or transmyocardial revascularization. Am Heart J. 142(1):72-74.
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, et al. 2019. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 40(2):87-165.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr., Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, et al. 2013. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 127(4):e362-425.
Povsic TJ, Broderick S, Anstrom KJ, Shaw LK, Ohman EM, Eisenstein EL, Smith PK, Alexander JH. 2015. Predictors of long-term clinical endpoints in patients with refractory angina. J Am Heart Assoc. 4(2).
Rocha AS, Dassa NP, Pittella FJ, Barbosa ON, Brito JO, Tura B, Silva PR. 2005. High mortality associated with precluded coronary artery bypass surgery caused by severe distal coronary artery disease. Circulation. 112(9 Suppl):I328-331.
Sartipy U, Albåge A, Lindblom D. 2006. Risk factors for mortality and hospital re-admission after surgical ventricular restoration. Eur J Cardiothorac Surg. 30(5):762-769.
Schlichter J, Hellerstein HK, Katz LN. 1954. Aneurysm of the heart: a correlative study of one hundred and two proved cases. Medicine (Baltimore). 33(1):43-86.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. 2018. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 72(18):2231-2264.
Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. 2000. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation. 102(12):1400-1406.
Zheng Z, Fan H, Feng W, Zhang S, Yuan X, Wang L, Song Y, Hu S. 2009. Surgery of left ventricular aneurysm: a propensity score-matched study of outcomes following different repair techniques. Interact Cardiovasc Thorac Surg. 9(3):431-436.
