Surgical Coronary Revascularization with or without Mitral Valve Repair of Severe Ischemic Dilated Cardiomyopathy

Authors

  • Dimitri Tsialtas
  • Roberto Bolognesi
  • Claudio Reverberi
  • Cesare Beghi
  • Carlo Manca
  • Tiziano Gherli

DOI:

https://doi.org/10.1532/HSF98.20041036

Abstract

Background: Because patients with dilated cardiomyopathy tend to have a poor prognosis with medical therapy, surgery with coronary bypass alone or associated with mitral valve repair should be a promising feasible therapeutic option. We evaluated the early effects of surgical coronary revascularization with or without mitral valve repair in patients with severe dilated ischemic cardiomyopathy.

Methods: The study group consisted of 38 patients aged 65 ± 8 years with severe dilated ischemic cardiomyopathy, chest pain, and heart failure. Twenty-four patients were in a New York Heart Association (NYHA) class ³ 3, and 14 patients were in class 2. Twenty patients had a degree of mitral regurgitation defined as an effective regurgitant orifice

20 mm2. The mean values ( SD) of the EuroSCORE, which evaluates operative risk, were 5 ± 2.2. Clinical and echocardiographic reevaluation followed at 6 months.

Results: All patients underwent coronary artery bypass surgery with a mean of 2.3 ± 0.8 grafts, and mitral valve repair with annuloplasty and Cosgrove ring insertion were performed in 20 patients. No deaths occurred during the operative period. Ten patients could not be reevaluated at 6 months, and 3 patients died (7.9% mortality). At 6 months, the end-systolic volumes in 15 patients who underwent coronary bypass plus mitral valve repair (group A) and in 13 patients who underwent coronary bypass alone (group B) decreased, respectively, from 139 ± 56 mL to 121 ± 94 mL and from 122 ± 48 mL to 96 ± 36 mL (P < .05). The wall motion score index also decreased from 1.9 ± 0.3 to 1.4 ± 0.4 and from 2.1 ± 0.3 to 1.8 ± 0.2, respectively. The mean values of the ejection fraction, the peak early mitral inflow velocity, and the ratio of the peak early mitral inflow velocity to the peak late mitral inflow velocity increased significantly in both groups (P < .001, P < .01, and P < .05, respectively). The mean NYHA functional class significantly improved in both groups (P < .0001). Conclusions: In patients with severe ischemic dilated cardiomyopathy, surgical coronary revascularization can be safely carried out during the operative and early postoperative periods with low mortality rates. This procedure decreased left ventricular end-systolic volume, consistently increased contractility, and subsequently ameliorated the ejection fraction to produce improvements in clinical condition according to the NYHA functional class. Similar results have been obtained in patients who have undergone coronary bypass surgery and mitral valve repair, despite a higher operative risk and longer cardiopulmonary bypass circulation and aortic cross-clamping times.

References

Baker DW, Jones R, Hodges J, Massie BM, Konstam MA, Rose E. 1994. Management of heart failure, III: the role of revascularization in the treatment of patients with moderate or severe left ventricular systolic dysfunction. JAMA 272:1528-34.nBax JJ, Poldermans D, Elhendy A, et al. 1999. Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol 34:163-9.nBishay E, McCarthy PM, Cosgrove DM, et al. 2000. Mitral valve surgery in patients with severe left ventricular dysfunction. Eur J Cardiothorac Surg 17:213-21.nBolling SF, Deeb GM, Brunsting LA, Bach DS. 1995. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg 109:676-83.nBounous EP, Mark DP, Pollock BG, et al. 1988. Surgical survival benefits for coronary disease patients with left ventricular dysfunction. Circulation 78:I-151-7.nCheitlin MD, Alpert JS, Armstrong WF, et al. 1997. ACC/AHA guidelines for the clinical application of echocardiography: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. J Am Coll Cardiol 29:862-79.nChristenson JT, Simonet F, Bloch A, Maurice J, Velebit V, Schmuziger M. 1995. Should a mild to moderate ischemic mitral valve regurgitation in patients with poor left ventricular function be repaired or not? J Heart Valve Dis 4:484-9.nCzer LSC, Maurer G, Trento A, et al. 1992. Comparative efficacy of ring and suture annuloplasty for ischemic mitral regurgitation. Circulation86:II-46-52.nDuarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA. 1999. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results. Ann Thorac Surg 68:426-30.nEmond M, Mock MB, Davis KB, et al. 1994. Long-term survival of medically treated patients in the coronary artery surgery study (CASS) registry. Circulation 90:2645-57.nEnriquez-Sarano M, Miller FAJ, Hayes SN, Bailey KR, Tajik AJ, Seward JB. 1995. Effective regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method. J Am Coll Cardiol 25:703-9.nEnriquez-Sarano M, Tajik AJ, Schaff HV, Arszulak TA, Bailey KR, Frje RL. 1994. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 90:830-7.nFlameng WJ, Herijgers P, Szecsi J, Sergeant PT, Daenen WJ, Scheys I. 1996. Determinants of early and late results of combined valve operation and coronary artery bypass grafting. Ann Thorac Surg 61:621-8.nNashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. 1999. European System for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9-13.nPegley PR, Beller GA, Watson DD, Gimple LW, Ragosta M. 1997. Improved outcome after coronary artery bypass surgery in patients with ischemic cardiomyopathy and residual myocardial viability. Circulation 95:793-800.nRankin JS, Feneley MP, Hickey MSJ, et al. 1988. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 95:165-77.nRihal CS, Nishimura R, Hatle LK, Bailey KR, Tajik AJ. 1994. Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy: relation to symptoms and prognosis. Circulation 90:2772-9.nvon Oppel UO, Stemmet F, Brink J, Commerford PJ, Heijke SAM. 2000. Ischemic mitral valve surgery. J Heart Valve Dis 9:64-73. Wijins W, Vatner SF, Camici PG. 1998. Hibernating myocardium. N Engl J Med 339:173-81.nFox KF, Cowie MR, Wood DA, et al. 2001. Coronary artery disease as a cause of incident heart failure in the population. Eur Heart J 22:221-36.nFucci C, Sandrelli L, Pardini A, Torracca L, Ferrari M, Alfieri O. 1995. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 9:621-7.nGillum RF. 1993. Epidemiology of heart failure in the United States. Am Heart J 126:1042-7.nGrigioni F, Enriquez-Sarano M, Kenton JZ, Kent RB, Tajik AJ. 2001. Ischemic mitral regurgitation: long-term outcome and prognostic implication with quantitative Doppler assessment. Circulation 103:1759-64.nLamas GA, Mitchell GF, Flaker GC, et al. 1997. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation 96:827-33.nMenicanti L, Di Donato M, Frigiola A, et al, RESTORE Group. 2002. Ischemic mitral regurgitation: intraventricular papillary muscle imbrications without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 123:1041-50.n

Published

2005-05-05

How to Cite

Tsialtas, D., Bolognesi, R., Reverberi, C., Beghi, C., Manca, C., & Gherli, T. (2005). Surgical Coronary Revascularization with or without Mitral Valve Repair of Severe Ischemic Dilated Cardiomyopathy. The Heart Surgery Forum, 8(3), E146-E150. https://doi.org/10.1532/HSF98.20041036

Issue

Section

Article