Favorable effects of left ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial

Abstract

ObjectiveWe sought to examine the hemodynamic effects at 1 month and 1 year of left ventricular reconstruction by means of endoventricular patch plasty for patients with acute or chronic, very severe post–myocardial infarction heart failure who would have been systematically excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial.MethodsFrom 2002 to May 2008, 274 patients underwent left ventricular reconstruction for post–myocardial infarction scarring; 117 of these patients would not have been eligible for the STICH trial. The pertinent criteria for exclusion included 12 patients with no coronary vessel suitable for coronary artery bypass grafting; 17 patients within a month of myocardial infarction, including 11 with acute heart failure (8 septal ruptures and 3 cases of ventricular tachycardia); 48 patients receiving intravenous inotropes, intra-aortic balloon pumping, or both; 15 patients with bifocal or posterior scarring; 4 patients scheduled for heart transplantation; and 21 patients meeting 5 other exclusion criteria. These patients (mean age, 64 years; age range, 34–83 years) preoperatively had a mean 49% (range, 35%–75%) scarred left ventricular circumference, as determined by means of magnetic resonance imaging assessment. In the patients with chronic heart failure, the preoperative ejection fraction was 26% ± 4% (range, 9%–34%), the end-diastolic volume index was 130 ± 43 mL/m2 (range, 62–343 mL/m2), and the end-systolic volume index was 95 ± 37 mL/m2 (range, 45–289 mL/m2). Mitral regurgitation was mild to severe in 56 patients and associated with annular dilatation (≥35 mm) in 51 patients. A strategy of left ventricular reconstruction by means of endoventricular circular suturing and patching excluded the scarred left ventricular wall and was balloon sized to provide a diastolic volume of 50 mL/m2. Circular patches were used for anteroseptoapical lesions, and triangular patches were used for posterior lesions. The mitral valve was repaired in 51 patients, and coronary revascularization was performed in 105 patients (arterial grafts in 95 and mixed in 12). Seventy-eight patients had endocardectomy, and cryotherapy was used in 39 patients for ventricular tachycardia.ResultsFour in-hospital and 2 delayed deaths occurred during the first year. In 101 patients with chronic heart failure, magnetic resonance imaging revealed that ejection fraction improved from 26% ± 4% preoperatively to 40% ± 8% at 1 month and 44% ± 11% at 1 year postoperatively. At these same time points, the end-diastolic volume index was reduced from 130 ± 43 mL/m2 to 81 ± 27 and 82 ± 25 mL/m2, respectively, and the end-systolic volume index was reduced from 96 ± 45 mL/m2 to 50 ± 21 and 47 ± 20 mL/m2, respectively.ConclusionsWith minimal associated mortality, left ventricular reconstruction produces durable improvement in left ventricular function in patients with a large scarred ventricular wall. Considering that this patient cohort would have been systematically excluded from the STICH trial, care should be taken not to extrapolate that study’s results too widely so as to inappropriately deny selected patients an effective treatment for ischemic cardiomyopathies with an injured ventricle