Severity of Remodeling, Myocardial Viability, and Survival in Ischemic LV Dysfunction After Surgical Revascularization

AbstractObjectivesThis study sought to test the hypothesis that end-systolic volume (ESV), as a marker of severity of left ventricular (LV) remodeling, influences the relationship between myocardial viability and survival in patients with coronary artery disease and LV systolic dysfunction.BackgroundRetrospective studies of ischemic LV dysfunction suggest that the severity of LV remodeling determines whether myocardial viability predicts improved survival with surgical compared with medical therapy, with coronary artery bypass grafting (CABG) only benefitting patients with viable myocardium who have smaller ESV. However, this has not been tested prospectively.MethodsInteractions of end-systolic volume index (ESVI), myocardial viability, and treatment with respect to survival were assessed in patients in the prospective randomized STICH (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease) trial of CABG versus medical therapy who underwent viability assessment (n = 601; age 61 ± 9 years; ejection fraction ≤35%), with a median follow-up of 5.1 years. Median ESVI was 84 ml/m2. Viability was assessed by single-photon emission computed tomography or dobutamine echocardiography using pre-specified criteria.ResultsMortality was highest among patients with larger ESVI and nonviability (p < 0.001), but no interaction was observed between ESVI, viability status, and treatment assignment (p = 0.491). Specifically, the effect of CABG versus medical therapy in patients with viable myocardium and ESVI ≤84 ml/m2 (hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.56 to 1.29) was no different than in patients with viability and ESVI >84 ml/m2 (HR: 0.87; 95% CI: 0.57 to 1.31). Other ESVI thresholds yielded similar results, including ESVI ≤60 ml/m2 (HR: 0.87; 95% CI: 0.44 to 1.74). ESVI and viability assessed as continuous rather than dichotomous variables yielded similar results (p = 0.562).ConclusionsAmong patients with ischemic cardiomyopathy, those with greater LV ESVI and no substantial viability had worse prognosis. However, the effect of CABG relative to medical therapy was not differentially influenced by the combination of these 2 factors. Lower ESVI did not identify patients in whom myocardial viability predicted better outcome with CABG relative to medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595

Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery.

Postoperative bleeding is common after cardiac surgery. Major bleeding (MB) is a determinant of red blood cell (RBC) transfusion, especially in patients with preoperative anemia. Preoperative anemia and RBC transfusions are recognized risk factors for operative mortality. The present study investigates the role of MB as an independent determinant of operative mortality in cardiac surger

Coronary artery fistulas: clinical consequences and methods of closure. A literature review

Coronary fistulas are uncommon anomalies of congenital and rarely iatrogenic etiology. Their clinical significance is mainly dependent on the severity of the left-to-right shunt they are responsible for. Symptoms, high-flow shunting and the occurrence of complications, only partially related to the magnitude of the shunt, are the main indications for their closure, especially in the adult population. Pediatric patients, even asymptomatic but presenting with electrocardiographic or chest X-ray abnormalities, should be treated in order to avoid the long-term complications related to the presence of the fistula. Treatment of adult asymptomatic patients with non-significant shunting is still a matter of debate. Surgery and direct epicardial or endocardial ligation were traditionally viewed as the main therapeutic method for the closure of coronary fistulas. Progress in the techniques of endoluminal intervention has led to fistula embolization using different devices including coils, balloons and chemicals. The success rate is good and the procedure-related morbidity acceptable

Right Ventricular Pulmonary Hypertension

In heart failure (HF) syndrome, the development of pulmonary hypertension (PH), right ventricular (RV) dysfunction and failure are ominous prognostic signs. Pathophysiology, clinical interest and targeted therapeutic approaches for left-sided PH and its consequences on RV function have been traditionally confined to advanced HF stages. Community- and population-based studies have clearly indicated that PH is frequent even in HF patients with preserved ejection fraction, and may carry important prognostic implications in normal ageing as well. HF guidelines are inconclusive on both preventive and curative strategies for left-sided PH and its consequences on RV function. The search for new therapeutic opportunities targeted on pulmonary vascular and right heart remodeling are an important challenge for the future

Surgical ventricular restoration : is there any difference in outcome between anterior and posterior remodeling?

The purpose of this study was to compare the early and long-term outcomes in a consecutive population who underwent surgical ventricular reconstruction (SVR) for either anterior or posterior remodeling. METHODS: Among 501 consecutive patients who underwent SVR at our institution between July 2001 and December 2011, 56 patients presented with posterior remodeling (group A; mean age, 65 \ub1 10 years), whereas anterior remodeling was evident in 445 patients (group B; mean age, 65 \ub1 9 years). The 2 groups were comparable regarding cardiac risk factors and comorbidities. Patients in group A presented with larger left ventricles, higher left ventricular (LV) cardiac mass, and higher ejection (EF) and stroke volume (p = 0.01) compared with patients in group B. Moderate to severe mitral regurgitation was present in 50% and 25% of patients in groups A and B, respectively (p = 0.01). RESULTS: Thirty-day mortality was not significantly different between the 2 groups (5.4% versus 8.3% in groups A and B, respectively; p = 0.32). At logistic regression analysis, only preoperative age, creatinine, and ejection fraction (ACEF) score was an independent predictor of early mortality. Sixteen patients (29%) in group A and 92 patients (21%) in group B died during follow-up (p = 0.12). Kaplan-Meier cumulative survival was comparable between the 2 groups (log-rank p = 0.27). At multivariate Cox regression analysis, preoperative age, advanced New York Heart Association (NYHA) class, preoperative severe mitral regurgitation (MR), and preoperative tricuspid annular plane systolic excursion (TAPSE) score less than 16 were independent predictors of late mortality. CONCLUSIONS: Patients presenting with posterior remodeling showed worse clinical signs of angina and congestive heart failure (CHF) and a higher proportion of moderate to severe MR; however in the present experience early and long-term outcomes after SVR seemed to be unaffected by remodeling location

Mitraclip procedure as a bridge therapy in a patient with heart failure listed for heart transplantation

Functional mitral regurgitation (MR) is frequently detected in patients with dilated cardiomyopathy and advanced heart failure, worsening quality of life and predicting poor survival. However, the optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a 55-year-old man with previous aortic valve replacement, severe MR with high-grade pulmonary hypertension, and refractory heart failure (HF). He was listed for cardiac transplant and underwent percutaneous MitraClip implantation as bridge therapy. The postoperative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 8 months after the procedure

Successful Concomitant Treatment of a Coronary-to-Pulmonary Artery Fistula and a Left Anterior Descending Artery Stenosis Using a Single Covered Stent Graft: A Case Report and Literature Review

This report describes a case of a 47-year-old man who presented with early post-Q wave myocardial infarction angina and an atherosclerotic left anterior descending stenosis associated to a coronary-to-pulmonary artery fistula. Both coronary stenosis and fistula were successfully treated with a single polytetrafluoroethylene-covered stent graft implantation by intravascular ultrasound-guided procedure