Surgical ventricular restoration in end-stage ischemic cardiomyopathy patients.

BACKGROUND

Surgical ventricular restoration (SVR) has generally been contraindicated in patients with an ejection fraction (EF) <20%, with pulmonary arterial (PA) pressure >60 mm Hg, and being treated with inotropic agents.

PATIENTS AND

METHODS

The patients in this study were 6 men and 5 women 50 to 78 years of age (mean, 62.4 years). Three patients were in New York Heart Association (NYHA) class III with an EF <30%. Eight patients were in NYHA class IV with EF <20%, PA pressure >70 mm Hg, and left ventricular asynergy. Three patients had had recent myocardial infarction (MI) with shock and multiple organ failure. Three patients had mitral regurgitation, 1 patient had ventricular septal defect (VSD), 4 patients had diabetes mellitus, and 5 had morbid obesity. All patients underwent intraoperative transesophageal echocardiography and were being treated with milrinone or nesiritide. Seven patients had intraaortic balloon pumps. All patients underwent coronary artery bypass (CAB), receiving 1 to 5 (average, 3.54) grafts per patient. The SVR (Dor) procedure was performed with a Chase Mannequin device. Preoperative end-diastolic volume was 240 to 330 mL, and postoperative volume decreased to 110 to 130 mL. Two patients underwent mitral valve repair, and 1 underwent VSD closure. One patient underwent microwave ablation for atrial fibrillation.

RESULTS

Ten (91%) of 11 patients were discharged home in 10 to 14 days. There was 1 death: A 78-year-old man with acute MI died 43 days later of septic shock due to hemodialysis.

CONCLUSION

End-stage ischemic cardiomyopathy patients with EF <20% can safely undergo surgery after meticulous preoperative preparation to decrease PA pressure, pulmonary capillary wedge pressure, and peripheral vascular resistance and to increase CO by SVR, CAB, and correction of associated lesions. Mortality was 9% with improved hemodynamics and relief of congestive heart failure in all survivors for 3 to 12 months.