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Ann Thorac Surg 1995;60:1059-1062
© 1995 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Left Ventricular End-Systolic Volume Index in Patients With Ischemic Cardiomyopathy Predicts Postoperative Ventricular Function

Atsushi Yamaguchi, MD, Takashi Ino, MD, Hideo Adachi, MD, Akihiro Mizuhara, MD, Seiichiro Murata, MD, Hitoshi Kamio, MD

Department of Cardiovascular Surgery, Jichi Medical School, Omiya Medical Center, Saitama, Japan

Accepted for publication May 1, 1995.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. We investigated the usefulness of the preoperative left ventricular end-systolic volume index (LVESVI) as a predictor of postoperative ventricular function.

Methods. We retrospectively reviewed the records of 310 patients who underwent coronary artery bypass grafting and identified 20 patients with ischemic cardiomyopathy with a preoperative ejection fraction less than 0.30. We determined the preoperative and postoperative ejection fraction, LVESVI, and left ventricular end-diastolic volume index using biplane left cineventriculography. Patients were divided into groups depending on whether their preoperative LVESVI was less than 100 mL/m2 (group A, n = 10) or greater than 100 mL/m2 (group B, n = 10).

Results. The mean ejection fraction increased significantly after coronary artery bypass grafting in group A from 0.25 ± 0.05 to 0.40 ± 0.09 (p < 0.01), but did not change significantly in group B (0.26 ± 0.05 versus 0.23 ± 0.06). The mean LVESVI decreased significantly in group A from 83.2 ± 13.7 to 61.7 ± 20.4 mL/m2 after operation (p < 0.05), but did not change significantly in group B (124.7 ± 21.0 versus 121.5 ± 37.6 mL/m2). In group B, 4 patients had signs of congestive heart failure during the follow-up period and had to be rehospitalized.

Conclusions. The mean ejection fraction improved significantly after coronary artery bypass grafting in patients with a preoperative LVESVI less than 100 mL/m2, despite the presence of a global left ventricular ejection fraction less than 0.30. Our results suggest that the preoperative LVESVI predicts the postoperative status and left ventricular function in patients with ischemic cardiomyopathy.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Coronary artery bypass grafting (CABG) has been found to be more beneficial than medical therapy [1–3] and coronary angioplasty [4] in patients with coronary artery disease in whom left ventricular function is impaired. However, the presence of left ventricular dysfunction, as indicated by an ejection fraction (EF) less than 0.30, is a major risk factor for surgery and for late mortality after CABG despite improvements in anesthesia, myocardial protection strategies, and postoperative pharmacologic and mechanical support [2, 5]. The most commonly used index of left ventricular dysfunction is the EF, which is measured during cardiac catheterization. However, it is not clear whether the EF is the most meaningful index of left ventricular dysfunction or the most useful prognostic indicator of postoperative status. Two potential mechanisms of an impaired EF have been proposed: poor contractile function due to extensive myocardial damage or continuing ischemia (so-called hibernating myocardium [6]), and left ventricular dilatation caused by infarct expansion and stretching of the myocardial scar. The main problem in patients with chronic ischemic cardiomyopathy is to distinguish hibernating myocardium from myocardial fibrosis.

We determined the left ventricular end-systolic volume index (LVESVI) in patients with left ventricular dysfunction using biplane left cineventriculography [7] to determine whether the preoperative LVESVI reflects the presence of hibernating myocardium and predicts postoperative left ventricular function.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Of the 310 patients who underwent isolated CABG at Omiya Medical Center between January 1990 and August 1994, 30 patients (9.8%) had left ventricular dysfunction due to ischemic cardiomyopathy, as indicated by a preoperative EF less than 0.30. We retrospectively assessed the usefulness of the preoperative LVESVI as an index of postoperative ventricular function in 20 of 30 patients who underwent both preoperative and postoperative biplane cineventriculography during left heart catheterization. Of 30 patients, one died of low output syndrome and irreversible ventricular fibrillation 28 days after CABG, with preoperative LVESVI and EF values of 152.3 mL/m2 and 0.098, respectively. Five patients were not subjected to postoperative cineventriculography because of renal failure, and 4 were evaluated postoperatively at other institutions. These 10 patients were excluded from the following comparison. Patients were classified into groups according to whether their preoperative LVESVI was less than 100 mL/m2 (group A, n = 10) or greater than 100 mL/m2 (group B, n = 10) (Table 1Go). Old myocardial infarctions were confirmed by history and electrocardiographic findings. Six patients of group A and 9 patients of group B suffered congestive heart failure with New York Heart Association (NYHA) class III to IV and received medical therapy with diuretic agents. Five patients of each group with unstable angina refractory to medical treatment required intraaortic balloon pumping. Urgent CABG was performed in 8 patients with unstable angina.


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  		Table 1. . Patient Profile
 
Coronary artery bypass grafting was performed using moderate systemic hypothermia (28°C), topical surface cooling with cold saline solution (4°C), and a membrane oxygenator. All patients underwent aortic cross clamping, blood cardioplegia (16°C), and complete myocardial revascularization. Treatment with inotropic agents was initiated before discontinuation of cardiopulmonary bypass in all cases.

Preoperative and postoperative cardiac catheterizations were performed in 20 patients. Postoperative studies were performed a mean of 28 days after CABG. Simultaneous biplane left cineventriculography was obtained in the 30-degree right anterior oblique and 60-degree left anterior oblique projections. Left cineventriculograms were projected on a video monitor, and the left ventricular silhouettes at end-diastole and end-systole were traced onto a commercial computer system (Cardio 500; Kontron, MA). The images were digitized to obtain the left ventricular volume. The LVESVI, left ventricular end-diastolic volume index (LVEDVI), and EF were calculated from the biplane data and an equation [7] that has been found to be superior to the area-length method [8] for evaluation of left ventricular volume.

Follow-up information was obtained during patient visits to an outpatient facility at our medical center or by telephone interviews. The mean duration of follow-up was 21 months (range, 2 to 55 months). Complete follow-up data were available in 20 patients. Heart failure status was determined according to the NYHA criteria.

Data are presented as the mean ± standard deviation. Perioperative changes in LVESVI, LVEDVI, and EF within each group were analyzed by Student's paired t test. Between-group differences were analyzed by the unpaired t test.


   Results
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The mean EF increased significantly after CABG in group A, from 0.25 ± 0.05 to 0.40 ± 0.09 (p < 0.01), but did not change in group B (0.26 ± 0.05 versus 0.23 ± 0.06). There was no significant difference between groups in the preoperative EF, but the postoperative EF was significantly higher in group A than in group B (p < 0.05). There was no correlation between preoperative and postoperative EFs in the overall study population (Fig 1Go).



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  		Fig 1. . Preoperative and postoperative ejection fractions (EF). (Closed circles = group A; open circles = group B.)

 
The mean LVESVI decreased significantly after CABG in group A, from 83.2 ± 13.7 to 61.7 ± 20.4 mL/m2 (p < 0.05), but did not change significantly in group B (124.7 ± 21.0 versus 121.5 ± 37.6 mL/m2). The preoperative and postoperative mean LVEDVIs in group A (112.2 ± 20.3 mL/m2 preoperatively and 101.1 ± 23.5 mL/m2 postoperatively) were significantly smaller than those in group B (167.8 ± 28.1 mL/m2 and 157.6 ± 43.6 mL/m2, respectively). There was no significant difference between the preoperative and postoperative mean LVEDVI either in group A or group B. The postoperative EF was greater than 0.30 in 9 of 10 patients with a preoperative LVESVI less than 100 mL/m2 and in only 2 of 10 patients with a preoperative LVESVI greater than 100 mL/m2. The postoperative EF was less than 0.30 in 8 of 10 patients with a preoperative LVESVI greater than 100 mL/m2 (Fig 2Go).



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  		Fig 2. . Relation between the preoperative left ventricular end-systolic volume index (LVESVI) and the postoperative ejection fraction (EF). (Closed circles = group A; open circles = group B.)

 
Most patients were in NYHA class I or II after CABG. In group A, 8 patients were in class I and 1 was in class II; in group B, classes I to IV included 3, 3, 2, and 2 patients, respectively. One patient in group A died 24 months after the operation of occlusion of the bypass graft and progressive heart failure. Her preoperative EF and LVESVI were 0.24 and 92.8 mL/m2, respectively. Evidence of congestive heart failure (NYHA class III--IV) was detected in 4 patients in group B during the follow-up period. The LVESVI was greater than 100 mL/m2 (range, 112.2 to 134.2 mL/m2) in these patients, who required rehospitalization.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The prognosis of ischemic cardiomyopathy is poor, particularly when coronary artery disease is diffuse and left ventricular dysfunction is severe in patients with an EF less than 0.35. Pigott and associates [2] found that the 7-year mortality rate was 66% in 133 patients who received medical treatment and 37% in 77 patients who underwent operation. Kron and co-workers [9] reported a 3-year surgical mortality rate of 17% in 39 patients with ischemic cardiomyopathy who had left ventricular EF less than 0.20. Surviving patients continued to have severe heart failure, and seven of eight late deaths were due to arrhythmia. The results of these studies confirm that advanced left ventricular dysfunction is associated with a poor long-term prognosis and increases the risk of death associated with CABG. However, an operation appears to revitalize ischemic, but not irreversibly damaged, myocardium with an acceptable level of risk in carefully selected patients.

A major concern is whether coronary revascularization in patients with severe left ventricular dysfunction will improve ventricular function and survival. Chronically ischemic heart muscle that may demonstrate improved function if successfully revascularized has been described as ``hibernating myocardium'' [6]. When myocardial perfusion is chronically reduced but still sufficient to maintain the viability of the tissue, myocardial function may remain impaired as long as myocardial perfusion remains inadequate. Impairment of myocardial contractile function under ischemic conditions may be a protective mechanism whereby ischemia and cellular necrosis are limited as a result of a reduction in oxygen demand. Revascularization increases blood flow to ischemic areas and subsequently improves ventricular function in viable myocardium. The goals of coronary revascularization are to preserve the remaining myocardial function, prevent further loss of functioning myocardium, and recruit hibernating myocardium to improve ventricular function. Therefore, the main problem in patients with ischemic cardiomyopathy is to distinguish hibernating myocardium from myocardial fibrosis. There are no reliable criteria for identifying patients with ischemic cardiomyopathy who will benefit from myocardial revascularization. Left ventricular function is usually evaluated in terms of the EF, but it is not clear that the EF can differentiate myocardium that is depressed because of reversible ischemia from myocardium that is depressed by fibrosis from a previous infarction. A low EF may, on the one hand, be caused by poor contractile function due to extensive myocardial damage and continuing ischemia or, on the other hand, to left ventricular dilatation caused by infarct expansion and stretching of the myocardial scar. Furthermore, these conditions may coexist in the same patient. The present results show that there is no relation between preoperative and postoperative EFs in patients with ischemic cardiomyopathy, suggesting that the preoperative EF alone is not enough to predict postoperative status after revascularization.

Myocardial infarct expansion increases left ventricular systolic and diastolic volumes, resulting in an increase in wall stress. Thus, an elevated left ventricular volume may be a more specific indicator of the presence of myocardial fibrosis in patients with ischemic cardiomyopathy than is the resting EF. Louie and colleagues [10] reported that a preoperative left ventricular end-diastolic dimension less than 70 mm adequately predicted successful revascularization in patients with EF less than 0.30. Pigott and associates [2] found that the late survival rate was lower in surgically treated patients with an elevated left ventricular end-diastolic volume (greater than 100 mL/m2) than in patients with a normal end-diastolic volume. White and co-workers [11] have suggested that determination of the left ventricular end-systolic volume by quantitative left cineventriculography was more specific for distinguishing between hypertrophic and dilatational cardiomegaly and that an end-systolic volume greater than 100 mL was a better predictor of postmyocardial infarction mortality than an increased end-diastolic volume or a decreased EF. When the EF is correlated with left ventricular size, either by volume or by dimensions, it may provide a better understanding of different clinical findings. The mean EF increased significantly in patients with an LVESVI less than 100 mL/m2 but not in patients with an LVESVI greater than 100 mL/m2 after CABG. Regional wall motion also improved after CABG in patients with an LVESVI less than 100 mL/m2. Although the LVESVI is independent of preload and dependent on afterload, our results suggest that the LVESVI may be a significant predictor of postoperative status. An LVEDVI in patients with an LVESVI greater than 100 mL/m2 before operation was greater than that in patients with the LVESVI less than 100 mL/m2. We can conclude that the larger hearts, both in diastolic and systolic dimensions, indicate a worse response to CABG.

Studies have suggested that surgery should be considered in patients with heart failure who have severe left ventricular dysfunction, especially in the presence of angina, when medical therapy does not reduce symptoms [12, 13]. In a study by Goor and colleagues [14], all operative deaths occurred in patients with cardiomegaly who had a cardiothoracic ratio greater than 50%. Dreyfus and associates [15] and Milano and co-workers [16] suggested that the left ventricle is overdistended in patients with a pulmonary artery pressure greater than 40 mm Hg and a cardiac index less than 1.5 L• min-1•m-2, and that these patients are not candidates for CABG. Status can also help the selection of patients with an impaired left ventricle, despite being less objective or reproducible than cineventriculography or echocardiography.

We used equations [7] to calculate ventricular volumes from the biplane cinefluorographic data. This method has been found to be more accurate than the area-length method, which is obtained from a single plane cinefluorogram [8]. Because the biplane method can detect an actively contracting septum or posterolateral wall, it has less error than the area-length method.

Our results showed that an LVESVI less than 100 mL/m2 in patients with a global left ventricular EF less than 0.30 was associated with a significant increase in the post-CABG EF. This finding suggests that the preoperative LVESVI may be a significant predictor of postoperative status and left ventricular function and may reflect the existence of hibernating myocardium. Our results suggest that preoperative evaluation of the left ventricular volume by biplane cineventriculography may be useful for selecting patients with ischemic cardiomyopathy who are likely to benefit from CABG.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Yamaguchi, 1-847 Amanuma Omiya City, Saitama, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Elefteriades JA, Tolis G Jr, Levi E, Mills LK, Zaret BL. Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol 1993;22:1411–7.[Abstract]
  2. Pigott JD, Kouchoukos NT, Oberman A, Cutter GR. Late results and medical therapy for patients with coronary artery disease and depressed left ventricular function. J Am Coll Cardiol 1985;5:1036–45.[Abstract]
  3. Alderman EL, Fisher LD, Litwin P, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983;68:785–95.[Abstract/Free Full Text]
  4. O'Keefe JH Jr, Allan JJ, McCallister BD, et al. Angioplasty versus bypass surgery for multivessel coronary artery disease with left ventricular ejection fraction <=40%. Am J Cardiol 1993;71:897–901.[Medline]
  5. Lansman SL, Cohen M, Galla JD, et al. Coronary bypass with ejection fraction of 0.20 or less using centigrade cardioplegia: long-term follow-up. Ann Thorac Surg 1993;56:480–6.[Abstract]
  6. Rahimtoola SH. A perspective on the three large multicenter randomized clinical trials of coronary bypass surgery for chronic stable angina. Circulation 1985;72(Suppl 5):123–35.
  7. Chapman CB, Baker O, Reynolds J, Bonte FJ. Use of biplane cinefluorography for measurement of ventricular volume. Circulation 1958;18:1105–17.[Medline]
  8. Sheehan FH. Cardiac angiography. In: Marcus ML, Schelbert HR, Skorton DJ, Wolf GL, eds. Cardiac imaging: a companion to Braunwald's heart disease. Philadelphia: Saunders, 1991:109--48.
  9. Kron IL, Flanagan TL, Blackbourne LH, Schroeder RA, Nolan SP. Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy. Ann Surg 1989;210:348–54.[Medline]
  10. Louie HW, Laks H, Milgalter E, et al. Ischemic cardiomyopathy. Criteria for coronary revascularization and cardiac transplantation. Circulation 1991;84(Suppl 3):290–5.
  11. White HD, Norris RM, Brown MA, Brandt PWT, Whitlock RML, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987;76:44–51.[Abstract/Free Full Text]
  12. Manley JC, King JF, Zeft HJ, Johnson WD. The ``bad'' left ventricle. Results of coronary surgery and effect on late survival. J Thorac Cardiovasc Surg 1976;72:841–8.[Abstract]
  13. Wechsler AS, Junod FL. Coronary bypass grafting in patients with chronic congestive heart failure. Circulation 1989;79(Suppl 1):92–6.
  14. Goor DA, Golan M, Bar-El Y, et al. Synergism between infarct-borne left ventricular dysfunction and cardiomegaly in increasing the risk of coronary bypass surgery. J Thorac Cardiovasc Surg 1992;104:983–9.[Abstract]
  15. Dreyfus GD, Duboc D, Blasco A, et al. Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization. Ann Thorac Surg 1994;57:1402–8.[Abstract]
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