Ann Thorac Surg 2008;85:1339-1343. doi:10.1016/j.athoracsur.2007.12.065
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Left Ventricular Reconstructive Surgery in Ischemic Dilated Cardiomyopathy Complicated With Cardiogenic Shock
Koji Takeda, MD,
Goro Matsumiya, MD*,
Hajime Matsue, MD,
Masayuki Sakaki, MD,
Taichi Sakaguchi, MD,
Tomoyuki Fujita, MD,
Yoshiki Sawa, MD
Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Accepted for publication December 26, 2007.
* Address correspondence to Dr Matsumiya, Osaka University Graduate School of Medicine, Department of Surgery, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan (Email: matsumg{at}surg1.med.osaka-u.ac.jp).
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Abstract
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Background: The feasibility of left ventricular restoration for patients with ischemic cardiomyopathy complicated with cardiogenic shock remains unclear. We report early and mid-term outcomes of surgical interventions including left ventricular restoration for patients with cardiogenic shock.
Methods: From April 2001 to June 2007, 10 patients with ischemic cardiomyopathy who developed cardiogenic shock underwent left ventricular restoration combined with mitral annuloplasty or coronary artery bypass grafting. All had been supported by a maximum dose of inotropic agents, 8 had required an intraaortic balloon pump, and 1 had required extracorporeal life support. Mean left ventricular end-diastolic and end-systolic volume indices were 142 ± 33 mL/m2 and 113 ± 28 mL/m2, respectively, and ejection fraction was 0.21 ± 0.059.
Results: There was no mortality at 30 days. Five patients demonstrated significant recovery after the operation. Three patients simultaneously underwent left ventricular assist system (LVAS) implantation with left ventricular restoration because of preexisting severe end-organ failure, and 2 of them were subsequently weaned from LVAS, although 1 required reimplantation. The other 2 patients eventually underwent LVAS implantation in the early postoperative period. Two patients who required prolonged LVAS support underwent successful heart transplantation. Seven patients are alive at a mean follow-up of 1.9 years. Patients who required prolonged LVAS support had significantly longer duration of heart failure symptoms (p = 0.04) and higher mean pulmonary artery pressure (p = 0.02) preoperatively.
Conclusions: Early combined surgical interventions including left ventricular restoration can be a choice of treatment even in patients with ischemic cardiomyopathy complicated with cardiogenic shock. Additional use of the LVAS followed by bridge to recovery or transplantation should be appropriately applied in these critically ill patients.
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Introduction
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The efficacy and safety of left ventricular restoration (LVR) has been described in patients with relatively stable congestive heart failure symptoms and preserved end-organ function [1]. However, reports on surgical results of LVR in patients with cardiogenic shock have been limited [2–4]. Because of the poor outcomes reported in early experiences, this subset of patients is generally treated with mechanical circulatory support and subsequent heart transplantation [5]. However, in countries in which donor organ supply is severely limited, another approach is required to maximize the chance of the patient’s recovery. In this study, we present a series of patients with ischemic cardiomyopathy complicated with cardiogenic shock who underwent LVR with combined surgical procedures, and examine their early and mid-term outcomes.
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Patients and Methods
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Patients
From August 2001 to June 2007, 10 patients with ischemic cardiomyopathy complicated with cardiogenic shock underwent LVR. Clinical, hemodynamic, and surgical follow-up data were retrospectively reviewed after internal review board approval. Written informed consent was given to all patients. Ages ranged from 31 to 73 years and all were male. Characteristics of individual patients are shown in Table 1. All patients were transferred with diagnoses of cardiogenic shock secondary to ischemic cardiomyopathy requiring maximum medical therapy. Patients with recent myocardial infarction (within 30 days) were not included in this study, because we do not perform LVR in this setting. Three patients had previously undergone coronary artery bypass grafting, and 7 had undergone percutaneous catheter revascularization. Six patients had no residual stenosis in the coronary artery system. Assessment of viability by myocardial scintigram had been done before the hemodynamic deterioration in 8 patients, and this showed no residual viability in the anteroseptal area and no large ischemic area in other parts. All patients had been intubated and supported with inotropic agents. Eight patients had been supported by intraaortic balloon pump, and 1 had required extracorporeal life support. End-organ failure included acute renal failure requiring hemodialysis (n = 4), hepatic dysfunction involving elevated serum bilirubin level (>2 mg/dL; n = 4), and pneumonia (n = 1). On echocardiographic study, mean left ventricular end-diastolic and end-systolic volume indices (LVEDVI and LVESVI) were 142 ± 33 mL/m2 and 113 ± 28 mL/m2, respectively, and mean left ventricular ejection fraction was 0.21 ± 0.059. More than mild mitral regurgitation was detected in 8 patients. Cardiac catheterization showed mean pulmonary artery pressure of 32 ± 8.1 mm Hg and mean cardiac index of 2.0 ± 0.3 L · min–1
· m–2.
Operations
Left ventricular restoration was applied to patients with a dyskinetic or akinetic anteroseptal infarcted scar. The selection of the type of LVR depended on the extent of the infarcted scar. When the scar extended to the proximal anteroseptal area, we preferred to perform septal anterior ventricular exclusion [6] or overlapping procedure [7] instead of a Dor-type procedure, which applies a pursestring suture at the transitional zone (Fontan stitch). In septal anterior ventricular exclusion, a longitudinal Dacron patch (2.5 x 7 cm) was sutured to the transitional zone to exclude a broad anteroseptal scar without a Fontan stitch [6]. In the overlapping procedure, the left marginal incision was sutured to the septum and the right marginal incision was sutured to the epicardium to cover the left ventricular free wall without a patch [7]. Restrictive mitral annuloplasty (two sizes smaller than measured size) was performed for more than mild regurgitation. Coronary artery bypass grafting was performed, aiming at complete revascularization. Whether or not to perform simultaneous left ventricular assist system (LVAS) implantation depends on the degree of end-organ dysfunction after cardiogenic shock [8]. When we performed LVAS implantation, the ventriculotomy line was closed, leaving the apical area open for the insertion of inflow cannula. Technical details were described previously [9].
Statistical Analysis
The SPSS (version 11.0, SPSS Inc, Chicago, IL) software was used for statistical analysis. The quantitative data are presented as mean ± standard deviation. Values obtained from preoperative and postoperative data were compared by using a paired Student’s t test. The unpaired Students t test was used to compare groups. Statistical significance was defined as a probability value less than 0.05.
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Results
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All operations were performed emergently or urgently under cardiopulmonary bypass and cardioplegic cardiac arrest. The type of LVR was septal anterior ventricular exclusion [6] in 4, Dor procedure in 2, and overlapping procedure [7] in 4 patients. Coronary artery bypass grafting was performed in 4 patients. Two of them underwent grafting to the anterior descending artery to relieve small residual septal ischemia. Other procedures performed during the operations were restrictive mitral annuloplasty using a Carpentier Edwards Physio Ring (Edward Lifesciences, Irvine, CA) in 8 patients, tricuspid annuloplasty in 3, cryoablation of the transitional zone for preoperative ventricular tachycardia in 2, and maze procedure in 1 patient. The LVAS (Toyobo-NCVC, Nipro, Japan) was simultaneously implanted at the initial operation in 3 patients who presented with profound end-organ dysfunction. The remaining 7 patients were successfully weaned from cardiopulmonary bypass with the aid of intraaortic balloon pump. Mean cardiopulmonary and aortic cross-clamp time were 198 ± 80 and 111 ± 38 minutes, respectively.
Table 2
shows the early and late outcomes in the individual patients. There was no hospital mortality at 30 days. Two patients could not be weaned from the support of the intraaortic balloon pump and required LVAS (Toyobo-NCVC, Nipro, Japan, in 1, Heart Mate IP, Thoratec Corp, Pleasanton, CA, in 1) implantation on the fourth and fourteenth postoperative days after the initial operation, respectively. Eventually, 5 patients (50%) required LVAS support. The mean duration of LVAS support was 562 ± 528 days (range, 67 to 1,247 days). Figure 1
demonstrates the change of left ventricular volume and left ventricular ejection fraction before and after the operation in individual patients. In patients who received LVAS, those variables were assessed during a temporary device halt [10]. Overall, LVEDVI and LVESVI significantly decreased to 89 ± 17 and 58 ± 12 mL/m2, respectively (p < 0.001 for each). Left ventricular ejection fraction significantly improved to 0.32 ± 0.069 (p = 0.001).
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Fig 1. Change of left ventricular volumes and ejection fraction (LVEF) in each patient. Open circles indicate patients who did not require left ventricular assist system support. Filled circles represent patients who required left ventricular assist system, in whom postoperative variables were obtained at the time of temporary left ventricular assist system halt to assess recovery of left ventricular function. * indicates patients who were weaned from left ventricular assist system (see text for detail). (LVEDVI = left ventricular end-diastolic volume index; LVESVI = left ventricular end-systolic volume index; Post = postoperative; Pre = preoperative.)
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Two patients underwent LVAS explantation after significant myocardial recovery after 67 and 78 days of support. Left ventricular ejection fraction during the temporary LVAS halt was 0.32 and 0.35, respectively (Fig 1). One patient required reimplantation of LVAS as a result of recurrent heart failure 85 days after device removal and eventually died of cerebral hemorrhage 240 days after the operation. The other was discharged home in New York Heart Association functional class II at 3.8 years after the LVAS removal. In the remaining 3 patients, cardiac function did not show significant recovery. Mean left ventricular ejection fraction during the temporal LVAS halt was 0.23 ± 0.023. Of those, 2 were successfully bridged to cardiac transplantation at 1,247 and 958 days postoperatively. One patient, who required hemodialysis because of persistent renal failure, died of sepsis associated with device infection.
Five patients who did not require LVAS were weaned from intraaortic balloon pump in the early postoperative period without significant end-organ failure and discharged home. In these patients, the latest echocardiography showed an left ventricular ejection fraction of 0.36 ± 0.051. During the follow-up period, 1 patient died of progressive renal failure. The remaining 4 patients are alive and are in New York Heart Association functional class II or III at 1.3 ± 1.5 years postoperatively. Eventually, 7 patients (70%) were alive at a mean postoperative follow-up of 1.9 ± 1.6 years.
Table 3
shows the comparison of preoperative variables according to the requirement of long-term LVAS support without functional recovery. Four patients who required long-term LVAS support had longer duration of heart failure symptoms (p = 0.04) and significantly higher preoperative mean pulmonary artery pressure (p = 0.02) than those who did not require long-term LVAS support (Table 3).
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Table 3 Comparison of Preoperative Variables According to the Requirement of Long-Term Left Ventricular Assist System Support
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Comment
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Despite the improvement of medical management for congestive heart failure, patients who experience decompensated chronic heart failure with profound shock continue to have dismal outcomes [11]. Moreover, patients whose disease has ischemic origins have a worse prognosis than those with other causes [12].
As an emerging treatment option, LVR has been increasingly used as one of the surgical interventions for ischemic cardiomyopathy [1–4, 6]. Recently, the RESTORE group has shown its excellent mid-term outcomes with acceptable operative mortality [1]. Nonetheless, it is unclear whether a good result is obtained in patients with advanced heart failure complicated with cardiogenic shock because of their poor cardiac function and the presence of end-organ dysfunction. Alternative treatment strategies may, therefore, be required to improve the prognosis in these high-risk patients.
A few reports have demonstrated the outcomes of LVR in patients with cardiogenic shock. Bolooki and colleagues [3] described their 22-year experience of LVR. Their study included 26 patients with cardiogenic shock. Although 25 of them underwent linear repair, which is a different technique from that of the RESTORE group and ours, they reported a high operative mortality of 46% and a poor 3-year survival of 36%. We obtained better early and mid-term results. Although patients were critically ill, there was zero mortality at 30 days, and 7 patients (70%) are doing well on an outpatient basis at 2-year follow-up.
We aggressively performed various surgical interventions including revascularization and reduction of mitral regurgitation, which might have also been beneficial to functional improvements. Especially, the patients who did not require LVAS might have obtained more benefit from revascularization and mitral valve surgery rather than the LVR itself because all of those patients underwent simultaneous coronary artery bypass grafting or restrictive mitral annuloplasty (Table 2). However, several reports have suggested that the effects of coronary artery bypass grafting with or without mitral valve surgery in patients with extensive ventricular remodeling are limited in terms of reverse remodeling and survival benefit [13–15]. Our patients had an extensively dilated left ventricle with an anterior myocardial scar. Consequently, we think that coronary artery bypass grafting or mitral valve operation was not sufficient, and LVR was feasible when we aimed at significant improvements of left ventricular function by surgical ventricular remodeling. There still exists no conclusive data about the role of LVR itself for ischemic cardiomyopathy because of the lack of a randomized study. The Surgical Treatment for Ischemic Heart Failure trial may address these controversial issues in a randomized controlled setting [16]. It should be also considered that concomitant LVR might have increased operative risks attributable to prolonged cross-clamp time, especially in high-risk patients; however, we did not have operative mortality. This might be explained by the timely application of the LVAS either concurrent with or subsequent to the LVR.
Although our study does not have statistically strong power because of the small number of patients, a better outcome was obtained in patients with a shorter duration of preoperative heart failure symptom. Because of the delayed surgical interventions, the patients who required long-term LVAS support had significantly higher pulmonary artery pressure, a trend toward a more enlarged left ventricle, and worse preoperative hepatic and renal function (Table 3). Early surgical interventions including revascularization and restoration of left ventricular size before progression of irreversible myocardial and end-organ injury might improve outcomes.
In our series, 5 of 10 patients required LVAS support because of poor recovery of left ventricular function or the presence of end-organ dysfunction. In many of the patients with cardiogenic shock, we think that LVR alone is insufficient to overcome perioperative end-organ failure because of marginal LV function [8, 9] and that the implantation of LVAS alone and subsequent transplantation are generally indicated for this complicated subset of patients. Perhaps our patients would have been bridged to transplantation with the application of LVAS alone. However, the severe shortage of donors remains problematic. In our country, many patients with LVAS need to wait for more than 2 years before heart transplantation [10]. Although the use of LVAS as a destination therapy could be another treatment option for patients with end-stage heart failure [17], the device availability is still limited in many countries. This circumstance makes us consider options to maximize the chances of a bridge to recovery while they wait for transplantation. Although we have reported both the beneficial influence of LVAS on end-organ function and the possibility of myocardial recovery during prolonged LVAS support [10], LVAS alone is not likely to provide a good chance of bridge to recovery in patients with ischemic cardiomyopathy. Although 4 of 5 patients requiring LVAS ended up with death or transplantation, a certain population of patients showed functional recovery of the left ventricle and achieved weaning from the LVAS. Although further modification such as simultaneous cellular therapy might be required to obtain better myocardial recovery, we believe that surgical interventions including LVR and simultaneous LVAS implantation can provide not only a good chance of end-organ recovery but also more chance for recovery of left ventricular function in severely ill patients.
In conclusion, the timely application of LVR with aggressive combined surgical procedures can be a choice of treatment even in ischemic dilated cardiomyopathy patients complicated with cardiogenic shock. Appropriate use of LVAS aiming at a bridge to recovery or transplantation could be a treatment option to improve the outcomes.
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References
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Abstract
Introduction
