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Ann Thorac Surg 2007;83:1387-1388
© 2007 The Society of Thoracic Surgeons
David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 62-258 CHS, Los Angeles, CA 90095
(Email: gbuckberg{at}mednet.ucla.edu).
End points about death and need for transplantation are the traditional, hard outcome markers about the quantity of life after surgical interventions for congestive heart failure, yet the central theme for patients relates to how an operation influences their quality of life as assessed by functional and mental outcomes. Sartipy and associates [1] show progression toward normal outcomes when incapacitated heart failure patients undergoing surgical ventricular restoration are compared with the overall Swedish population. These data provide a snapshot preview of how quality of life (QOL) is altered by this procedure. Clinical overall results from this smaller study cohort closely matches the early and late mortality and New York Heart Association data from greater than 1,000 patient population evaluated by Dor [2] and the RESTORE team [3] analysis. Most importantly, the progressive time-dependent improvement of functional and mental outcome differs from results after ongoing cardiac dilation after other treatments.
Some limitations of QOL markers and the 6-minute walk test are reported, and others suggest that this test may not relate to function and is only moderately related to oxygen exercise capacity measurements [4]. However, return to class I/II New York Heart Association status defines increased functional capacity, and these dynamics exist despite no measurement.
The authors implicate that body oxygen consumption during exercise introduces the potential vital noninvasive guideline, because subsequent measurements may functionally calibrate improvement and become routinely evaluated by the family physician or cardiologist in their office. Conceivably adding echocardiographic pulmonary artery pressure measurement could allow a noninvasive measure of cardiac emptying and filling and simultaneously lower expensive monitoring costs.
The balance between the 6-minute walk and body oxygen uptake (VO2) is most evident in cardiac resynchronization therapy (CRT) data in which the 6-minute walk is used as a positive yardstick in congestive heart failure (CHF) patients. This marker is raised much more by surgical ventricular restoration and assist devices and transplantation. Whereas CRT only raises oxygen uptake from 9 mL/kg/min to 10 mL/kg/min to achieve statistical significance, there is marginal functional benefit [5]. A similar limitation analogy exists with drugs that statistically raise systolic pressure from 100 to 105 without impacting cardiac dynamics.
The progressively improved QOL markers after restoration should only be contrasted against values in coronary artery bypass (CABG) patients undergoing revascularization for CHF rather than for angina, because progressive deterioration follows procedures that do not prevent ongoing ventricular size enlargement.
Despite these limitations, evaluation of the 6-minute walk and the SF-36 physical and mental measurements is a vital introduction into improving the understanding of how the QOL is impacted by surgical ventricular restoration. Hopefully, subsequent studies can add two other noninvasive markers of oxygen uptake with exercise and echocardiographic pulmonary pressures to determine how treatment therapies change the filling and emptying functions of the failing heart.
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