Surgical Remodeling of the Left Ventricle in Patients with Post-Infarction Dilation and Heart Failure

INTRODUCTION The cause of heart failure in patients with coronary artery disease after anterior myocardial infarction may be dilatation of the cavity of the left ventricle (LV) with subsequent unfavorable course of the disease. In the case of early reperfusion, which prevents transmural myocardial necrosis, the damaged segment more often becomes akinetic than dyskinetic. Surgical remodeling of the left ventricle (SRLV) is aimed at reducing the volume and restoring its elliptical shape by eliminating scars in the akinetic and/or dyskinetic segments.

AIM OF STUDY To evaluate the survival of patients with chronic heart failure (CHF) who had anterior wall myocardial infarction in the early and late periods after surgical remodeling of the left ventricle, in combination with coronary bypass grafting and/or interventions on the mitral valve.

MATERIAL AND METHODS The study included 99 patients with coronary artery disease (CAD) who had myocardial infarction of the anterior LV wall and with severe heart failure, who underwent surgical LV remodeling in the period from 2002 to 2020. The analysis of early and long-term results was carried out. The risk factors influencing lethality were determined.

The mean age of the patients was 56.0±10.2 years (from 23 to 81 years). The vast majority of patients (90%) were men. LV ventriculoplasty was combined with coronary bypass grafting in 97 (98%) patients, with mitral valve repair in 2 (2%) patients, with mitral valve replacement in 2 (2%) patients.

RESULTS In the early postoperative period, all patients showed an improvement in global LV systolic function. The ejection fraction (EF) of the left ventricle increased from the average preoperative average value of 34.2±3.7% to 43±4.2% in the postoperative period (р<0,001). Left ventricular end systolic volume index (LVESV) decreased from 71.4±15.3 ml/m² to 43.8±9.6 ml/m², respectively (р<0,001). In the early postoperative period, 5 (5%) patients used the following means of mechanical hemodynamic support: intra-aortic balloon pump (IABP), non-implantable device for temporary support of the left ventricle (LVAD) and extracorporeal membrane oxygenation (ECMO). The 30-day mortality rate after LVESV was 6%. Prior to surgery, all patients had NYHA functional class (FC) III or IV. In the postoperative period, all patients experienced regression of heart failure symptoms and improved exercise tolerance. NYHA functional class improved to I and II in 100% of cases. Using univariate analysis, it was possible to determine that EF ≤30%, LVESV ≥80 ml/m² and pulmonary artery pressure (PAP) >60 mm Hg. were risk factors for hospital mortality. The overall fifteen-year survival rate was 59.8±0.13%. The absence of readmission to the hospital due to recurrent angina pectoris, mitral valve dysfunction and progression of heart failure (HF) was 72% among surviving patients.

CONCLUSION Surgical remodeling reduces the volume of the dilated left ventricle and restores its elliptical shape in patients with CAD after anterior myocardial infarction. The results of our study demonstrate an improvement in LV systolic function in all patients in the early postoperative period and low mortality, an acceptable fifteen-year survival rate, and a low readmission rate due to the progression of chronic heart failure (CHF).

1. Gheorghiade M, Bonow RO. Chronic heart failure in the United States: a manifestation of coronary artery disease. Circulation. 1998;97(3):282–289. PMID: 9462531 https://doi.org/10.1161/01.cir.97.3.282 15

2. Gaudron P, Eilles C, Kugler I, Ertl G. Progressive left ventricular dysfunction and remodeling after myocardial infarction: potential mechanisms and early predictors. Circulation. 1993;87(3):755–763. PMID: 8443896 https://doi.org/10.1161/01.cir.87.3.755

3. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J Med. 2001;345(20):1435–1443. PMID: 11794191 https://doi.org/10.1056/NEJMoa012175

4. Reimer KA, Jennings RB. The “wavefront phenomenon” of myocardial ischemic cell death. II. Transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest. 1979;40(6):633–644. PMID: 449273

5. Sallin EA. Fiber orientation and ejection fraction in the human left ventricle. Biophys J. 1969;9(7):954–964. PMID: 5791550 https://doi.org/10.1016/S0006-3495(69)86429-5

6. White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation. 1987;76(1):44–51. PMID: 3594774 https://doi.org/10.1161/01.cir.76.1.44

7. Buckberg GD. Defining the relationship between akinesia and dyskinesia and the cause of left ventricular failure after anterior infarction and reversal of remodeling to restoration. J Thorac Cardiovasc Surg. 1998;116(1):47–49. PMID: 9671896 https://doi.org/10.1016/s0022-5223(98)70241-7

8. Di Donato M, Sabatier M, Dor V, Gensini GF, Toso A, Maioli M, et al. Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery. J Thorac Cardiovasc Surg. 2001;121(1):91–96. PMID: 11135164 https://doi.org/910.1067/mtc.2001.111379

9. Jatene AD. Left ventricular aneurysmectomy. Resection or reconstruction. J Thorac Cardiovasc Surg. 1985;89(3):321–331. PMID: 3974267

10. Dor V. Reconstructive left ventricular surgery for post-ischemic akinetic dilatation. Semin Thorac Cardiovasc Surg. 1997;9(2):139–145. PMID: 9253076

11. Di Donato M, Sabatier M, Dor V, Toso A, Maioli M, Fantini F. Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair. J Am Coll Cardiol. 1997;29(7):1569–1575. PMID: 9180121 https://doi.org/10.1016/s0735-1097(97)00092-2

12. Kennedy JW, Baxley WA, Figley MM, Dodge HT, Blackmon JR. Quantitative angiocardiography. I. The normal left ventricle in man. Circulation. 1966;34(2):272–278. PMID: 5969358 https://doi.org/10.1161/01.cir.34.2.272

13. Migrino RQ, Young JB, Ellis SG, White HD, Lundergan CF, Miller DP, et al. End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality. The Global Utilization of Streptokinase and t-PA for Occluded Coro nary Arteries (GUSTO)-I Angiographic Investigators. Circulation. 1997;96(1):116–121. PMID: 9236425 https://doi.org/10.1161/01.cir.96.1.116

14. Ingels NB Jr. Myocardial fiber architecture and left ventricular function. Technol Health Care. 1997;5(1–2):45–52. PMID: 9134618

15. Bogaert J, Bosmans H, Maes A, Suetens P, Marchal G, Rademakers FE. Remote myocardial dysfunction after acute anterior myocardial infarction: impact of left ventricular shape on regional function: a magnetic resonance myocardial tagging study. J Am Coll Cardiol. 2000;35(6):1525–1534. PMID: 10807456 https://doi.org/10.1016/s0735-1097(00)00601-x

16. Di Donato M, Sabatier M, Toso A, Barletta G, Baroni M, Dor V, et al. Regional myocardial performance of non-ischaemic zones remote from anterior wall left ventricular aneurysm: effects of aneurysmectomy. Eur Heart J. 1995;16(9):1285–92. PMID: 8582393 https://doi.org/10.1093/oxfordjournals.eurheartj.a061087

17. Alderman EL, Fisher LD, Litwin P, Kaiser GC, Myers WO, Maynard C, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation. 1983;68(4):785–795. PMID: 6352078 https://doi.org/10.1161/01.cir.68.4.785

18. Elefteriades J, Edwards R. Coronary bypass in left heart failure. Semin Thorac Cardiovasc Surg. 2002;14(2):125–132. PMID: 11988950 https://doi.org/10.1053/stcs.2002.32321

19. Shah PJ, Hare DL, Raman JS, Gordon I, Chan RK, Horowitz JD, et al. Survival after myocardial revascularization for ischemic cardiomyopathy: a prospective ten-year follow-up study. J Thorac Cardiovasc Surg. 2003;126(5):1320–1327. PMID: 14666002 https://doi.org/10.1016/s0022-5223(03)00809-2

20. Trachiotis GD, Weintraub WS, Johnston TS, Jones EL, Guyton RA, Craver JM. Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg. 1998;66(5):1632–1639. PMID: 9875763 https://doi.org/10.1016/s0003-4975(98)00773-5

21. Louie HW, Laks H, Milgalter E, Drinkwater DC Jr, Hamilton MA, Brunken RC, et al. Ischemic cardiomyopathy: criteria for coronary revascularization and cardiac transplantation. Circulation. 1991;84(5 Suppl):III290–5. PMID: 1934422

22. Yamaguchi A, Ino T, Adachi H, Murata S, Kamio H, Okada M, et al. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg. 1998;65(2):434–438. PMID: 9485241 https://doi.org/10.1016/s0003-4975(97)01155-7

23. Luciani GB, Montalbano G, Casali G, Mazzucco A. Predicting long-term functional results after myocardial revascularization in ischemic cardiomyopathy. J Thorac Cardiovasc Surg. 2000;120(3):478–489. PMID: 10962408 https://doi.org/10.1067/mtc.2000.108692

24. Stanley AW Jr., Athanasuleas CL, Buckberg GD. Left ventricular remodeling and functional mitral regurgitation: mechanisms and therapy. Semin Thorac Cardiovasc Surg. 2001;13(4):486–495. PMID: 11807745 https://doi.org/10.1053/stcs.2001.30135

25. Enriquez-Sarano M, Schaff HV, Frye RL. Mitral regurgitation: what causes the leakage is fundamental to the outcome of valve repair. Circulation. 2003;108(3):253–256. PMID: 12876134 https://doi.org/10.1161/01.CIR.0000083831.17708.25

26. Dahlberg PS, Orszulak TA, Mullany CJ, Daly RC, Enriquez-Sarano M, Schaff HV. Late outcome of mitral valve surgery for patients with coronary artery disease. Ann Thorac Surg. 2003;76(5):1539–1548. PMID: 14602283 https://doi.org/10.1016/s0003-4975(03)01071-3

27. Di Donato M, Toso A, Maioli M, Sabatier M, Stanley AW Jr, Dor V. Intermediate survival and predictors of death after surgical ventricular restoration. Semin Thorac Cardiovasc Surg. 2001;13(4):468–475. PMID: 11807742 https://doi.org/10.1053/stcs.2001.29972

28. Keck BM, Bennett LE, Rosendale J, Daily OP, Novick RJ, Hosenpud JD. Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation. Clin Transpl. 1999;35–49. PMID: 11038624