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Is it worth performing surgical ventricular restoration in patients with ischemic cardiomyopathy and akinetic but non-aneurysmal segments in the left ventricle?

^a Cardiology Department, Drexel University College of Medicine, Philadelphia, PA, USA
^b James Cook University Hospital, Middlesbrough, UK

Received 28 April 2008; received in revised form 28 April 2008; accepted 29 April 2008

*Corresponding author. Tel./fax: +1-215-501-7051.

E-mail address: hsubrama{at}DrexelMed.edu (H. Subramanian).

	Abstract

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is worth performing surgical ventricular restoration (SVR) in patients with ischemic cardiomyopathy and akinetic but non-aneurysmal segments in the left ventricle. Altogether 237 papers were identified using the below mentioned search. Fifteen presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. The RESTORE group and others have demonstrated that in patients with ischaemic cardiomyopathy and an akinetic anterior ventricular wall, significant improvements in survival and symptoms can be obtained with an acceptable operative risk. Improvements in EF of 10–15% have been consistently demonstrated with significant improvements in symptoms also. The RESTORE group peri-operative mortality was 5.3%. Currently, 25% of US centres participating in the National Cardiac Database have performed at least one SVR procedure, although most only perform low numbers. In this database over 2 years from 2002, there were 731 procedures. The mortality was 9.4% and 33% of patients suffered a major complication or death, cautioning that in the ‘real-world’ results may not be as good as those from high volume tertiary referral centres. Patient selection may be a reason for these differences. The STICH trial has now completed the recruitment of 2136 patients into a randomised trial of medical therapy vs. coronary artery bypass grafting (CABG) vs. CABG and SVR surgery. With first results expected in 2009, this study will be a landmark in providing the evidence base for the selection of patients for surgical ventricular restoration surgery.

Key Words: Evidence-based medicine; Ventricular reconstruction; Surgical ventricular restoration; Ischemic cardiomyopathy; Cardiovascular surgical procedures

	1. Introduction

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
A best evidence topic was constructed according to the structured protocol. This protocol is fully described in the ICVTS [1].

	2. Clinical scenario

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
You are seeing a 71-year-old gentleman who suffered an anterior myocardial infarction 3 years ago, treated with a stent to the left anterior descending artery. He has, however, gradually been getting more short of breath. Recent angiography showed severe triple vessel disease and he is keen to undergo coronary artery bypass grafting. Echocardiography reveals a left ventricular ejection fraction of 20%, with a large akinetic region in the anterior left ventricular wall. You wonder whether, if you also performed surgical ventricular restoration by excising this akinetic segment, this would further improve his symptoms without an excessive risk of mortality.

	3. Three-part question

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
In patients with [ischemic cardiomyopathy] is it worth performing [surgical ventricular restoration] to improve [Survival and Symptoms].

	4. Search strategy

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
Medline 1950–October 2007.

[ventricular restoration.mp OR ventricular remodel$.mp OR endoventricular patch plasty.mp OR ventricular aneurysmectomy.mp OR ventricular reconstruction.mp] AND [ischemic cardiomyopathy.mp OR ischaemic cardiomyopathy.mp OR ventricular dysfunction.mp or akinetic scar.mp] AND [exp Thoracic Surgery/OR exp Cardiovascular Surgical Procedures/OR exp Coronary Artery Bypass/OR Cardiac Surgery.mp]. Clinicaltrials.gov was also searched with the term [Surgical ventricular restoration].

	5. Search outcome

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
A total of 237 papers were found. Fifteen papers were deemed to represent the best evidence on the topic and are summarised in Table 1.

	6. Discussion

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

Dor et al. [4], in their retrospective study of 100 patients who underwent endoventricular circular patch-plasty (Dor procedure), reported a mortality of 12% for the akinetic group and 14% for the dyskinetic group over a study period starting in 1987, but with improvement in ejection fraction of around 15% and improvements in functional class. Similar results have been published by Maxey et al., Yamaguchi et al., and Mickelborough et al. [5, 7, 8, 14].

Maxey et al. [5] compared CABG with CABG and SVR. In total, 18% of patients with CABG suffered recurrent heart failure compared to only 4% who also had SVR and the late mortality was halved in this group.

The study published by Ribeiro et al. [6], randomised 74 patients with ischaemic cardiomyopathy and a viable akinetic anterior wall to CABG alone or CABG with SVR. The results demonstrated significant improvements in EF, ventricular volumes, functional class when CABG was combined with SVR than when done alone (EF 30% pre-operatively to 46% at 2 years). Recurrent heart failure was reduced from 26% to 2.6% with SVR. Only one patient died perioperatively. A second study by the same group reported similar results [9].

To look at the results of SVR surgery in the ‘real-world’ after the very encouraging results of the RESTORE group, Hernandez et al. [15] provided a report from the STS National Cardiac Database of 731 SVR procedures performed from 2002 to 2004. In total, 25% of all American centres in the STS registry performed at least one procedure but only 20 centres performed over 10 procedures. The mortality was twice the RESTORE mortality at 9.3% and 33% suffered a major complication or mortality including 14% of patients requiring a reoperation. Reasons for this may include low case volume, and an increased number of patients who had suffered a recent MI or were emergency cases.

The STICH (Surgical Treatment for Ischaemic Heart Failure) trial is currently underway and will be the first major randomised controlled trial comparing medical vs. surgical therapy for patients with ischaemic cardiomyopathy. The trial has three arms including medical therapy alone, medical therapy with CABG and CABG with SVR for patients with dominant anterior akinesia or dyskinesia. Recruitment has now ended and they have successfully randomised 2136 patients (www.stichtrial.org) [13]. The results of the study are expected in 2009 and will resolve many of the issues regarding patient selection, optimal methods of investigation and will provide multi-centre randomised trial data to support surgical ventricular restoration over medical therapy or CABG alone.

	7. Clinical bottom line

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 
The RESTORE group and others have demonstrated that in patients with ischaemic cardiomyopathy and an akinetic anterior ventricular wall, significant improvements in survival and symptoms can be obtained with an acceptable operative risk. Improvements in EF of 10–15% have been consistently demonstrated with significant improvements in symptoms also. The RESTORE group peri-operative mortality was 5.3%. Currently, 25% of US centres participating in the National Cardiac Database have performed at least one SVR, although most only perform low numbers. In this database over 2 years from 2002, there were 731 procedures. The mortality was 9.4% and 33% of patients suffered a major complication or death, cautioning that in the ‘real-world’ results may not be as good as those from high volume tertiary referral centres. Patient selection may be a reason for these differences. The STICH trial has now completed the recruitment of 2136 patients into a randomised trial of medical therapy vs. CABG vs. CABG and SVR surgery. With first results expected in 2009, this study will be a landmark in providing the evidence base for the selection of patients for surgical ventricular restoration surgery.

	References

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Discussion 7. Clinical bottom line References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joel Dunning Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Subramanian, H. Articles by Dunning, J. Search for Related Content PubMed PubMed Citation Articles by Subramanian, H. Articles by Dunning, J. Related Collections Cardiac - other Education Related Articles