End-Stage Ischemic Heart Disease: Effects of Complete Myocardial Revascularization and Left Ventricular Patch Repair Following Scar Resection

Summary

In the present study we describe clinical and hemodynamic results following left ventricular aneurysm resection, endoventricular circular patch repair, and complete coronary grafting in patients with end-stage ischemic heart disease. Eighty patients with a preoperative ejection fraction (EF) =≤25% were selected for the analysis from a large group of 450 consecutive patients submitted to the same type of surgery. Perioperative mortality rate was 17.5% in patients with EF <25%, while it was 6.7% in patients with EF >25% (p < .001). Surviving patients had a significant improvement in EF (from 19 ± 4% to 38 ± 10% p < .0001) at early control; this improvement was maintained in patients controlled after 1 year from surgery (from 19 ± 4 to 39 ± 11, p < 0.0001). At multivariate analysis the variables related to early mortality were the extent of coronary disease and the duration of cardiopulmonary bypass. Variables related to an unsatisfactory improvement of EF (postoperative EF ≤30%) were higher left ventricular basal volumes, the critical involvement of the right coronary artery, and the presence of severe asynergy in regions remote from the aneurysm. A significant improvement in functional class was observed after 1 year (only 1 patient was in NYHA class IV, four were in class III, and the majority were in NHYA II). In conclusion, the technique of endoventricular patch repair associated with complete coronary revascularization in patients with end-stage ischemic heart disease induces a significant improvement in pump function and clinical status, and can be considered an alternative to heart transplantation in high-risk selected patients.

In recent years coronary bypass grafting has been extended to patients with poor left ventricular (LV) pump function, owing to the improvement in surgical technique and in myocardial protection; however, controversies still exist concerning operative risk, functional improvement, and survival. In the present study we report the results obtained in patients with high-grade LV dysfunction due to a postinfarction LV aneurysm submitted to resection and endoventricular patch repair associated with complete myocardial revascularization and subtotal endocardiectomy and cryosurgery when indicated for clinical or inducible ventricular arrhythmias. We attempt to define predictors of early mortality and LV pump function improvement by analyzing several clinical, hemodynamic, and demographic variables.