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J Thorac Cardiovasc Surg 2004;128:27-37
© 2004 The American Association for Thoracic Surgery
Surgery for acquired cardiovascular disease |
a University of Toronto, Toronto, Ontario, Canada
Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.
Received for publication May 4, 2003; revisions received July 1, 2003; accepted for publication August 4, 2003.
* Address for reprints: Lynda L. Mickleborough, MD, 1221 Gervais Rd, RR #1, Waubaushene, Ontario L0K 2C0, Canada
l.mickleborough{at}on.aibn.com
OBJECTIVES: In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning.
METHODS: Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% ± 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%).
RESULTS: Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 ± 48 months, 8 patients required transplantation (interval of 49 ± 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 ± 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% ± 9%.
CONCLUSIONS: Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.
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