Outcome of left ventricular surgical remodelling after the STICH trial

Objectives: After the publication of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, surgical indications to left ventricular surgical remodelling (LVSR) have become more restrictive. The experience we report reflects the changes in the real world after the publication of STICH trial.

Methods: From May 2009 to July 2014, 113 patients underwent LVSR, targeted mainly to the left anterior descending territory (89.4%). Of these, 18 patients (15.9%) were operated on an emergency basis. Early and mid-term outcomes were assessed to identify clinical and echocardiographic risk factors.

Results: Most patients (90.3%) had chronic ischaemic mitral regurgitation (CIMR) and were in New York Heart Association (NYHA) class III/IV (77.9%). The median ejection fraction (EF) was 26% [95% confidence interval (CI): 26, 28] and scarred areas were akinetic (86.7%) in most cases. Severe left ventricular diastolic dysfunction (LVDD) was found in 33.6% of patients. Mitral valve surgery was performed in 84.1% of patients. Five patients (4.4%) died while in hospital, all from cardiac causes. Risk factors were abnormal bilirubin and emergency status. After a median follow-up of 12 (95% CI: 6, 18) months, 22 patients died, 17 from cardiac causes. Five-year freedom from death any from cause was 73 ± 5%, emergency status and MR Grade 4 being the only risk factors. Five-year freedom from death from any cause and NYHA class III/IV was 61 ± 6%. Severe LVDD and emergency status were risk factors, along with high bilirubin and diabetes mellitus on insulin. Five-year freedom from death from any cause and non-fatal cardiovascular events (rehospitalization, reoperation and stroke) was 55 ± 6%. LVDD and atrial fibrillation were found to be risk factors. After a median follow-up of 31 (95% CI: 19, 38) months, 91 patients underwent postoperative echocardiography. EF increased by 20%, but stroke volume remained unchanged. Postoperatively, patients with severe LVDD had lower EF and higher end-systolic volumes than patients without LVDD.

Conclusions: Our findings show that patients, who are candidates for LVSR, have mostly akinetic areas and CIMR requiring surgical correction and are severely symptomatic. Severe LVDD is common and, along with emergency status, is the most important risk factor for early and late outcome.