Severe ischemic cardiomyopathy with mechanical complications: Still a surgical disease

Background: Surgical treatment of ischemic cardiomyopathy (ICM) with mechanical complications has been limited in favor of suboptimal treatments because of the perception of poor outcome.

Methods and results: From May 2009 till June 2014 115 patients with severe ICM (ejection fraction, EF, ≤25%) and mechanical complications were operated on. Median EF was 24% (19, 24), mean end-systolic volume index (ESVi) was 86±27ml/m² and all patients had an MR grade of 2 or more. The right ventricle (RV) was hypokinetic in 33 patients. All of them underwent mitral valve surgery. Left ventricular (LV) surgical remodeling was performed in 60 patients (52.2%) and tricuspid surgery in 58 (50.4%). In-hospital mortality was 4.3% (5 patients). Six-year freedom from death any cause and from death any cause and NYHA class III/IV were, respectively, 70.5±4.9% and 66.4±4.8%. Cox regression analysis showed that risk factors were lower EF (cutpoint≤20%) and RV hypokinesia. Eighty-six patients had a follow up echocardiogram after a median of 31 (19, 51) months. EF increased by 60%, from 24 (19, 24) to 35 (27 ,46) (p=0.00), and ESVi decreased by 32%, from 87±29 to 59±27ml/m² (p=0.00). SVi increased by 32%, from 23±7 to 32±12ml/m². MR grade was ≥2 only in 6 patients (7%) and was not severe in any of them.

Conclusions: Surgery for severe ICM with MR can be performed with low surgical risk and good midterm survival. These findings have to be taken into account while abandoning a clear surgical indication in favor of suboptimal alternative therapies.