Bové Thierry, Van Belleghem Yves, Vandenplas Guy, Caes Frank, François Katrien, De Backer Julie, De Pauw Michel, Van Nooten Guido
Heart Centre, University Hospital of Ghent, De Pintelaan 185, 5K12, Ghent 9000, Belgium.
Eur J Cardiothorac Surg. 2009 Jun;35(6):995-1003; discussion 1003. doi: 10.1016/j.ejcts.2008.11.007. Epub 2009 Jan 10.
Based on the adverse relationship between left ventricular (LV) remodeling and clinical outcome in ischemic cardiomyopathy, surgical ventricular restoration (SVR) is proposed as a valuable adjunct procedure. This study reports on the short-term clinical and hemodynamical performance of SVR.
Using end-systolic LV volume as indication for SVR, 78 patients with ischemic cardiomyopathy are divided in two groups: group 1 comprised 55 patients treated by coronary revascularization and mitral annuloplasty, group 2 comprised 23 patients undergoing additional SVR. Hemodynamic investigation included echocardiographic assessment of systolic and diastolic function. Clinical follow-up focused on survival and functional status with exercise performance.
Both surgical approaches resulted in improvement of NYHA class (2.9-1.6 in group 1; 3.3-1.5 in group 2, p<0.001), achieving similar exercise performance (peak VO2 13.7 vs 15.4 ml/kgmin in groups 1 and 2, p=0.25) and plasma BNP values (group 1: 1350 pg/ml and group 2: 767 pg/ml, p=0.23). SVR provided additional benefit as patients basically had a worse NYHA class (2.9 in group 1 vs 3.3 in group 2, p=0.03). Within mean follow-up of 20 months, survival rate was 84% in group 1 and 74% in group 2 (p=0.11), including operative mortality of 7% and 13% (p=0.42). Through effective volume reduction (LVEDVI 41%; LVESVI 49%) systolic function improved immediately after SVR (LVEF 27-39% in group 2, p<0.05). Worsening of diastolic function was specifically observed after SVR within the first year (E/A-ratio 1.38-1.74 cm/s, p=0.02). Recurrent mitral regurgitation (p=0.004) and secondary remodeling (p=0.01) were major determinants of decreasing LV compliance. Clinical outcome in terms of cardiac events and survival was compromised by restrictive diastolic function (p=0.02) and increased LV volumes (p=0.04).
SVR in addition to coronary revascularization and restrictive mitral annuloplasty results in significant clinical improvement in selected patients with advanced ischemic heart disease and severely dilated ventricles. SVR entails immediate improvement of systolic function, which remains sustained during short-term follow-up. Serial assessment of diastolic function is mandatory as LV compliance seems more sensitive to early changes induced by recurrence of mitral regurgitation and secondary ventricular dilation. Moreover, worsening of diastolic dysfunction should be timely recognized because of its adverse clinical impact.
基于缺血性心肌病中左心室（LV）重构与临床结局之间的不良关系，手术性心室修复（SVR）被提议作为一种有价值的辅助手术。本研究报告了SVR的短期临床和血流动力学表现。
以收缩末期LV容积作为SVR的指征，将78例缺血性心肌病患者分为两组：第1组包括55例接受冠状动脉血运重建和二尖瓣环成形术治疗的患者，第2组包括23例接受额外SVR的患者。血流动力学研究包括超声心动图评估收缩和舒张功能。临床随访重点关注生存和功能状态以及运动表现。
两种手术方法均导致纽约心脏协会（NYHA）分级改善（第1组从2.9降至1.6；第2组从3.3降至1.5，p<0.001），运动表现相似（第1组和第2组的峰值VO2分别为13.7和15.4 ml/kg·min，p=0.25），血浆脑钠肽（BNP）值也相似（第1组：1350 pg/ml，第2组：767 pg/ml，p=0.23）。SVR带来了额外益处，因为患者最初的NYHA分级更差（第1组为2.9，第2组为3.3，p=0.03）。在平均20个月的随访期内，第1组的生存率为84%，第2组为74%（p=0.11），包括手术死亡率分别为7%和13%（p=0.42）。通过有效减少容积（左心室舒张末期容积指数[LVEDVI]降低41%；左心室收缩末期容积指数[LVESVI]降低49%），SVR后收缩功能立即改善（第2组的左心室射血分数[LVEF]从27%提高到39%，p<0.05）。在第一年，SVR后特别观察到舒张功能恶化（E/A比值从1.38变为1.74 cm/s，p=0.02）。二尖瓣反流复发（p=0.004）和继发性重构（p=0.01）是左心室顺应性降低的主要决定因素。心脏事件和生存方面的临床结局受到限制性舒张功能（p=0.02）和左心室容积增加（p=0.04）的影响。
对于选定的晚期缺血性心脏病和严重扩张心室的患者，除冠状动脉血运重建和限制性二尖瓣环成形术外，SVR可带来显著的临床改善。SVR可使收缩功能立即改善，并在短期随访期间持续保持。由于左心室顺应性似乎对二尖瓣反流复发和继发性心室扩张引起的早期变化更敏感，因此必须对舒张功能进行连续评估。此外，由于舒张功能障碍的不良临床影响，应及时识别其恶化情况。
