Dipartimento di Scienze Cardiovascolari, Università degli Studi di Milano, IRCCS MultiMedica, Via Milanese 300, I-20099 Sesto San Giovanni, Milano, Italy.
Eur J Cardiothorac Surg. 2010 May;37(5):1093-100. doi: 10.1016/j.ejcts.2009.12.006. Epub 2010 Jan 8.
Post-infarction ventricular remodelling has been graded (I-III) according to the loss of systolic left ventricular silhouette curvature changes. Although surgical ventricular restoration (SVR) has been extended to type III ischaemic cardiomyopathy, the results are less satisfactory. We sought to identify geometric and functional predictors of late outcome after SVR.
Among 144 patients who underwent SVR since 1998, a subgroup of 31 patients (age: 65.2+/-7.6 years) was analysed. Inclusion criteria were: type III cardiomyopathy, no associated procedure except coronary artery bypass grafting, prior anterior infarction, absent-to-2+ mitral regurgitation, elective operation, follow-up > or =18 months (mean: 44+/-26; longest: 96 months). Probability of events was estimated with the Kaplan-Meier method. A Cox multivariable regression model was constructed selecting eight potential predictors of four adverse events: death, cardiac death, recurrent heart failure (New York Heart Association class III or IV) and left ventricular re-remodelling, defined as a 25% increase of end-systolic volume index after SVR, or an end-systolic volume index > or =50 ml.m(-2).
Early and late mortality were zero and 6% (2/31 patients, one cardiac-related death). NYHA class and all echocardiographic functional variables significantly improved early after SVR. Freedom (+/-standard error (SE)) from heart failure was 97%+/-3%, 93%+/-5%, 77%+/-11% and 64%+/-15%, whereas freedom from left ventricular re-remodelling was 97%+/-3%, 80%+/-8%, 60%+/-12% and 39%+/-15%, respectively, 1, 3, 5 and 7 years after SVR. Multivariable analysis identified baseline mitral regurgitation degree and sphericity index as independent predictors of recurrent heart failure (p=0.025; hazard ratio (HR)=7.80 (95% confidence intervals (CIs): 1.29-47.19)) and left ventricular re-remodelling (p=0.047; HR=2.84 (95% CIs: 1.01-7.95)). Both predictors also correlated with a higher recurrence of end-systolic volume index > or =50 ml.m(-2) at late follow-up.
Despite advanced cardiomyopathy, SVR determines left ventricular volume reduction and improved systolic function. Baseline absent-to-moderate mitral regurgitation and a more spherical left ventricular geometry predict a less favourable clinical and functional outcome, suggesting a possible rationale for wider indications for combined correction of 2+ mitral regurgitation and undersizing of the mitral annulus, particularly in patients with sphericity index > or =0.75.
根据收缩期左心室轮廓曲率变化的丧失程度对心肌梗死后心室重构进行分级（I-III 级）。虽然外科心室修复术（SVR）已扩展到 III 型缺血性心肌病，但结果并不理想。我们试图确定 SVR 后晚期结果的几何和功能预测因素。
在 1998 年以来接受 SVR 的 144 例患者中，分析了 31 例（年龄：65.2+/-7.6 岁）患者的亚组。纳入标准为：III 型心肌病，除冠状动脉旁路移植术外无其他相关手术，前壁梗死，无至 2+级二尖瓣反流，择期手术，随访>或=18 个月（平均：44+/-26；最长：96 个月）。用 Kaplan-Meier 法估计事件的概率。构建 Cox 多变量回归模型，选择四个不良事件的八个潜在预测因子：死亡、心脏死亡、复发性心力衰竭（纽约心脏协会 III 或 IV 级）和左心室再重构，定义为 SVR 后左室收缩末期容积指数增加 25%，或左室收缩末期容积指数>或=50ml.m(-2)。
早期和晚期死亡率均为 0%和 6%（31 例患者中有 2 例，1 例与心脏相关的死亡）。SVR 后早期 NYHA 分级和所有超声心动图功能变量均显著改善。SVR 后 1、3、5 和 7 年，心力衰竭的无事件率分别为 97%+/-3%、93%+/-5%、77%+/-11%和 64%+/-15%，左心室再重构的无事件率分别为 97%+/-3%、80%+/-8%、60%+/-12%和 39%+/-15%。多变量分析确定基线二尖瓣反流程度和球形指数为复发性心力衰竭（p=0.025；风险比（HR）=7.80（95%置信区间（CI）：1.29-47.19））和左心室再重构（p=0.047；HR=2.84（95%CI：1.01-7.95））的独立预测因子。这两个预测因子也与晚期随访时左室收缩末期容积指数>或=50ml.m(-2)的更高复发率相关。
尽管存在晚期心肌病，SVR 仍可导致左心室容积减少和收缩功能改善。基线无至中度二尖瓣反流和更球形的左心室几何形状预测预后和功能更差，提示对于联合纠正 2+级二尖瓣反流和二尖瓣环缩小的更广泛适应证具有可能的合理性，特别是在球形指数>或=0.75 的患者中。
