Calafiore Antonio M, Iaco' Angela L, Kheirallah Hatim, Sheikh Azmat A, Al Sayed Hussain, El Rasheed Mohammed, Allam Ahmed, Awadi Mohammed O, Alfonso Juan J, Osman Ahmed A, Di Mauro Michele
Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
Eur J Cardiothorac Surg. 2016 Oct;50(4):693-701. doi: 10.1093/ejcts/ezw103. Epub 2016 Apr 12.
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.
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.
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.
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.
在缺血性心力衰竭外科治疗（STICH）试验公布后，左心室外科重塑（LVSR）的手术指征变得更加严格。我们报告的经验反映了STICH试验公布后现实世界中的变化。
2009年5月至2014年7月，113例患者接受了LVSR，主要针对左前降支区域（89.4%）。其中，18例患者（15.9%）接受了急诊手术。评估早期和中期结果以确定临床和超声心动图风险因素。
大多数患者（90.3%）患有慢性缺血性二尖瓣反流（CIMR），纽约心脏协会（NYHA）心功能分级为III/IV级（77.9%）。中位射血分数（EF）为26%[95%置信区间（CI）：26，28]，大多数情况下瘢痕区域无运动（86.7%）。33.6%的患者存在严重左心室舒张功能障碍（LVDD）。84.1%的患者进行了二尖瓣手术。5例患者（4.4%）在住院期间死亡，均死于心脏原因。风险因素为胆红素异常和急诊状态。中位随访12（95%CI：6，18）个月后，22例患者死亡，17例死于心脏原因。任何原因导致的5年无死亡生存率为73±5%，急诊状态和MR 4级是唯一的风险因素。任何原因导致的5年无死亡生存率和NYHA III/IV级为61±6%。严重LVDD、急诊状态以及高胆红素和胰岛素依赖型糖尿病是风险因素。任何原因导致的5年无死亡生存率和无致命心血管事件（再次住院、再次手术和中风）为55±6%。LVDD和心房颤动被发现是风险因素。中位随访31（95%CI：19，38）个月后，91例患者接受了术后超声心动图检查。EF增加了20%，但每搏输出量保持不变。术后，严重LVDD患者的EF低于无LVDD患者，收缩末期容积高于无LVDD患者。
我们的研究结果表明，适合LVSR的患者大多有无运动区域和需要手术矫正的CIMR，且症状严重。严重LVDD很常见，并且与急诊状态一起，是早期和晚期结果的最重要风险因素。
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