Predictors of adverse events after surgical ventricular restoration for advanced ischaemic cardiomyopathy

Objectives: Postinfarction ventricular remodelling has been graded (I–III) according to the loss of systolic LV silhouette curvature changes. Although surgical ventricular restoration (SVR) has been extended to type III ischaemic cardiomyopathy, results are less satisfactory. We sought to identify geometric-functional predictors of late outcome after SVR. Methods: Among 144 patients who underwent SVR since 1998, a subgroup of 31 (age 65.2±7.6 years) was analysed. Inclusion criteria were: type III cardiomyopathy, no associated procedure except CABG, prior anterior infarction, absent-to-2+ MR, elective operation, follow-up >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 functional predictors and four adverse events: death, cardiac death, recurrent CHF (NYHA III–IV) and LV re-remodelling (LVESVI 25% increase after SVR). Results: Early and late mortality was zero and 6.4% (2/31 patients, 1 cardiac death). NYHA class and all echocardiographic functional variables significantly improved early after SVR. Freedom [±S.E.] from CHF was 96.7±3.3, 92.6±5.0, 76.9±11.3, and 64.0±15.0%, whereas freedom from LV re-remodelling was 96.5±3.4, 79.5±8.2, 60.3±11.9 and 38.8±14.8%, respectively 1, 3, 5, and 7 years after SVR. Multivariable analysis identified baseline MR degree and sphericity index as independent predictors of recurrent CHF (P=0.025; HR=7.80 [95% CIs: 1.29–47.19]) and LV re-remodelling (P=0.047; HR=2.84 [95% CIs: 1.01–7.95]). Conclusions: Despite advanced cardiomyopathy, SVR determines LV reduction and improved systolic function. Baseline absent-to-moderate MR degree and a more spherical LV predict a less favourable clinical and functional outcome, suggesting a possible rationale for wider indications for combined undersized mitral annuloplasty