Ventricular restoration with associated mitral annuloplasty: determinants of late outcome

Background. Mitral annuloplasty may be associated to surgical ventricular restoration (SVR), but risk-to-benefit ratio remains poorly defined. We sought to outline outcome determinants in this high-risk population. Methods. Twenty-six patients with ischaemic cardiomyopathy, prior anteroseptal AMI, NYHA class III-IV, and EF ≤35% who underwent SVR and prosthetic ring mitral annuloplasty were analyzed. Associated cardiac surgical procedures except CABG were excluded. Risk factors for adverse events were identified with logistic and Cox regression. Probabilities of late events were estimated with the Kaplan-Meier method. Primary endpoints were death and hospitalisation for recurrent HF. Results. Preoperative characteristics: age 66 ± 8 years; NYHA class 3.2 ± 0.4; EF 27 ± 5%; WMSI 2.4 ± 0.2; end-systolic volume index (ESVI) 80 ± 25 ml/m2; MR degree 3.3 ± 0.5; EuroSCORE II 15 ± 11. CPB and aortic crossclamp times were 203 ± 68 and 131 ± 28 min. Operative mortality was 11%. No independent predictors of early death emerged. High-dose inotropic support, IABP, and ECMO were necessary in 13, 12, and 1 case. At a mean follow-up of 49 ± 3 months (longest, 112 months), the probability of survival at 1, 3, 5, and 7 years after the operation were 84%, 76%, 72% and 54%, whereas the corresponding probabilities of rehospitalisation for HF were 81%, 52%, 48% and 12%. Baseline ESVI (p=0.03; HR=1.02) and cross-clamp time (p=0.02; HR=1.04) were outlined as independent predictors of late death, but no predictor of recurrent heart failure emerged. Conclusions. Surgical mitral-ventricular restoration can be performed with a near-10% operative risk, and results in over 50% survival at 7 years in advanced ischemic cardiomyopathy. Myocardial viability testing likely represents a crucial additional tool to stratify and optimize patients’ selection with respect to late outcome.