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J Thorac Cardiovasc Surg 2004;128:38-43
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy

^a Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^b Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^c George M. and Linda H. Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^d Transplant Center, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^e Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

^* Address for reprints: Patrick M. McCarthy, MD, Department of Thoracic and Cardiovascular Surgery/F25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
mccartp{at}ccf.org

OBJECTIVES: Activation of the neuroendocrine axis in congestive heart failure is of prognostic significance, and neurohumoral blocking therapy prolongs survival. The hypothesis that surgical reduction of left ventricular size and function decreases neuroendocrine activation is less established. We evaluated the neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy.

METHODS: Norepinephrine, plasma renin activity, and angiotensin II were measured in 10 patients before and 12 months after left ventricular reconstruction. In an additional 5 patients, brain natriuretric peptide was measured before and 3 months postoperatively. Three-dimensional cardiovascular imaging was used to assess ejection fraction and left ventricular end-diastolic volume index.

RESULTS: Concurrent with improvements of New York Heart Association functional class (2.9 ± 0.5 preoperatively vs 2.0 ± 0.4 postoperatively, P < .001), ejection fraction (23.9% ± 6.6% vs 36.2% ± 6.2%, P < .01), and left ventricular end-diastolic volume index (140.8 ± 33.8 mL/m² vs 90.6 ± 18.3 mL/m², P < .01), considerable reductions were observed for median plasma profiles of norepinephrine (562.0 pg/mL vs 319.0 pg/mL, P < .05), plasma renin activity (5.75 µg/L/h vs 3.45 µg/L/h, P < .05), angiotensin II (41.0 ng/mL vs 23.0 ng/mL, P = .051), and brain natriuretric peptide (771.0 pg/mL vs 266.0 pg/mL, P < .05). The more plasma renin activity or angiotensin II decreased after left ventricular reconstruction, the higher was the increase in ejection fraction (R = –.745, P < .05 [plasma renin activity]; R = –.808, P < .05 [angiotensin II]).

CONCLUSIONS: Surgical improvements of ejection fraction and left ventricular end-diastolic volume index by left ventricular reconstruction were accompanied by improvement of both the neuroendocrine activity and the functional status in patients with congestive heart failure. Whether this favorable neurohormonal response is predictive of an improved survival requires further evaluation.

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