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Nishant D. Patel
Christopher J. Barreiro
Pramod N. Bonde
Michele M. Waldron
John V. Conte
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J Thorac Cardiovasc Surg 2005;130:1698-1706
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Surgical ventricular remodeling for multiterritory myocardial infarction: Defining a new patient population

Nishant D. Patel, BA a , Jason A. Williams, MD a , Christopher J. Barreiro, MD a , Pramod N. Bonde, MD, FRCS a , Michele M. Waldron, MT, RN, CCRP a , David C. Chang, PhD a , David A. Bluemke, MD, PhD b , John V. Conte, MD a , *

a Divisions of Cardiac Surgery
b Radiology, The Johns Hopkins Medical Institutions, Baltimore, Md

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication April 13, 2005; revisions received August 12, 2005; accepted for publication August 17, 2005.

* Address for reprints: John V. Conte, MD, Director of Heart and Lung Transplantation, The Johns Hopkins Hospital, Division of Cardiac Surgery, 600 North Wolfe St, Blalock 618, Baltimore, MD 21287-4618 (Email: jconte{at}csurg.jhmi.jhu.edu).

OBJECTIVE: Because of limited medical and surgical options for patients with end-stage congestive heart failure, we expanded the criteria for surgical ventricular remodeling to include patients with multiterritory myocardial infarction, a group historically considered high-risk candidates. We present our series of patients with multiterritory myocardial infarction who underwent surgical ventricular remodeling and propose a new patient population who may benefit from this procedure.

METHODS: Data were analyzed for 51 consecutive patients undergoing surgical ventricular remodeling from January 2002 to June 2004, with 100% follow-up. Three left ventricular vascular territories were defined: anteroapicoseptal (left anterior descending), lateral (circumflex), and inferior (right coronary artery). Infarction was assessed with magnetic resonance imaging and intraoperative findings.

RESULTS: Multiterritory myocardial infarction was found in 64.7% of patients (33/51) undergoing surgical ventricular remodeling. Mean age was 61.6 ± 11.1 years (range 40-81 years). Sixty-one percent (20/33) demonstrated evidence of myocardial infarction in all three territories. Five patients underwent concomitant mitral valve repair or replacement. Operative mortality was 6.1% (2/33) and did not differ from that of patients with single-territory infarction (11.1%, P = .61). Surgical ventricular remodeling significantly improved left ventricular volumes and ejection fraction in patients with multiterritory myocardial infarction. Three patients required assist device implantation, and 2 patients required defibrillator placement. Sixty-nine percent of patients in preoperative New York Heart Association functional class III or IV (22/32) had improvement to class I or II at follow-up (P < .01). Cox regression analysis discriminated a preoperative left ventricular end-systolic volume index greater than 100 mL/m2 as a significant risk factor for mortality (odds ratio 12.1, 95% confidence interval 1.27-114.51, P = .03). Thirty-month survival of patients with multiterritory myocardial infarction (73.5% ± 8.3%) did not differ statistically from that of patients with single-territory infarction (n = 18).

CONCLUSION: Surgical ventricular remodeling improves cardiac function and New York Heart Association functional status in patients with multiterritory myocardial infarction. Our initial results are promising and should prompt further studies to confirm our results and potentially expand the surgical ventricular remodeling inclusion criteria to include patients with multiterritory myocardial infarction.

Abbreviations and Acronyms CHF = congestive heart failure; EF = ejection fraction; IABP = intra-aortic balloon pump; LVAD = left ventricular assist device; LVESVI = left ventricular end-systolic volume index; LVEDVI = left ventricular end-diastolic volume index; MI = myocardial infarction; MR = mitral regurgitation; MRI = magnetic resonance imaging; MTI = multiterritory myocardial infarction; NYHA = New York Heart Association; POD = postoperative day; RESTORE = Reconstructive Endovascular Surgery returning Torsion Original Radius Elliptical shape; STI = single-territory myocardial infarction; SVR = surgical ventricular remodeling




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