THE ROLE OF SURGERY IN HEART FAILURE - PART 7 ppt

39 patients in the aortic valve replacement group
and 56 patients in the control group. One- and
4-year survival rates were markedly improved in
patients in the aortic valve replacement group
(82% and 78%) compared with patients in the
control group (41% and 15%; P ! .0001). By mul-
tivariable analysis, the main predictor of improved
survival was aortic valve replacement [74]. Perio-
perative outcomes and long-term results were also
evaluated in a group of 132 consecutive patients
who had impaired left ventricular systolic function
(!40%) undergoing aortic valve replacement with
or without concomitant CABG between 1990 and
2003. Patients who had other valve pathology
were excluded. Preoperatively, 82% of the patients
were in NYHA III or IV. Sixty patients (45%) un-
derwent aortic valve replacement for severe aortic
stenosis, whereas 72 (55%) had aortic insufficiency.
In the aortic stenosis group, the mean left ventricu-
lar ejection fraction and aortic valve area were
26 Æ 4% and 0.8 Æ 0.4 cm
2
, respectively. All
patients had a mean LVEF of 27 Æ 6% and a
mean left ventricular end-systolic diameter of
52 Æ 9 mm. Fifty-seven (43%) required concomi-
tant CABG. LVEF increased to 29 Æ 10% and 34
Æ 12% after 6 months in the aortic stenosis and
aortic insufficiency groups, respectively. The
mean follow-up period was 6.1 years with no differ-
ences for both groups with respect to either perio-

perative or long-term outcomes. Overall survival
was 96%, 79%, and 55% at 1, 5, and 10 years, re-
spectively [75]. Overall, these results suggests that
both aortic valve replacement for patients who
have low gradient aortic stenosis and aortic regur-
gitation confines a greater survival benefit than that
of heart transplantation, although special care
should be taken in the selection of prosthetic valve
used for replacement. The ACC/AHA guidelines
for evaluation of patients who have aortic valve dis-
ease states that aortic valve replacement is indi-
cated for symptomatic patients who have severe
aortic regurgitation irrespective of left ventricular
systolic function as well as in patients who have se-
vere aortic stenosis and left ventricular systolic dys-
function, which is defined as ejection fraction less
than 50% [72].
Left ventricular geometry restoration
Prospective randomized comparison is being
conducted by the STICH trial, which evaluates
whether surgical ventricular shape restoration in
combination with CABG improve outcome com-
pared with coronary revascularization alone and
medical therapy alone in one of the study arms
[56]. The safety and efficacy of surgical anterior
ventricular endocardial restoration, which in-
cludes the exclusion of noncontracting segments
in the dilated remodeled ventricle after anterior
myocardial infarction was evaluated in an obser-
vational effort of 11 centers. From January 1998

to July 1999, 439 patients underwent the proce-
dure and were followed for 18 months. Concomi-
tant with safety and efficacy of surgical anterior
ventricular endocardial restoration, coronary
artery bypass grafting was done in 89% of the pa-
tients, mitral valve repair in 22%, and replace-
ment in 4%. Hospital mortality was 6.6%.
Postoperatively, ejection fraction increased from
29 Æ 10.4 to 39 Æ 12.4%, and left ventricular
end-systolic volume index decreased from
109 Æ 71 to 69 Æ 42 mL/m
2
(P ! .005). At 18
months, survival was 89.2% (84% in the overall
group and 88% among the 421 patients who
had coronary artery bypass grafting or mitral
valve repair) [76]. The international Reconstruc-
tive Endoventricular Surgery returning Torsion
Original Radius Elliptical shape to the left ven-
tricle (RESTORE) group evaluated surgical ven-
tricular restoration in a registry of 1198
postinfarction patients between 1998 and 2003.
Concomitant procedures included CABG in
95%, mitral valve repair in 22%, and mitral valve
replacement in 1%. Overall 30-day mortality was
5.3% (8.7% with mitral repair versus 4.0% with-
out repair, P ! .001). Perioperative mechanical
support was uncommon (!9%). Left ventricular
ejection fraction increased from 29.6 Æ 11.0% to
39.5 Æ 12.3% (P ! .001), and left ventricular

end systolic volume index decreased from 80.4 Æ
51.4 mL/m
2
to 56.6 Æ 34.3 mL/m
2
(P ! .001).
Overall 5-year survival was 68.6 Æ 2.8%. In this
study, and ejection fraction 30% or less, left
ventricular end-systolic volume 80 mL/m
2
or
greater, advanced NYHA functional class, and
age equal or greater than 75 years as risk factors
for death. Five-year freedom from hospital read-
mission for CHF was 78%. Preoperatively, 67%
of patients were class III or IV, and postopera-
tively 85% were class I or II. Based on these
data, the authors concluded that surgical ventric-
ular restoration improves ventricular function
and is highly effective therapy in the treatment
of ischemic cardiomyopathy with excellent 5-
year outcome [76]. The results of the STICH trial
will probably solve the real role of surgical resto-
ration therapy compared with conventional
approaches.
330 CADEIRAS et al