Surgical Ventricular Reconstruction Does Work
Date: July 1, 2009
For patients who survive a myocardial infarction, the aftermath is often left ventricular remodeling causing dilation of LV, congestive heart failure—and poor quality of life. When medications fail to adequately relieve ongoing symptoms, one alternative to a heart transplant that cardiac surgeon John Conte has found effective in carefully selected patients is surgical ventricular reconstruction. When performed at the same time as coronary artery bypass grafting, the procedure to return the heart to its more normal size and elliptical shape, he says, can allow the heart to work more normally by lowering pressure build-up inside the heart cavity and reducing the amount of oxygen and energy the heart needs to keep pumping.
Although it’s been debated whether CABG plus SVR is more beneficial than CABG alone, at least year’s annual meeting of the Society of Thoracic Surgeons, Conte presented results of the first head-to-head comparison of the single and dual procedures that applied strict scientific controls. Patients in both groups were carefully matched for degree of heart failure and medical history, and outcomes were from the same team of surgeons to ensure that surgical quality was uniform.
Given these findings and his own experience—he’s performed more than 150 of the dual procedures since 2000 and has trained more than 100 surgeons to perform the procedure—Conte was disconcerted by recently reported conclusions of another study that also had set out to compare CABG alone to CABG plus SVR. Dubbed STICH (for Surgical Treatment for Ischemic Heart Failure), the study had originally called for enrollees to have had nonviability following myocardial infarction documented via MRI or nuclear imaging or stress echocardiogram; and there should have been demonstrated akinesis or dyskinesis. “Instead,” says Conte, 13 percent of the STICH patients had no history of infarction, and in 50 percent there was no demonstration of nonviability.” Additionally, the volume reduction averaged only 19 percent while the average in the literature is 40 percent, calling into question the quality of the surgery.
“Basically,” Conte says, “you had the wrong operation for the wrong patients in this trial.”
What Conte agrees can be said is that patients with viable anterior walls and reductions do no better than patients receiving CABG alone. The procedure, he says, is most appropriate for patients with moderate to severe heart failure whose ejection fraction has dropped to less than 35 percent and who have had a clearly defined left ventricular enlargement and, most importantly, demonstration of nonviability.
“From the volume of patients we see at Johns Hopkins,” he says, “we estimate that about one in 20 CABG patients who have congestive heart failure might fit into this category.”