Adult: Coronary
Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial

https://doi.org/10.1016/j.jtcvs.2022.04.016Get rights and content

Abstract

Objective

The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data.

Methods

Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality.

Results

The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001).

Conclusions

Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.

Graphical abstract

Visual summary of the study findings highlighting significantly better long-term results of SVR in an experienced center than those reported in the STICH trial, and its implications. SVR, Surgical ventricular reconstruction; STICH, Surgical Treatment for Ischemic Heart Failure trial; AHR, adjusted hazard ratio; CI, confidence interval.

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Section snippets

Study Design

The aims of the study were (1) to describe the long-term outcomes in one of the largest series of SVR and (2) to compare them with the results of the STICH trial. The study for the San Donato cohort was approved by the local institutional review board (protocol #:179/int/2019).

Individual patients' data from hypothesis 1 and 2 of the STICH trial and from the STICH Extended Study (STICHES) trial were obtained through the Biologic Specimen and Data Repository Information Coordinating Center of the

San Donato Cohort

A total of 725 patients were included in the San Donato cohort. Baseline characteristics are summarized in Table 1. The median age was 66.0 (Q1, Q3: 58.0, 72.0). The majority of patients were male (n = 596, 82.3%). Most patients had hypertension, hyperlipidemia, and class NYHA II-III symptoms. One-hundred ninety-two (26.4%) patients had diabetes, 56 (7.7%) had renal failure, 202 (28.1%) underwent previous PCI, and 12 (1.7%) had a history of previous CABG. A total of 492 patients (67.8%) were

Discussion

The San Donato cohort represents one of the largest SVR series with the longest follow-up published to date. The operative mortality was 7.4%, and this highlights the added operative risk of the procedure, even when performed in a highly experienced center. The cumulative 5- and 10-year survival were 74.7% and 54.9%, respectively, which is comparable with the survival reported for patients with depressed LVEF undergoing CABG alone and better to what reported in most previous SVR studies.7, 8, 9,

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Gianmarco Cancelli is supported by the “Enrico and Enrica Sovena Foundation” in Rome, Italy.

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