Strategy of Treatment for Ischemic Cardiomyopathy

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Background: Ischemic cardiomyopathy (ICM) is defined as diffuse akinesis of the left ventricle (LV) due to chronic myocardial ischemia. Due to poor prognosis by isolated coronary revascularization, surgical ventricular restoration (SVR) had been developed. Surgical strategy for ICM was studied by our experiences over 12 years. Patients and methods: Between 2000 and 2012, 173 patients with ICM underwent surgery. The NYHA functional class was in class III for 97 and IV for 76. Since 2005, speckle-tracking echocardiography was applied to determined accurate akinetic area. The patients were followed up for a mean of 41.3±37.1 months up to139 months. Results: SVR was performed for the anterior wall in 150 patients and for the posterior in 23. Hospital death was 6 in 149 elective operations and 5 in 24 emergent operations. After SVR, the NYHA functional class improved to class I–II in 107 patients. The late death occurred in 33 patients. The five- or ten-year overall survival rate was 66.7% or 55.9%, respectively. Since 2005, the five-year survival rate improved to 80.1% after introduction of speckle-tracking echocardiography (P=0.0106) due to effective reduction of LV volume. The LV end-systolic volume index (LVESVI) became less than 100 ml/m² in 74 patients (Group-S) and greater than 100 ml/m² in 33 patients (Group-L). In Group-S, the five- or ten-year survival rate was 81.7% or 75.5%, while in Group-L, the five-year survival rate was 45.0% with significant poor outcome (P<0.0001). Multivariate analysis showed that post-operative LVESVI (<100 ml/m²) and tricuspid annuloplasty due to tricuspid regurgitation were independent risk factors for long-term survival (LVESVI: hazard ratio 4.7058; 95% confidence interval 1.3490–16.4156; P=0.0151, tricuspid anuloplasty: hazard ratio 3.1059; 95% confidence interval 1.6545–5.8308; P=0.004), while no statistical differences in mitral valve surgery, coronary artery bypass grafting or three kinds of SVRs. Conclusion: For patients with ICM, accurate detection of myocardial lesion by speckle-tracking echocardiography is very important for SVR. Effective volume reduction contributes to a better long-term survival.