39 patients in the aortic valve replacement groupand 56 patients in the control group.. One- and 4-year survival rates were markedly improved in patients in the aortic valve replacement
Trang 139 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 4% and 0.8 0.4 cm2, respectively All
patients had a mean LVEF of 27 6% and a
mean left ventricular end-systolic diameter of
52 9 mm Fifty-seven (43%) required
concomi-tant CABG LVEF increased to 29 10% and 34
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 10.4 to 39 12.4%, and left ventricular end-systolic volume index decreased from
109 71 to 69 42 mL/m2
(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 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 11.0% to 39.5 12.3% (P ! 001), and left ventricular end systolic volume index decreased from 80.4 51.4 mL/m2 to 56.6 34.3 mL/m2 (P ! 001) Overall 5-year survival was 68.6 2.8% In this study, and ejection fraction 30% or less, left ventricular end-systolic volume 80 mL/m2 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 ventricventric-ular 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