Decision-making in Surgical Management of Ischemic Cardiomyopathy
Dustin Y. Yoon, Nicholas G. Smedira, Edward R. Nowicki, Katherine J. Hoercher, Jeevanantham Rajeswaran, Eugene H. Blackstone; Cleveland Clinic, Cleveland, OH
Comment on this Abstract
Objective: The surgical approach to ischemic cardiomyopathy that yields the best short- and long-term survival remains controversial, and surgeons’ decisions may be further complicated by secondary conditions of mitral regurgitation, left ventricular remodeling and dilatation, and ultimately, heart failure. We sought to develop comparative prediction models that can be used to estimate short- and long-term survival after 4 operative interventions: CABG alone, CABG+mitral valve (MV) anuloplasty, CABG+surgical left ventricular restoration (SVR), and cardiac transplantation.
Methods: From 1997 to 2007, 1,321 patients with ischemic cardiomyopathy (ejection fraction <.3) underwent CABG alone (n=386), CABG+MV anuloplasty (n=212), CABG+SVR (n=360), or cardiac transplantation (n=363). Median follow-up was 4±2.8 years, with 5,455 patient-years of data available for analysis. Survival was estimated, and multivariable analyses were performed in the multiphase hazard function domain to identify risk factors for early and late mortality separately for each procedure. All final models contained all variables identified in any of the 4 analyses. These were programmed as a web-based strategic decision support tool.
Results: Survival estimates at 1, 3, 5, and 9 years were: CABG, 92%, 83%, 72%, and 53%; CABG+MV anuloplasty, 87%, 72%, 57%, and 33%; CABG+SVR, 93%, 85%, 75%, and 54%; cardiac transplantation, 90%, 85%, 80%, and 63% (Figure). Multiphase hazard analyses identified lower ejection fraction, older age, higher NYHA class, numerous comorbidities, and long interval from myocardial infarction to operation as risk factors. Patient-specific simultaneous solutions of the 4 procedure modules revealed the procedures that potentially provide maximum survival benefit. (Figure: patient age 60 years; NYHA class II; ejection fraction .17; complete heart block; 3-system disease; several comorbidities.)
Conclusion: Prediction models incorporating specific clinical and angiographic data can help surgeons recommend the patient-specific treatment plan that optimizes short- and long-term survival for ischemic cardiomyopathy.
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