Long-Term Results of Surgical Ventricular Reconstruction in Ischemic Cardiomyopathy

In patients with ischemic cardiomyopathy, the long-term results of surgical ventricular reconstruction (SVR) performed at a specialized center were significantly better than those reported in the randomized Surgical Treatment for Ischemic Heart Failure (STICH) trial. These findings were published in The Journal of Thoracic and Cardiovascular Surgery.

Data from the STICH Extended Study (STICHES) were compared with those from the STICH trial. Recognizing the limitations of the STICH trial and the fact that the role of SVR for the treatment of patients with ischemic left ventricular (LV) dysfunction remains unclear, the researchers sought to compare long-term results of SVR between a high-volume SVR institution and the STICH trial, via the use of data obtained from individual patients. Patients who underwent SVR at San Donato Hospital in Milan, Italy, were compared with those who underwent SVR in STICH (as-treated principle) with the use of inverse probability treatment-weighted Cox regression. The primary study outcome was all-cause mortality.

A total of 725 participants comprised the San Donato cohort; the STICH-SVR cohort included 501 individuals. Overall, participants in the San Donato cohort were significantly older than those in the STICH-SVR cohort (66.0 years vs 61.9 years, respectively; P <.001) and had significantly lower LV end-systolic volume index (LVESVI) at baseline than patients in the STICH-SVR arm (77.0 vs 80.8, respectively; P =.02).

At 4 years of follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.53-0.95; P =.001). Additionally, postoperative LVESVI was independently associated with mortality in both the San Donato group (aHR, 1.02; 95% CI, 1.01-1.03; P <.001) and the STICH-SVR group (aHR, 1.02; 95% CI, 1.01-1.02; P <.001).

In the San Donato arm, 62.5% of patients at the 6-month follow-up had an LVESVI below the cutoff for the association with mortality, whereas in the STICH-SVR arm, 47.1% of participants at the 4-month follow-up had an LVESVI below the cutoff for the association with mortality.

A major limitation of the analysis is the fact that the comparison of results from institutional series such as STICHES and randomized trials such as STICH-SVR is open to intrinsic biases. Randomized studies include a carefully chosen subgroup of the general patient population and have limited external validity, whereas institutional series typically reflect real-world practice and include more heterogeneous patients.

“…in an experienced center the long-term results of SVR in patients with depressed ventricular function and post-infarction LV remodeling were favorable and significantly better than those reported in the STICH trial,” the study authors noted. “Our data suggest that a new trial testing the SVR hypothesis with clearly defined and standardized criteria for patients’ enrollment and intervention delivery may be warranted.”

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  

Reference

Gaudino M, Castelvecchio S, Rahouma M, et al. Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial. J Thorac Cardiovasc Surg. Published online April 24, 2022. doi:10.1016/j.jtcvs.2022.04.016