Ventricular aneurysms, shock, and late follow-up in patients with heart failure

See related article on page 374. B olooki and colleagues describe their 22-year experience repairing left ventricular (LV) aneurysms using 3 surgical techniques that were introduced sequentially, with the technique used in group 3 being introduced most recently in 1992. During those 22 years, much has changed in the management of patients with heart failure and in cardiac surgery in general. Routine use of angiotensinconverting enzyme inhibitors and implantable cardioverter-defibrillators started after the initiation of their study. The addition of -blockers, spironolactones, and biventricular synchronous pacing was introduced during the 1990s. These interventions for heart failure have had a significant positive effect on the short-term and midterm prognoses for patients. Therefore, it is no surprise that the midterm survival for their most recent patients is better than that for the patients who underwent surgical intervention at an earlier time (groups 1 and 2). Was the improvement in survival in group 3 patients as described by Bolooki and colleagues the result of the concept of surgical intervention being inherently better than in the techniques used in group 1 and 2 patients? Although they imply that their results are better, “especially with endoventricular patch technique,” with so many other changes evolving during the same time, this is a classic apples and oranges comparison. Unfortunately, no amount of statistical matching would be able to account for the evolution of medical therapy during this period. Furthermore, the patients’ pathologies were different, which could make a crucial difference in late outcomes. The group 3 patients were chosen for this procedure because of minimal involvement of the septal wall; therefore these patients had a more localized infarct than those who had a “large dyskinetic septal scar” (group 2). Also, there are no data to compare ventricular volumes or even dimensions to allow more meaningful comparison between the groups. Therefore, with the evolution of medical therapies and different populations, it is not surprising that group 3 patients achieved better 5-year survival, and this cannot be attributed to the surgical technique. What is surprising is that there was no improvement in perioperative mortality in the more recent group compared with in the groups that began to be treated in 1979. Surgical procedures also evolved during the past 2 decades, with changes such as more effective techniques of cardioplegia, intraoperative echocardiography, and the availability of new inotropic drugs, such as phosphodiesterase inhibitors. Most surgeons think that surgical intervention is safer today than it was 22 years ago. Also, the operative mortality in this report is high compared with modern standards. The high mortality probably relates to the inclusion of patients with cardiogenic shock as an indication for surgical intervention. The operative mortality for this group of patients was 46%, and the 3-year survival was 36%. No information was given regarding late functional outcome of the patients with cardiogenic shock. Were those patients still limited by heart failure? There are broadly 2 scenarios in which a patient with an aneurysm would experience shock: an acute infarction in a vessel remote from the aneurysm or progressive disease that has caused remote muscle to fail. If a patient has an aneurysm and then infarction occurs in another vessel, there might be little remaining viable myocardium to support cardiac function. Similarly, if remote areas of muscle are so dysfunctional that the patient experiences shock, there are some problems that conventional cardiac surgery cannot reliably reverse. From these data, it seems that patients with LV From the Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio.