DYNAMIC CARDIOMYOPLASTY AT 7 YEARS

Since January 1985, the date of the first dynamic cardiomyoplasty, unt il April 1992, 52 patients with end-stage heart disease were operated on in our institution. Mean preoperative New York Heart Association fu nctional class was 3.3 and ventricular ejection fraction 16% +/- 3%. A ssociated procedures in 23 patients comprised ventricular aneurysm res ection (10), valve surgery (9), coronary artery bypass (8), and tumor resection (3). Thirty-eight patients had a ventricular reinforcement, 13 a ventricular substitution, and 1 an atrial reinforcement using the left latissimus dorsi muscle. Preassist mortality rate before full la tissimus dorsi muscle stimulation was 7 of 13 patients (54%) in the 19 85 to 1987 period and 5 of 39 (12%) in the 1988 to 1992 period. The ca uses of death were heart failure (4), multiorgan failure (4), septicem ia (2), ventricular fibrillation (1), and sudden death (1). Multivaria te analysis of factors influencing hospital mortality showed that age, cardiac suture technique, associated surgical procedures, biventricul ar heart failure, and hemodynamic instability plus inotropic drug supp ort were predictors of unfavorable outcome. All patients were followed up for from 2 months to 7 years (mean 21 months). Postassist mortalit y rate was 8 of 40 (20%). Causes of death included heart failure (5), ventricular fibrillation (1), myocardial infarction (1), and gastric b leeding (1). Preoperative risk factors influencing long-term mortality were permanent New York Heart Association functional class IV, bivent ricular heart failure, atrial fibrillation, cardiothoracic ratio great er than 60%, and ejection fraction less than 15%. Actuarial survival a t 7 years was 70.4% (preassist mortality excluded). Surviving patients were in a mean New York Heart Association functional class of 1.8 (pr eoperatively 3.3, p < 0.05). The average ejection fractions (rest/stre ss) were 25%/28% at 1 year, 26%/30% at 2 years, and 23%/28% at 3 years . Average cardiothoracic ratios were 57% +/- 3% at 1 year, 56% +/- 2% at 2 years, and 57% +/- 2.5% at 3 years. Catheterization obtained in 2 0 patients showed no significant changes at rest in capillary wedge pr essure, pulmonary artery pressure, and diastolic left ventricular pres sure when compared with preoperative pressures. Average ejection fract ions increased from 24% to 30.6%. Maximal oxygen consumption increased from 12.8 +/- 3.5 to 18.6 +/- 4 ml/min per kilogram. The number of re hospitalizations resulting from congestive heart failure was reduced t o 0.4 hospitalizations per patient per year (preoperatively 2.4, p < 0 .05). In 62% of the patients, pharmacologic therapy was diminished aft er the operation. Three patients required orthotopic heart transplanta tion 6 months, 4 years, and 5 years after cardiomyoplasty. All are ali ve.