Left-ventricular-volume reduction for end-stage heart failure

Abstract

See Commentary page 456 L/m per min (p=0·001). There were three deaths in hospital. Two patients died of technical complications: one from dehiscence of the left-ventricle suture line (day 1) and the second from rupture of the pulmonary artery, a recognised complication of Swan-Ganz catheterisation (day 6). A third patient had chronic renal failure preoperatively, and died on day 6 from multiorgan failure. Inhospital survival was 78·5% and mean hospital stay was 19 (range 8–31) days. At mean follow up of 6 (1–20) months, nine patients were in NYHA functional class I or II and one was in class III. There was one late death: a patient died suddenly 3 months after operation, probably from an arrhythmia. This death prompted us to use amiodarone prophylactically and no episodes of arrhythmia have since been reported. Repeated transthoracic echocardiography did not show any significant change in left-ventricular dimension or function from early postoperative assessment (table). Contrary to the early experience reported by the Cleveland Clinic in the USA, 13 of the candidates for ventricular reduction in our series were patients unsuitable for heart transplantation. The aetiology was not exclusively idiopathic, age was not a contraindication (mean age 65 years compared with 50 years in the Cleveland Clinic series). Two of the inhospital deaths were in the first four patients and only one patient died in the last ten. Our preliminary findings encourage the belief that surgical remodelling of the patient’s own heart can cause sustained improvement in ventricular function. We do not believe that, at this stage, ventricular reduction has been sufficiently evaluated to be offered to patients suitable for heart transplantation. We appreciate, however, that the demand for donor hearts is much greater than supply, and this means that more thorough clinical evaluation of left-ventricular reduction is required.