Outcomes Following Surgical Ventricular Restoration for Patients with Clinically Advanced Congestive Heart Failure (New York Heart Association Class IV)

Abstract

Introduction: Patients with more advanced CHF (NYHA class IV) have poorer outcomes with medical therapy, but comparisons of patients with NYHA IV heart failure undergoing surgical ventricular restoration (SVR) versus those with less severe CHF have not been thoroughly addressed. Hypothesis: Patients in preoperative NYHA class IV exhibit similar improvements following SVR when compared to patients with less severe CHF. Methods: We retrospectively reviewed SVR patients at our institution between 1/2002-12/2005. Patients were divided into those in preoperative NYHA class IV and NYHA class II/III for statistical comparison. Echocardiography and MRI were used to determine ejection fraction (EF), left ventricular end-systolic volume indices (LVESVI), and stroke volume indices (SVI). Results: Seventy-eight patients underwent SVR; 34 patients were NYHA IV and 44 patients were NYHA II/III prior to surgery. Preoperatively, both groups were well matched, although NYHA IV patients were more likely to have renal insufficiency (14.7 vs 0%, p = 0.01). Preoperatively, MRI demonstrated that NYHA IV patients had significantly worse EF (21.0 vs 31.4%, p = 0.0002), LVESVI (116.4 vs 83.3 mL/m2, p = 0.01), and SVI (28.2 vs 36.5 mL/m2, p = 0.002). Both groups demonstrated significant improvement in EF (p < 0.0001, p = 0.01) and LVESVI (p = 0.005, p = 0.01) following SVR, and there were no differences with regard to postoperative EF (34.0 vs 39.1%, p = 0.13), LVESVI (66.1 vs 60.1 mL/m2, p = 0.52), or SVI (33.3 vs 35.6 mL/m2, p = 0.55). NYHA IV patients trended towards a higher incidence of mitral valve replacement (14.7 vs 2.3%, p = 0.08). There were 3 operative deaths in each group (p = 1.00). Sixty-five percent (22/34) of NYHA IV patients and 82% (36/44) of NYHA II/III patients improved to NYHA class I/II at follow-up, which was significant for both groups (p < 0.0001, p < 0.0001). NYHA IV patients trended towards reduced 32-month Kaplan-Meier survival when compared to NYHA II/III patients (68 vs 88%, p = 0.08). NYHA IV was not a significant predictor of mortality on Cox regression analysis. Conclusion: We have shown similar improvements in cardiac function following SVR for patients in NYHA IV compared to those with less severe clinical heart failure. Although patients with NYHA class IV trended towards worse survival, these patients have better outcomes than medically managed patients and should be considered for SVR when clinically indicated.