Role of Surgical Ventricular Restoration in the Treatment of Ischemic Cardiomyopathy

Transcription

1 Role of Surgical Ventricular Restoration in the Treatment of Ischemic Cardiomyopathy Jun Liu, MD, Zixiong Liu, MD, Qiang Zhao, MD, Anqing Chen, MD, Zhe Wang, MD, and Dan Zhu, MD Department of Cardiovascular Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China Background. Surgical ventricular restoration (SVR) has been applied as a valuable adjunct procedure for patients undergoing coronary artery bypass grafting (CABG) to correct the geometry of the left ventricle on the basis of myocardial revascularization. It is necessary to find out at least which patient cohort is more likely to benefit from this procedure. Methods. A case-control study was conducted on 221 patients with ejection fraction (EF) <0.35 and New York Heart Association (NYHA) class III or IV, who received CABG SVR or CABG alone from 1998 to Comparisons were made between CABG SVR and CABG alone within two groups of patients: group 1 (preoperative left ventricular end-systolic volume index [LVESVI] <80 ml/m 2,n 127) and group 2 (preoperative LVESVI >80 ml/m 2,n 94). Outcomes included improvement in EF, NYHA class, readmissions, and survival. Results. Patients in either group receiving SVR achieved significant LVESVI reduction postoperatively (p < 0.001). In group 1, EF improvement (defined as over.05 improvement in EF) was observed in 53.7% of CABG SVR patients compared with 48.5% for CABG patients (p 0.570). A similar percentage of patients improved to NYHA class I or II (63.0% for CABG SVR versus 55.9% for CABG, p 0.430). Readmissions after CABG SVR were 27.8% compared with 38.2% after CABG (p 0.225). There was no difference in survival between CABG SVR and CABG (p 0.709). In group 2, the CABG SVR patients showed greater EF improvement (55.6% versus 30.8%, p 0.020) and were more likely to improve to NYHA class I or II (58.3% versus 36.5%, p 0.044). Readmissions were fewer for the CABG SVR patients than for the CABG patients (30.6% versus 57.7%, p 0.012). CABG SVR yielded better survival than did CABG (p 0.031). Conclusions. Patients with much advanced LVESVI are more likely to benefit from surgical ventricular restoration, and this surgical procedure still holds its ground in the treatment of ischemic cardiomyopathy. (Ann Thorac Surg 2013;95: ) 2013 by The Society of Thoracic Surgeons Surgical ventricular restoration (SVR) is a surgical option for patients with ischemic cardiomyopathy caused by postinfarction ventricular dilation featuring poor ventricular systolic function and low ejection fraction (EF). After a myocardial infarction (MI), the process of compensatory left ventricular (LV) dilatation begins in the surrounding myocardium and is known as remodeling, resulting in the loss of the normal LV elliptical shape and a change in the ventricular volume, leading to the development of a marked ventricular dyssynchrony and nonuniform contraction. As the normal elliptical shape transforms to a spherical shape the global systolic function worsens, and the prognosis becomes extremely poor, with frequent readmissions and a very low 5-year survival rate. In this case, surgical treatment remains one of the major resources and is expected to cope with this Accepted for publication Dec 7, Address correspondence to Dr Zixiong Liu, Department of Cardiovascular Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 197 Ruijin Rd, Shanghai, , China; pieero@sina.com. severe situation. Coronary artery bypass grafting (CABG) constitutes the basic part in the treatment of coronary artery disease with postinfarction LV impairment. Its clinical efficacy is sometimes unsatisfactory because the ongoing remodeling process keeps the LV performance at a very low level, even though the ischemic area is revascularized. Although several studies have demonstrated that SVR carried out on the basis of CABG can reversely remodel ventricular size and shape, improving the ventricular systolic function to a certain degree, whether the surgically induced ventricular geometric changes will lead to better clinical outcomes remains controversial. Unfortunately, owing to differences in experience and the lack of uniform understanding of the specific technique among surgeons, some eligible patients who might benefit from SVR do not receive the procedure, whereas other patients for whom the procedure may prove unnecessary undergo it anyway. This study investigated the influence of preoperative LV end-systolic index (LVESVI) on the clinical outcome in patients who undergo SVR, with the aim of finding a simple and useful way to help decide who really needs this procedure by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 1316 LIU ET AL Ann Thorac Surg SVR FOR ISCHEMIC CARDIOMYOPATHY 2013;95: Fig 1. Process of patient selection and categorization. (CABG coronary artery bypass grafting; EF ejection fraction; LVESVI left ventricular end-systolic volume index; SVR surgical ventricular restoration.) Patients and Methods Study Design A total of 330 patients with EF.35 and NYHA class III or IV underwent either CABG or CABG SVR between 1998 and Of the 330 patients, 262 were considered to be SVR candidates according to the typical indications, which included dilated ventricle, a prior left anterior descending artery territory infarct, either akinetic or dyskinetic anterior wall segment, and generally acceptable basal and lateral wall motion. To make an appropriate control group, the SVR candidates were randomly assigned to either CABG or CABG SVR at the time of operation. As for patients with LV aneurysms, they were not considered as candidates. If the LV wall was generally thinned (less than 5 mm) or total myocardial reserve analysis showed poor viability, the patient was rejected for either operation. This study was approved by our institutional board, and all the patients admitted to the study gave informed consent to the scientific analysis of their clinical data in an anonymous form. The patient data were finally reviewed again by a senior experienced physician, who was masked to patient group for confirmation that they were SVR candidates. Patients with moderate to severe mitral regurgitation who underwent additional valve repair or replacement were excluded to avoid confounding factors. Echocardiography and/or magnetic resonance imaging were used to demonstrate either the dyskinetic or the akinetic area in the anterior wall. Other exclusion criteria included nonanterior dyskinesia or akinesia, myocardial infarction less than 30 days, previous cardiac operation, and severe concomitant noncardiac ailment that would apparently predispose the patient to poor clinical outcome or short life expectancy. Finally, 221 patients (aged 63 9 years) were found to satisfy the selection criteria and were included in the analysis. All patients had coronary artery disease and a previous anterior infarction with ventricular dilation, and the interval between infarction and surgical procedure averaged 1.3 years (range, 0.24 to 8 years). Echocardiographic studies were performed on them before operation and at discharge. According to preoperative LVESVI, the patients were divided into two groups: group1 (preoperative LVESVI 80 ml/m 2,n 127) and group 2 (preoperative LVESVI 80 ml/m 2,n 94). Follow-up information was obtained from hospital medical records or through telephone interviews with the patients or family members. Follow-up was 95.9% complete (9 of 221 patients were lost to follow-up), with a mean time of months (Fig 1). Patient Variables Data collection included demographics, NYHA functional class, preoperative risk factors, hemodynamic data, and postoperative complications and procedures. Magnetic resonance imaging and/or echocardiography were used to measure LV ejection fraction (LVEF) and LV end-systolic volume (LVESV). Mortality data were obtained from hospital medical records. Cardiac-related readmission, reoperation, and cardiac-related death were recorded as cardiacrelated events. Guideline-based medications for coronary artery disease and congestive heart failure at discharge included anticoagulants, statins, -blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, diuretics, and aldosterone antagonists. Echocardiography Both preoperative and postoperative echocardiographic measurements were performed in all patients. Postoper-

3 Ann Thorac Surg LIU ET AL 2013;95: SVR FOR ISCHEMIC CARDIOMYOPATHY 1317 ative transthoracic echocardiographic data for each group of patients were obtained at the sixth month after discharge. Two-dimensional echocardiography and color Doppler imaging were routinely applied. The LVEF was measured to assess the LV systolic function. The LVESV and LVEF were calculated from both two-chamber and four-chamber images with the improved Simpson s technique. Outcomes The primary endpoint was all-cause mortality within the entire study period. Outcomes included early mortality, cardiac death (defined as death of heart failure, arrhythmia, ischemic events, or sudden death), readmission for heart failure, improvement in EF, and NYHA functional class. Surgical Techniques All patients underwent median sternotomy, and normothermic cardiopulmonary bypass was commenced with cannulation in the aorta and right atrium, respectively. CABG was performed first, immediately after the bypass grafts were obtained. Complete myocardial revascularization was pursued by arterial and venous grafting. Left internal mammary arterial grafting for the left anterior descending coronary artery was performed in all cases without specific contraindications. Usually we prefer to perform the SVR procedure with the patient under parallel circulation without cardioplegic arrest, which facilitates the identification of the junction between viable and nonviable tissue through transmural palpation of contracting muscle. SVR was carried out according to the technique as previously described by Dor and associates [2]. A longitudinal incision was made in the infarcted anterior wall segment parallel to the left anterior descending artery. After close inspection of the ventricular cavity, an endocardial encircling suture was placed along the transitional zone between scarred tissue and viable myocardium and then tightened and tied to allow the LV to resume the normal elliptical shape. A tailored Dacron patch was secured to the opening within the encircling suture. Finally, the incision on the LV was closed with two parallel felt strips by use of the standard sandwich technique. An on-pump coronary artery bypass technique was applied in those patients who underwent CABG alone without cross-clamping the ascending aorta so as to achieve better myocardial protection. Statistical Analysis All data are presented as mean standard deviation. Continuous and categoric variables were compared with Student s t test and 2, respectively. Cumulative survival rates are presented as Kaplan-Meier estimates. A twotailed p value of 0.05 was used to indicate statistical significance. SPSS version 13 software (SPSS Inc., Chicago, IL) was used for statistical analyses. Results Patient Characteristics Of all the 221 patients reviewed, 127 had a preoperative LVESVI less than 80 ml/m 2 (mean, ml/m 2 ), and 94 had a preoperative LVESVI equal to or more than 80 ml/m 2 (mean, ml/m 2 ). In group 1, the mean age was years for CABG patients and years for the CABG SVR patients; in group 2 the mean age was years for CABG patients and years for CABG SVR patients. No major significant differences in baseline clinical characteristics were observed between patients undergoing either CABG alone or CABG SVR in both groups, except in group 1, where a slightly higher percentage of CABG patients received percutaneous cardiac intervention before undergoing operation than did the CABG SVR patients (p 0.032). In terms of baseline demographic characteristics, the only statistically significant difference between the two surgical approaches was sex, observed only in group 1, where 52.1% of the CABG patients were male compared with 69.6% for the CABG SVR patients (p 0.045). The baseline characteristics are presented in Table 1. Operative Data The SVR was performed by the Dor procedure as described previously. There were no intraoperative mortalities. All patients were successfully weaned from cardiopulmonary bypass. Early mortality defined as death within 30 days of operation or before hospital discharge was similar between the CABG-alone patients and the CABG SVR patients in both group 1 and group 2. The cause of death included low cardiac output syndrome, multisystem organ failure, and irreversible ventricular fibrillation. There was no difference in intensive care unit duration or mean hospital stay between CABG SVR and CABG alone for both groups. When discharged from the hospital, all patients were in acceptable clinical condition. The surgical data are summarized in Table 2. Outcomes The mean follow-up time was months. In group 1, the LVESVI of the CABG SVR patients decreased from ml/m 2 preoperatively to ml/m 2 postoperatively (P 0.001). Survival at 3 years was 61.1% for CABG SVR compared with 67.6% for CABG alone, and survival at 5 years was 57.4% for CABG SVR compared with 60.3% for CABG alone; the difference of cumulative survival was not statistically significant (p 0.709) (Fig 2). Improvement in EF (defined as over.05 improvement in EF) was observed in 53.7% of patients undergoing CABG SVR compared with 48.5% for CABG alone (p 0.570). Readmissions for cardiac causes did not differ significantly between patients receiving CABG SVR and those receiving CABG alone (p 0.225). Similar postoperative NYHA functional class improvement was observed with both surgical approaches: 63.0% of CABG SVR patients improved to NYHA functional class I or II compared with 55.9% in the CABG-alone patients (p 0.430).

4 1318 LIU ET AL Ann Thorac Surg SVR FOR ISCHEMIC CARDIOMYOPATHY 2013;95: Table 1. Baseline Characteristics of Patients Group 1 (LVESVI 80 ml/m 2 ) Group 2 (LVESVI 80 ml/m 2 ) Variable CABG CABG SVR CABG CABG SVR (n 71) (n 56) p Value (n 56) (n 38) p Value LVESVI (ml/m 2 ) Mean age (y) Sex: male* (%) Diabetes (%) Hypertension (%) COPD (%) Renal failure a (%) PCI history b (%) Angina history (%) Atrial fibrillation (%) Stroke (%) QRS duration (ms) Hyperlipidemia (%) Smoker (%) PH c (%) LVEFI NYHA class III (%) IV (%) MR grade Mild (%) Mild-moderate (%) Coronary lesions 2 vessels (%) vessels (%) Left main (%) VT (%) Preoperative Medication Diuretics (%) Nitrates (%) ACEI (%) blockers (%) Anticoagulants (%) a Defined as preoperative creatinine level 120 mmol/l; b p 0.05 considered significant for between-group comparisons; c defined as mean pulmonary arterial pressure 30 mm Hg. ACEI angiotensin converting enzyme inhibitors; CABG coronary artery bypass grafting; COPD chronic obstructive pulmonary disease; LVEFI left ventricular ejection fraction index; LVESVI left ventricular end-systolic volume index; MR grade grade of mitral regurgitation assessed by preoperative echocardiography; NYHA New York Heart Association; PCI percutaneous cardiac intervention; PH pulmonary hypertension; SVR surgical ventricular restoration; VT ventricular tachycardia. In group 2, CABG SVR achieved a remarkable reduction in LVESVI: from ml/m 2 to ml/m 2 (p 0.001), and it remained unchanged for CABG alone. Survival at 3 years was 63.9% for CABG SVR versus 38.5% for CABG alone; survival at 5 years was 52.8% for CABG SVR versus 28.8% for CABG alone. CABG SVR provided better cumulative survival compared with CABG alone (p 0.031) (Fig 3). Improvement in EF (defined as over.05 improvement in EF) was observed in 55.6% of patients undergoing CABG SVR compared with 30.8% for those receiving CABG alone (p 0.020). Postoperative improvement of NYHA functional class was different between the two surgical approaches: 58.3% of the patients receiving CABG SVR improved to NYHA functional class I or II compared with 36.5% for those receiving CABG alone (p 0.044). Patients from the CABG SVR group were less likely to experience heart failure related symptoms or to be rehospitalized for cardiac causes than were those receiving CABG alone (30.6% versus 57.7%, p 0.012); most of those rehospitalized were treated medically for recurrent heart failure, and others underwent reoperations for rhythm disturbances (ie, implantation of an internal cardioverter or

5 Ann Thorac Surg LIU ET AL 2013;95: SVR FOR ISCHEMIC CARDIOMYOPATHY 1319 Table 2. Comparisons of Operative Data Between CABG Alone and CABG SVR Group 1 (LVESVI 80 ml/m 2 ) Group 2 (LVESVI 80 ml/m 2 ) (n 71) (n 56) p Value a (n 56) (n 38) p Value a CPB time (min) IABP (%) Number of grafts Mean hospital stay (days) day mortality (%) ICU duration (days) Inotropic support 24 h (%) a p 0.05 considered significant for between-group comparisons. CABG coronary artery bypass grafting; CPB cardiopulmonary bypass; IABP intra-aortic balloon pump; ICU intensive care unit; LVESVI left ventricular end-systolic volume index; SVR surgical ventricular restoration. pacemaker device). The outcome results are shown in Table 3. After the primary analysis was performed, an additional analysis was conducted comparing the clinical outcomes in patients with the same final volume index treated with the two different strategies. Thirty patients each were chosen from the CABG and CABG SVR groups with similar mean final volume index ( ml/m 2 for CABG versus ml/m 2 for CABG SVR, p 0.352). Patients treated with CABG SVR showed greater postoperative EF improvement than did those treated with CABG alone (66.7% versus 40.0%, p 0.038). No difference was observed in readmission rate, with 43.3% for CABG alone and 33.3% for CABG SVR (p 0.426). Postoperative NYHA functional class improvement was similar: 36.7% of CABG patients improved to NYHA functional class I or II compared with 56.7% of CABG SVR patients (p 0.121). Survival at 5 years was 56.7% for CABG alone and 63.3% for CABG SVR; the difference was not statistically significant (p 0.711). Comment The debate about whether concomitant SVR should be performed in CABG is still going on. Some reports suggest that SVR, at least for a certain group of patients, can provide ideal symptomatic relief from advanced congestive heart failure caused by ischemic cardiomyopathy [1 3]. Currently, the selection of candidates eligible for SVR depends on a comprehensive study of preoperative echocardiographic findings or magnetic resonance Fig 2. Kaplan-Meier survival chart of patients whose preoperative left ventricular end-systolic index was less than 80 ml/m 2. There was no significant difference in cumulative survival between patients receiving coronary artery bypass grafting (interrupted line) and coronary artery bypass grafting plus surgical ventricular restoration (solid line). Fig 3. Kaplan-Meier survival chart of patients whose preoperative left ventricular end-systolic index was equal to or more than 80 ml/ m 2. The survival of patients undergoing coronary artery bypass grafting plus surgical ventricular restoration (solid line) was significantly greater than that of those undergoing coronary artery bypass grafting alone (interrupted line).

6 1320 LIU ET AL Ann Thorac Surg SVR FOR ISCHEMIC CARDIOMYOPATHY 2013;95: Table 3. Comparisons of Clinical Outcome: CABG Alone versus CABG SVR Group 1 (LVESVI 80 ml/m 2 ) Group 2 (LVESVI 80 ml/m 2 ) (n 68) (n 54) p Value (n 52) (n 36) p Value Readmission for cardiac causes (%) NYHA functional class I or II (%) EF improvement (%) p 0.05 considered significant for between-group comparisons; categoric variables were compared with 2. CABG coronary artery bypass grafting; EF ejection fraction; LVESVI left ventricular end-systolic volume index; NYHA New York Heart Association; SVR surgical ventricular restoration. images and the results of a dobutamine challenge test, along with the surgeon s own experience in the analysis of myocardial reserve [4, 5]. Studies pertaining to SVR so far have generated some mixed results [6 8]. It is still hard to convince everyone because some researchers have found that SVR is not always beneficial [9 11]. Through their excellent work, Athanasuleas and colleagues [1] have identified LVESVI equal to or more than 80 ml/m 2 as a risk factor for poor clinical outcome or death, which agrees with our clinical practice in this group of patients. Although it is believed by some researchers that the ventricular remodeling process continues after SVR [5, 12], the results of our research showed that SVR in addition to CABG can provide a better clinical outcome than CABG alone, at least in the cohort of patients with preoperative LVESVI equal to or more than 80 ml/m 2. For ischemic cardiomyopathy a in less advanced stage (LVESVI 80 ml/m 2 ) we believe that effective revascularization is most essential in maintaining ventricular function. It was observed that SVR was not essential in this group of patients because no difference in clinical outcome was observed; however, somehow SVR inflicted no harm on patients if it was performed just as an additional surgical procedure. Although in far advanced cases of ischemic cardiomyopathy (LVESVI 80 ml/m 2 ), revascularization alone seemed unable to provide enough protection for the injured myocardium, our study demonstrated that CABG SVR was effective in treating severe ischemic cardiomyopathy. From this perspective, SVR may well serve as a temporary bridge to more aggressive treatments, such as heart transplantation [13, 14]. In this study, we observed a 20% 1-year mortality, which did not seem like an ideal outcome in this population. According to published reports, it has ranged from 7% to 22%. Here it has to be pointed out patients in the East used not to be open to the idea of heart operations, especially when they were in a serious condition and were usually rushed to operation by their relatives. In such cases they were less likely to recover psychologically and were more prone to depression. Their unhealthy postoperative mental status caused them to be bedridden without enough beneficial physical exercise, which in a way contributed to the deterioration of their condition within the first year. Fortunately, in recent years this trend has changed because people are not as resistant to major operations as before, thanks to better preoperative psychological preparation. We hypothesize that what underlies the different outcomes among different patient cohorts may be a potential threshold beyond which myocardial compensation may prove to be insufficient. When myocardial infarction renders the affected area noncontractile, the global contractile harmony is damaged, and the undamaged myocardium undergoes hypertrophy to compensate for the lack of contractility of the necrotic wall; thus, the socalled remodeling process is initiated usually starting from the border along the infarcted area [15, 16], where the myocardial tissue is still viable but severely lacks a blood supply because the strongest tension was inflicted here [17]. If effective myocardial revascularization is carried out in timely manner and the myocardium is revitalized before severe destruction to the LV takes place, a good clinical outcome is expected whether or not the SVR procedure is performed. If the remodeling process continues to develop beyond a certain limit, involving a much larger part of the myocardial mass presenting with an extremely abnormal ventricular geometry, it will be unlikely for the impaired ventricular function to recover even though the blood supply has been restored. Although the prognosis is generally poorer compared with that in less advanced cases, patients will probably still benefit from SVR even if the remodeling process cannot be completely reversed. We can see from the result of the Surgical Treatment of Intracerebral Hemorrhage study that the SVR procedure reduced the end-systolic volume index by 19%, compared with a reduction of 6% in patients receiving CABG alone [18]. Why wasn t the improvement in the shape of the LV associated with better improvement in symptoms or a reduction in the rate of death resulting from cardiac causes? One reason may be that the comparison is made between the two surgical strategies, not discriminating between the degrees of geometric changes of the LV [18]. LVESVI, which is indicative of the postinfarction ventricular morphology [19], is adopted in our research as an important criterion in patient selection. We stratified patients who underwent either CABG alone or CABG SVR into two different groups according to their preoperative LVESVI. The results of our study indicate that SVR seems more to favor patients in whom the geometric shape of the LV is much further away from normal, and this may provide some references for the selection of potential candidates for the specific procedure.

7 Ann Thorac Surg LIU ET AL 2013;95: SVR FOR ISCHEMIC CARDIOMYOPATHY 1321 Limitations Our results reflect a single-center experience, and the observational nature of this research has the inherent limitations of a retrospective database study. This study was limited by the fact that the surgical strategies determining who would receive CABG and who would receive CABG SVR were not completely randomized, and baseline differences may have introduced some bias. We also acknowledge several methodologic limitations that might arouse caution about our results and limit the implications of this study. It is known many patients with from ischemic cardiomyopathy usually have accompanying mitral regurgitation that needs repair. Given that the conclusion drawn from this study supports the beneficial effects of the SVR procedure in patients with lower preoperative LVESVI, further evidence is still needed to observe how it works for those patients with concomitant procedures such as mitral valve repair. Here it has to be pointed out that all of the patients included in this study received on-pump CABG because it is more likely to disturb the hemodynamic stability maneuvering the heart during revascularization, especially when the LV is remarkably dilated and EF is compromised. Some centers prefer the off-pump technique to the on-pump technique in CAQG. Although most studies comparing the two techniques (off-pump versus on-pump) have shown no significant differences in vascular graft patency or survival, a conclusion has still not been drawn whether one technique is better than the other. References 1. Athanasuleas CL, Buckberg GD, Stanley AW, et al. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. J Am Coll Cardiol 2004;44: Dor V, Sabatier M, Di Donato M, Montiglio F, Toso A, Maioli M. Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scar. J Thorac Cardiovasc Surg 1998;116: Di Donato M, Toso A, Dor V, et al. Surgical ventricular restoration improves mechanical intraventricular dyssynchrony in ischemic cardiomyopathy. Circulation 2004;109: Fauchier L, Marie O, Casset-Senon D, Babuty D, Cosnay P, Fauchier JP. Interventricular and intraventricular dyssynchrony in idiopathic dilated cardiomyopathy: a prognostic study with Fourier Phase analysis of radionuclide angioscintigraphy. J Am Coll Cardiol 2002;40: Bogaert J, Bosmans H, Maes A, Suetens P, Marchal G, Rademakers FE. Remote myocardial dysfunction after acute anterior myocardial infarction: impact of left ventricular shape on regional function: a magnetic resonance myocardial tagging study. J Am Coll Cardiol 2000;35: Yamaguchi A, Ino T, Adachi H, et al. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg 1998;65: Klein P, Bax JJ, Shaw LJ, et al. Early and late outcome of left ventricular reconstruction surgery in ischemic heart disease: a systematic review of the literature. Eur J Cardiothorac Surg 2008;34: Yamaguchi A, Adachi H, Kawahito K, Murata S, Ino T. Left ventricular reconstruction benefits patients with dilated ischemic cardiomyopathy. Ann Thorac Surg 2005;79: Jackson BM, Gorman JH, Moainie SL, et al. Extension of border zone myocardium in postinfarction dilated cardiomyopathy. J Am Coll Cardiol 2002;40: Jackson BM, Gorman JH 3rd, Salgo IS, et al. Border zone geometry increases wall stress after myocardial infarction: contrast echocardiographic assessment. Am J Physiol 2003; 284:H Maxey TS, Reece TB, Ellman PI, et al. Coronary artery bypass with ventricular restoration is superior to coronary artery bypass alone in patients with ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2004;127: Gaudron P, Eilles C, Kugler I, Ertl G. Progressive left ventricular dysfunction and remodeling after myocardial infarction: potential mechanisms and early predictors. Circulation 1993;87: Menicanti L, Castelvecchio S, Ranucci M, et al. Surgical therapy for ischemic heart failure: single center experience with surgical anterior ventricular restoration. J Thorac Cardiovasc Surg 2007;134: Subramanian H, Kunadian B, Dunning J. Is it worth performing surgical ventricular restoration in patients with ischemic cardiomyopathy and akinetic but non-aneurysmal segments in the left ventricle? Interact CardioVasc Thorac Surg 2008;7: Di Donato M, Sabatier M, Toso A, et al. Regional myocardial performance of non-ischaemic zones remote from anterior wall left ventricular aneurysm: effects of aneurysmectomy. Eur Heart J 1995;16: Ribeiro GA, da Costa CE, Lopes MM, et al. Left ventricular reconstruction benefits patients with ischemic cardiomyopathy and non-viable myocardium. Eur J Cardiothorac Surg 2006;29: Steendijk P, Baan J Jr, van der Velde ET, Baan J. Effects of critical coronary stenosis on global systolic left ventricular function quantified by pressure-volume relations during dobutamine stress in the canine heart. J Am Coll Cardiol 1998;32: Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009;360: White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987;76: INVITED COMMENTARY The authors of this study [1] investigated how the preoperative left ventricular end-systolic volume index (LVESVI) influenced the clinical outcome in patients with anterior akinesia or dyskinesia eligible for coronary artery bypass grafting (CABG) with or without surgical ventricular restoration (SVR). Patients with the left ventricular wall thinned to less than 5 mm or with moderate to severe mitral regurgitation were excluded from the study. The patients were divided into two groups: group 1, 127 patients with ESVI 80 ml/m 2 ; and group 2, 94 patients with ESVI 80 ml/m 2. The 127 patients with the smallest left ventricles had a mean ESVI of ml/m 2, and the 94 patients with the larger hearts had an ESVI of ml/m 2. Follow-up was 95.9% complete 2013 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc