Cardiac support device, restrictive mitral valve annuloplasty, and optimized medical treatment: A multimodality approach to nonischemic cardiomyopathy

Objective: Nonischemic dilated cardiomyopathy with functional mitral regurgitation carries a poor prognosis. Mitral valve surgery with implantation of a cardiac support device can treat mitral regurgitation and promote left ventricular reverse remodeling. This observational study evaluates clinical and echocardiographic outcomes of an individualized medico-surgical approach, focusing on mitral regurgitation recurrence and left ventricular reverse remodeling. Methods: Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 +/- 73 mL, ejection fraction 26% +/- 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years' median follow-up. Results: Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% +/- 4%, 79% +/- 5%, and 63% +/- 7%. New York Heart Association class improved from 3.1 +/- 0.4 to 2.0 +/- 0.5 (P<.01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33% vs 18%; P=.007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% +/- 8% vs 63% +/- 11%; P=.067). Conclusions: An individualized medico-surgical approach to nonischemic cardiomyopathy combining restrictive mitral annuloplasty, cardiac support device implantation, and optimal medical management leads to favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling. (J Thorac Cardiovasc Surg 2011;142:e93-100)