Surgical Ventricular Restoration for Advanced Congestive Heart Failure: Should Pulmonary Hypertension Be a Contraindication?

Background: Surgical ventricular restoration (SVR) is an established therapy for congestive heart failure due to ischemic cardiomyopathy. Pulmonary hypertension (PHTN) has been considered a contraindication for SVR owing to a presumed increase in operative risk. However, outcomes in these patients and the impact of SVR on PHTN have not been specifically evaluated. Methods: We retrospectively reviewed SVR patients between January 2002 and June 2005. Patients were classified as PHTN (mean pulmonary artery pressure ≥ 25 mm Hg) and no PHTN (mPAP < 25 mm Hg) based on preoperative cardiac catheterization. Cardiac function was assessed using magnetic resonance imaging and echocardiography. Follow-up was 100%. Results: Sixty-nine patients underwent SVR for congestive heart failure. Thirty-six percent (25 of 69) had preoperative PHTN. Preoperatively, PHTN patients had significantly lower ejection fraction (21.1% versus 30.0%; p = 0.005) and larger left ventricular end-systolic volume index (119.0 versus 88.7 mL/m²; p = 0.04) than patients without PHTN. All PHTN patients and 95.5% (42 of 44) of the no PHTN group were New York Heart Association (NYHA) class III/IV preoperatively. There was 1 operative death in the PHTN group. Surgical ventricular restoration significantly improved cardiac function and pulmonary pressures for PHTN patients. Both groups had similar cardiac function postoperatively. Seventy-two percent (18 of 25) of PHTN patients and 69.0% (29 of 42) of patients without PHTN improved to NYHA class I/II at follow-up. Kaplan-Meier survival of PHTN patients was 68.1% at 3 years, which was lower than patients without PHTN (81.4%; p = 0.44), but not statistically significant. Kaplan-Meier 3-year survival for all SVR patients was 76.6%. Conclusions: Surgical ventricular restoration is a good treatment option in patients with advanced congestive heart failure and PHTN. Our early results are promising and should prompt further studies to confirm these findings.