Existe lugar para a ventriculectomia parcial esquerda no tratamento da cardiomiopatia dilatada?

Abstract

A ventriculectomia parcial esquerda tem sido realizada como alternativa ao transplante cardíaco no tratamento das miocardiopatias. Neste trabalho foi analisada a influência desse procedimento sobre a evolução clínica e o comportamento da função ventricular em 37 pacientes portadores de cardiomiopatia dilatada. Métodos: Os pacientes estavam em classe funcional III (16) ou IV (21) no pré-operatório. A ressecção parcial do ventrículo esquerdo (VE) foi associada à anuloplastia mitral em 27 pacientes e à substituição mitral em 2. Resultados: Ocorreram 7 (18,9%) óbitos hospitalares e os pacientes sobreviventes foram seguidos por período que variou entre 2 e 33 meses (média de 16,2 meses). Outros 9 pacientes faleceram durante os primeiros 6 meses de pós-operatório, por progressão de insuficiência cardíaca (5) ou por eventos relacionados à arritmia (4). A sobrevida atuarial foi de 56,7 ± 8,1% dos 6 aos 30 meses de seguimento. Através de análise unifatorial e de regressão logística foi identificada relação significativa entre o grau de hipertrofia das fibras miocárdicas e o risco de mortalidade após a ventriculectomia parcial, sendo observada sobrevida de 73,6 ± 10,1% em 2 anos para os pacientes operados com diâmetro médio de fibras miocárdicas abaixo de 22. Por outro lado, a classe funcional melhorou nos pacientes sobreviventes de 3,5 ± 0,5 para 1,7 ± 0,9 aos 6 meses de pós-operatório (p Partial left ventriculectomy has been performed as an alternative to heart transplantation in the treatment of severe cardiomyopathies. This study reports the clinical and left ventricular function results of this procedure in 37 patients with dilated cardiomyopathy. Methods: All patients were in class III (16) or IV (21) NYHA. Partial ventriculectomy was associated with mitral annuloplasty in 27 patients and with mitral replacement in two. Results: There were seven operative deaths (18.9%) and the surviving patients were followed from 2 to 36 (mean, 16.2) months. Another nine patients died during the first 6 months of follow-up due to progression of heart failure (5) related to arrhythmia (4). Actuarial survival was 56.7 ± 8.1% from 6 to 24 months. Unifactorial and logistic regression analysis of factors influencing outcome showed that mid-term survival was significantly affected by myocardial cell hypertrophy. A survival of 73.6 ± 10.1% at 2 years was observed for patients operated with mean myocardial cell diameter of less than 22 microns. Otherwise, functional class improved from 3.5 ± 0.5 to 1.7 ± 0.9 in the survivors (p < 0.001). Furthermore, left ventricular diastolic volume decreased from 523 ± 207 to 380 ± 148 ml (p < 0.001) and left ventricular ejection fraction increased from 17.1 ± 4.6 to 23 ± 8% (p < 0.001), whereas significant changes in cardiac index, stroke index and pulmonary pressures were found at 1 month follow-up. Although left ventricular diastolic volume tended to increase in the late postoperative period, left ventricular ejection fraction and hemodynamic variables did not change significantly. Conclusions: Partial ventriculectomy improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy for up to 24 months of follow-up. Nevertheless, this procedure's clinical application is limited by the high mortality observed in the first postoperative months. But it has opened new perspectives for its use through the identification that intrinsic changes of the myocardial fibers are affected by the p.o. prognosis of partial ventriculotomy.

Keywords

• Miocardiopatia congestiva
• Procedimentos cirúrgicos cardíacos
• Ventrículo cardíaco
• Cardiomyopathy
• Cardiomyopathy
• Cardiac surgical procedures
• Heart ventricle