Surgery for left ventricular aneurysm: Early and late survival after simple linear repair and endoventricular patch plasty

Surgery for Left Ventricular Aneurysm: Early and Late Survival After Simple Linear Repair and Endoventricular Patch Plasty

rence of a 6-month composite of cardiovascular events after vascular surgery. Methods: One hundred patients were randomly assigned to receive either 20 mg atorvastatin or placebo once a day for 45 days, irrespective of their serum cholesterol concentration. Vascular surgery was performed on average 30 days after randomization, and patients were prospectively followed over 6 months. The cardiovascular events studied were death from cardiac cause, nonfatal myocardial infarction (MI), unstable angina, and stroke. Results: Fifty patients received atorvastatin, and 50 received placebo. During the 6-month follow-up, primary end points occurred in 17 patients, 4 in the atorvastatin group and 13 in the placebo group. The incidence of cardiac events was more than three times higher with placebo (26.0%) compared with atorvastatin (8.0%; p⫽0.031). The risk for an event was compared between the groups with the Kaplan-Meier method, as event-free survival after vascular surgery. Patients given atorvastatin exhibited a significant decrease in the rate of cardiac events, compared with the placebo group, within 6 months following vascular surgery (p⫽0.018). Conclusions: The researchers concluded that short-term treatment with atorvastatin significantly reduces the incidence of major adverse cardiovascular events after vascular surgery. Perspective: Results of this randomized prospective trial indicate that the incidence of cardiovascular events in the first 6 months after surgery, including death from cardiac causes, nonfatal acute MI, ischemic stroke, and unstable angina, can be reduced with perioperative use of atorvastatin in patients who must undergo vascular surgery, irrespective of their serum cholesterol concentration. On the basis of clinical data from this study, there appears to be clear benefit to the use of atorvastatin in the perioperative phase. These results need to be confirmed in a larger multicenter randomized clinical trial. DM

Lundblad R, Abdelnoor M, Svennevig JL. J Thorac Cardiovasc Surg 2004;128:449 –56. Study Question: Are there differences in early mortality and long-term survival between simple linear resection and endoventricular patch plasty for the repair of postinfarction left ventricular aneurysm? Methods: Records were retrospectively reviewed from 159 patients who underwent surgical resection of left ventricular aneurysm (74 simple linear repair, 85 endoventricular patch plasty) between 1989 and 2003. End points were early mortality and long-term survival. Results: Early mortality was 8.2% for all patients: 13.5% after linear repair and 3.5% after endoventricular patch plasty. When adjusted for confounding variables, the risk of early mortality was significantly higher after simple linear repair than after endoventricular patch plasty (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.1–17.8). Mean follow-up was 5.8⫾3.8 years (range 0 –14.0 years). Overall 5-year cumulative survival was 78%: 70.1% after linear repair and 91.4% after endoventricular patch plasty. When controlled for confounding variables, the risk of total mortality was significantly higher after linear repair than after endoventricular patch plasty (relative risk 4.5; 95% CI 2.0 –9.7). Linear repair dominated early in the series and patch plasty dominated later, giving a possible learningcurve bias in favor of patch plasty that could not be adjusted for in the regression analysis. Conclusions: Postinfarction left ventricular aneurysm can be repaired with satisfactory early and late results. Surgical risk was lower and long-term survival was higher after endoventricular patch plasty than after simple linear repair. Perspective: This single-center, retrospective study suggests that mortality was better after left ventricular aneurysm repair using endoventricular patch plasty than after simple linear repair. However, because of the retrospective study design and the chronology of the two repair methods (linear repair early, patch plasty later), differences in outcome should be interpreted with caution. DB

Comparison of Angioplasty and Stenting With Cerebral Protection Versus Endarterectomy for Treatment of Internal Carotid Artery Stenosis in Elderly Patients Kastrup A, Schulz JB, Raygrotzki S, Gröschel K, Ernemann U. J Vasc Surg 2004;40:945–51.

Reduction in Cardiovascular Events After Vascular Surgery With Atorvastatin: A Randomized Trial

Study Question: Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy (CEA) for treatment of severe carotid artery stenosis. Because CAS does not require general anesthesia and is less traumatic, it might be especially advantageous in older patients, but data comparing these two treatment methods in older patients are scarce. The objective of this study was to compare directly within 30 days the complication rates associated with either protected CAS or CEA in a homogeneous population of patients aged 75 years and older.

Durazzo AES, Machado FS, Ikeoka DT, et al. J Vasc Surg 2004;39:967–76. Study Question: Cardiovascular complications are the most important cause of perioperative morbidity and mortality among patients undergoing vascular surgery. Statin therapy may reduce perioperative cardiac events through stabilization of coronary plaques. This prospective, randomized, placebo-controlled, double-blind clinical trial analyzed the effect of atorvastatin compared with placebo on the occur-

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