Surgical Treatment of Patients With Cardiac Cachexia: Discussion

In spite of the recent improvement in operative results in open heart surgery, operative mortality in patients with cardiac cachexia is still high. Various risk factors affecting operative mortality have been reported in patients with cardiac cachexia associated with mitral valve disease. Many authors have reported that tricuspid regurgitation associated with mitral valve disease significantly increased postoperative mortality.5,6 In this series, mortality in patients with advanced tricuspid
regurgitation was slightly, but not significantly, higher than in those with moderate regurgitation. This may be due to the fact that complete repair by tricuspid annuloplasty, when needed, results in excellent postoperative hemodynamics and decreases operative mortality.
Advanced age and female sex have been mentioned as predisposing factors for operative mortality. However, these risk factors are common to cardiac surgery generally, and may not be specific to patients with cardiac cachexia.
The value of plication of giant left atrium remains controversial. Actually, excision of aneurysm of the left atrium can decrease the volume of the atrial chamber, as Hougen et al and Krueger et al have pointed out. Plaschkes et al reported that postoperative complications like respiratory failure and serious congestive heart failure were caused by myocardial damage resulting from rheumatic myocarditis and chronic congestive heart failure, and they did not see any sense in performing plication because this procedure needs more prolonged cardiac arrest time. Matsuda et al similarly reported that postoperative respiratory failure was attributable to the myocardial damage caused by a long history of congestive heart failure. According to the report of Furuta et al, plication itself may be considered to have a negative effect on postoperative hemodynamics, because giant left atrium can play an important role in decreasing the preload of the left ventricle. canadian health & care mall

In contrast, Kawazoe et al2 have reported that the posterobasal wall of the compressed portion of the left ventricle is bent inward by the downward expansion of the left atrium and that the left main bronchus is compressed by leftward and upward expansion of the left atrium. Thus, they noted that plication of the left atrium will result in a significant decrease in the incidence of respiratory failure and postoperative low cardiac output because compression by the left atrium is the major factor in these postoperative complications. In addition, they suggested that transmitral flow in the central-flow prosthetic valve flowed in an unphysiologic direction when giant left atrium was left untreated.