Background. Surgical ventricular restoration (SVR) in patients with left ventricular (LV) aneurysm aims to improve survival and heart failure symptoms through appropriate volume reduction and reshaping of the LV geometry. Our purpose was to refine the planning for SVR using cardiac computed tomography (CCT) for assessment of LV volumes and scar extension and speckle-tracking echocardiography (STE) for evaluation of mechanics of remote non-infarcted LV myocardium.

Methods. We evaluated data of 135 consecutive patients (mean age 63±15, 23.9% women) with LV antero-apical aneurysm who underwent SVR combined with coronary artery bypass surgery (73.9%), mitral valve repair/replacement (20.9%) and thrombectomy (20.9%). Preoperative LV volumetric parameters and segmental wall motion abnormalities were assessed by CCT within routine planning for SVR. Additionally peak global and basal longitudinal strain were quantified for all patients. Preoperative CCT and STE parameters were evaluated for association with an outcome. Endpoints/events were defined as all-cause mortality, LV assist device implantation, or heart transplantation.

Results. During a median follow-up of 4.8 years (IQR: 1.4 – 7.9 years), events occurred in 55 patients (41%). Stratification according to tertiles of preoperative LVESVI revealed a significantly higher event-free survival rate in the lower tertile group (<80 ml/m²) than in the groups with a LVESVI of 80-121 ml/m² and >121 ml/m² (p=0.039). An average 50 ml increase of preoperative LVESVI was associated with a 30% increase of the hazard of events (p=0.043). Aneurysms limited to apical and antero-septal mid-ventricular LV segments were associated with a lower event risk in long-term follow-up (n=49, HR 0.43, CI 0.23–0.82, p=0.01). Those patients with LVESVI ≥80 ml/m² and scar extension beyond antero-apical region (with involvement of basal antero-septal segments of LV or/and any other region of LV) demonstrated higher probability of events (n=71, HR 1.58, 95%CI: 1.2-2.1, p=0.003). In this group of patients, considered as a less favorable for SVR, basal peak longitudinal strain (BLS) ≤ -7.3% (higher deformation, cut-off defined in previous work (1)) was associated with better event-free survival in Kaplan-Meier analysis (Figure). Median event-free survival in patients with BLS ≤ -7.3% was 8.9 years (IQR: 5.9-11.8), whereas in patients with BLS > -7.3% (less deformation) median survival was only 1.6 years (IQR: 0-5.6), p=0.009.

Conclusion. Patients with LV aneurysm with severely enlarged left ventricle and scar extension beyond antero-apical region benefit less from SVR in terms of long-term outcome. Preserved BLS is associated with longer event-free survival and may be used to supplement the preoperative evaluation of these patients.

Figure. Kaplan-Meier curves for event-free survival according to BLS in patients less favorable for SVR.

Ref:
1. Nemchyna O., N. Solowjowa, M. Dandel, Y. Hrytsyna, J. Stein, S. Soltani, J. Knierim, F. Schönrath, V. Falk, C. Knosalla. Basal Left Ventricle Longitudinal Strain Predicts Survival After Surgical Ventricular Repair. AHA Sessions 2019, Philadelphia. Circulation. 2019; 140: A10117. (https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.10117)