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(Circulation. 2004;110:II-18 – II-22.)
© 2004 American Heart Association, Inc.

Surgery for Coronary Artery Disease

Extensive Left Ventricular Remodeling Does Not Allow Viable Myocardium to Improve in Left Ventricular Ejection Fraction After Revascularization and Is Associated With Worse Long-Term Prognosis

Jeroen J. Bax, MD; Arend F.L. Schinkel, MD; Eric Boersma, MSc; Abdou Elhendy, MD; Vittoria Rizzello, MD; Alexander Maat, MD; Jos R.T.C. Roelandt, MD; Ernst E. van der Wall, MD; Don Poldermans, MD

From the Department of Cardiology (J.J.B., E.E.v.d.W.), Leiden University Medical Center, The Netherlands; and the Departments of Cardiology (A.F.L.S., A.E., V.R., J.R.T.C.R., D.P.), Epidemiology and Statistics (E.B.), and Thoracic Surgery (A.M.), ThoraxCenter Rotterdam, The Netherlands.

Correspondence to Jeroen J. Bax, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. E-mail jbax{at}knoware.nl

Background— Extensive left ventricular (LV) remodeling may not allow functional recovery after revascularization, despite the presence of viable myocardium.

Methods and Results— Seventy-nine consecutive patients with ischemic cardiomyopathy (left ventricle ejection fraction [LVEF] 29±7%) underwent surgical revascularization. Before revascularization, viability was assessed by metabolic imaging with F18-fluorodeoxyglucose and SPECT. LV volumes and LVEF were assessed by resting echocardiography. LVEF was re-assessed by echocardiography 8 to 12 months after revascularization. Three-year clinical follow-up (events: cardiac death, infarction, and hospitalization for heart failure) was also obtained. Forty-nine patients had substantial viability; 5 died before re-assessment of LVEF. Of the remaining 44 patients, 24 improved 5% in LVEF after revascularization, whereas 20 did not improve in LVEF. LV end-systolic volume was the only parameter that was significantly different between the groups (109±46 mL for the improvers versus 141±31 mL for the nonimprovers; P<0.05). The change in LVEF after revascularization was linearly related to the baseline LV end-systolic volume, with a higher LV end-systolic volume associated with a low likelihood of improvement in LVEF after revascularization. During the 3-year follow-up, the highest event-rate (67%) was observed in patients without viable myocardium with a large LV size, whereas the lowest event rate (5%) was observed in patients with viable myocardium and a small LV size. Intermediate event rates were observed in patients with viable myocardium and a large LV size (38%), and in patients without viable myocardium and a small LV size (24%).

Conclusion— Extensive LV remodeling prohibits improvement in LVEF after revascularization and affects long-term prognosis negatively, despite the presence of viability.

Key Words: myocardial viability • hibernating myocardium • heart failure • left ventricle remodeling • surgical revascularization