Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, Milan, Italy.
Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy.
Eur J Cardiothorac Surg. 2018 Jan 1;53(1):143-149. doi: 10.1093/ejcts/ezx197.
Post-infarction myocardial scar causes adverse left ventricular remodelling and negatively affects the prognosis. We sought to investigate whether scar extent and location obtained by cardiac magnetic resonance may affect the reverse remodelling and survival of heart failure patients undergoing surgical ventricular reconstruction.
From January 2011 to December 2015, 151 consecutive patients with previous myocardial infarction and left ventricular remodelling underwent surgical ventricular reconstruction at our Institution, of which 88 (58%) patients had a preoperative protocol-standardized late gadolinium enhancement (LGE)-cardiac magnetic resonance examination during the week before surgery. We excluded 40 patients with devices (26%), 15 patients with irregular heart rhythm (permanent atrial fibrillation, 10% not included in the device group) or mixed contraindications (severe claustrophobia or presence of material magnetic resonance not compatible). Among the 145 survivors, 11 patients received an implantable cardioverter defibrillator after surgery (mostly for persistent low ejection fraction) and were excluded as well, yielding a total of 59 patients (48 men, aged 65 ± 9 years) who repeated a protocol-standardized LGE-cardiac magnetic resonance examination even 6 months postoperatively and therefore represent the study population. Patients were grouped according to the presence of LGE in the antero-basal left ventricular segments (Group A) or the absence of LGE in the same segments (Group B). The postoperative left ventricular end-systolic volume index was considered the primary end-point.
After surgery, left ventricular end-systolic volume index and end-diastolic volume index significantly decreased (P < 0.001, for both), while diastolic sphericity index and ejection fraction significantly increased (P = 0.015 and P < 0.001, respectively). The presence of LGE in the antero-basal left ventricular segments (10 patients, Group A) was the only independent predictor of outcome (P = 0.02) at multivariate analysis, being the postoperative left ventricular end-systolic volume index significantly higher compared to that of patients of Group B (49 patients) (78 ± 26 ml/m2 vs 55 ± 20 ml/m2, P = 0.003). Furthermore, patients with a postoperative left ventricular end-systolic volume index >60 ml/m2 showed a higher risk of cardiac events (hazard ratio = 3.67, P = 0.02).
In patients undergoing surgical ventricular reconstruction, LGE scar location affects the left ventricular reverse remodelling, which in turn might limit the survival benefit.
心肌梗死后的心肌瘢痕会导致不良的左心室重构，并对预后产生负面影响。我们旨在研究心脏磁共振检查获得的瘢痕范围和位置是否会影响接受心室重构手术的心力衰竭患者的逆重构和生存。
从 2011 年 1 月至 2015 年 12 月，我院对 151 例既往有心肌梗死和左心室重构的连续患者进行了心室重构手术，其中 88 例（58%）患者在手术前一周进行了术前规范化的晚期钆增强（LGE）心脏磁共振检查。我们排除了 40 例有器械的患者（26%）、15 例有不规则心律（永久性心房颤动，10%未包含在器械组中）或混合禁忌症的患者。在 145 例存活患者中，11 例患者在手术后接受了植入式心脏复律除颤器（主要是因为持续的射血分数较低），也被排除在外，因此共有 59 例（48 名男性，年龄 65±9 岁）患者在手术后 6 个月时再次进行了规范化的 LGE 心脏磁共振检查，因此作为研究人群。患者根据前基底左心室节段是否存在 LGE（A 组）或同一节段是否不存在 LGE（B 组）进行分组。术后左心室收缩末期容积指数被视为主要终点。
手术后，左心室收缩末期容积指数和舒张末期容积指数显著降低（P<0.001，均），而舒张球形指数和射血分数显著增加（P=0.015 和 P<0.001，分别）。前基底左心室节段存在 LGE（10 例，A 组）是多变量分析中唯一的独立预后预测因素（P=0.02），与 B 组（49 例）相比，术后左心室收缩末期容积指数显著升高（78±26ml/m2 vs 55±20ml/m2，P=0.003）。此外，术后左心室收缩末期容积指数>60ml/m2 的患者发生心脏事件的风险更高（风险比=3.67，P=0.02）。
在接受心室重构手术的患者中，LGE 瘢痕位置会影响左心室的逆重构，从而可能限制生存获益。
