Original Article
Prognostic value of ventricular mechanical dyssynchrony in patients with left ventricular aneurysm: A comparative study of medical and surgical treatment

https://doi.org/10.1007/s12350-020-02343-6Get rights and content

Abstract

Background

The prognostic value of left ventricular (LV) mechanical dyssynchrony (MD) in patients with LV aneurysm (LVA) is unclear. This study aimed to investigate the long-term prognostic value of LVMD in LVA patients.

Methods

92 consecutive patients who underwent 99mTc-sestamibi-gated SPECT myocardial perfusion imaging (GSPECT) were retrospectively analyzed and followed-up for a median of 63 months (range, 1-73 months). LV function and histogram bandwidth (BW) were analyzed by QGS software. LVMD was defined by ROC analysis. Cardiac death was defined as the primary endpoint, and the composite of cardiac deaths and severe or acute heart failure (MACE) as the secondary endpoint.

Results

The annual cardiac mortality rate of LVA patients with LVMD and treated by surgical therapy was significantly lower than those treated by medical therapy (2.40% vs. 6.40%, P < .05) but not annual MACE rate (6.61% vs. 10.06%, P > .05). In patients without LVMD, no significant difference in survival and MACE-free survival between medical and surgical treatment. In addition, the occurrence of LVMD is related to the worsen cardiac outcome in terms of MACE and cardiac death, independent of the treatment methods. BW was an independent predictor for MACE (HR 1.010, P < .01) and LVEF (HR .928, P < .05) was an independent predictor for cardiac death in all LVA patients.

Conclusions

LVA patients with LVMD might be associated with high risk for cardiac death and surgical treatment might improve cardiac survival compared to medical therapy in these patients.

Introduction

Left ventricular (LV) aneurysm is a complication of acute myocardial infarction that may lead to reverse LV remodeling and progressive congestive heart failure (HF), thromboembolic events, arrhythmias, and sudden cardiac death.1, 2, 3 Patients with LV aneurysm (LVA) and HF-related symptoms usually presented a poor prognosis underwent conventional medical treatment.1 Previous studies showed that surgical reversal of adverse LV remodeling resulting from LVA could improve cardiac function, clinical symptoms and life expectancy, but accompanied with high perioperative morbidity and mortality.4 Therefore, it is essential to select the patients who could benefit most from surgery. Multimodal cardiac imaging comprising LV morphology and function were needed to optimize individual treatment strategy of patients with LVA.

The prognosis of patients with LVA is heterogeneous, it could be associated with aneurysmal anatomy, global cardiac function and viability in LV aneurysm.5, 6, 7 Systolic and diastolic dyssynchrony was highly prevalent in LVA patients irrespective of QRS duration and adverse hemodynamic consequences.8 Cardiac phase analysis on myocardial perfusion imaging using gated single-photon emission computed tomography (GSPECT) has become an evolving technique for measuring LV mechanical dyssynchrony (LVMD) in routine clinical practice. It could accurately provide a robust, reproducible semi-quantification of LVMD by different parameters.9,10 Previous investigations demonstrated a significant prognostic value of LV dyssynchrony in patients with LV dysfunction, ischemic cardiomyopathy or HF.11 Nevertheless, the prognostic value of LVMD in patients with LVA was still not clear.

The aims of this study were to assess the prognostic value of LVMD in the prediction of cardiac death and major adverse cardiovascular events (MACE) in patients with LVA, and to compare medical and surgical treatment on the long-term outcomes in LVA patients.

Section snippets

Study Population

The study population was recruited from the patients referred to the Cardiovascular Institute and Fuwai Hospital between January 2010 and December 2011 for scheduled cardiac functional assessment with 99mTc-sestamibi gated SPECT myocardial perfusion imaging (MPI) at rest. Hospitalized patients with LVA diagnosed by echocardiography and/or cardiac magnetic resonance (CMR) imaging were included in this study12 while patients with recent myocardial infarction (≤ 8 week), rheumatic valvular

Patients

A total of 132 LVA patients were initially enrolled in the study. Patients concomitant with rheumatic valvular disease (N = 9), previous aneurysmectomy surgery (N = 10), cardiomyopathy (N = 5), arrhythmia (N = 9) were excluded. 7 patients (5.3%) were lost during follow up. Finally, the study population consisted of 92 patients with LVA (78 male, 56.8 ± 10.0 years) and the mean resting LVEF by GSPECT was 33.1% ± 12.0%. Baseline demographics and clinical characteristics are summarized in Table 1.

Discussion

In this retrospective study, we assessed the value of LVMD for predicting the long-term cardiac survival of LVA patients and compared the surgical and medical treatment outcomes. We found that the presence of LVMD might be associated with adverse outcomes in LVA patients, and surgical treatment could improve the long-term cardiac survival and the MACE-free survival. While LVA patients absent LVMD had prolonged cardiac survival even if treated by medical therapy.

Impairment of global ventricular

New Knowledge Gained

LVA is a severe complication of heart disease with unpreferable clinical outcomes by conventional medical or surgical treatment. We found that LVMD presented prognosis value for treatment management of LVA patients. Surgical treatment might improve the outcome for patients with LVMD.

Limitations

Our study has several limitations: Initially, it was retrospective, an observational cohort in a single center. The small population could give a result which may not be sufficiently powered to detect differences between the categorized groups. Nevertheless, our data might provide preliminary information for LVA patients’ management by the determination of LVMD. The low mortality rate as endpoints/ground truth was recorded in this study, and these unbalanced outcome cohorts could also limited

Conclusions

LVA patients absent LVMD presented a long-term survival prevalence of LVMD might be associated with severe adverse cardiac outcomes in LVA patients in this study. Surgical treatment might specifically improve the cardiac prognosis in LVA patients with LVMD in comparison with medical therapy.

Disclosures

The authors (Xia Lu, Min Zhao, CongnaTian, Hongxing Wei, Mingxin Gao, Xiubin Yang, Xiaoli Zhang, Xiang Li) declare to have no relationships with industry and financial associations in the past 2 years that might pose a conflict of interest in connection with the submitted article. This work was supported by National Natural Science Foundation of China (81071177, 81871377, 81571717) and Capital Characteristic Clinical Application Research (Z181100001718071).

Funding

This work was supported by National Natural Science Foundation of China (81071177, 81871377, 81571717) and Capital Characteristic Clinical Application Research (Z181100001718071).

References (28)

  • AquilaniR et al.

    Is nutritional intake adequate in chronic heart failure patients?

    J Am Coll Cardiol

    (2003)
  • MeizlishJL et al.

    Functional left ventricular aneurysm formation after acute anterior transmural myocardial infarction: incidence, natural history, and prognostic implications

    N Engl J Med

    (1984)
  • RuzzaA et al.

    Left ventricular reconstruction for postinfarction left ventricular aneurysm: Review of surgical techniques

    Tex Heart Inst

    (2017)
  • RajaSG et al.

    Impact of technique of left ventricular aneurysm repair on clinical outcomes: current best available evidence

    J Card Surg

    (2009)

    • Cited by (0)

    Xia Lu and Min Zhao have contributed equally to the manuscript.

    The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com.

    View full text
    Copyright © 2022 American Society of Nuclear Cardiology. Published by ELSEVIER INC. All rights reserved. Published by Mosby, Inc. All rights reserved.