Prediction of global left ventricular functional recovery in patients with heart failure undergoing surgical revasculari
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RESEARCH
Open Access
Prediction of global left ventricular functional recovery in patients with heart failure undergoing surgical revascularisation, based on late gadolinium enhancement Cardiovascular Magnetic Resonance Tammy J Pegg1,2,3, Joseph B Selvanayagam1,3, Joslin Jennifer1, Jane M Francis1, Theodoros D Karamitsos1, Erica Dall’Armellina1, Karen L Smith4, David P Taggart2, Stefan Neubauer1*
Abstract Background: The new gold standard for myocardial viability assessment is late gadolinium enhancementcardiovascular magnetic resonance (LGE-CMR); this technique has demonstrated that the transmural extent of scar predicts segmental functional recovery. We now asked how the number of viable and number of viable+normal, segments predicted recovery of global left ventricular (LV) function in patients undergoing CABG. Finally, we examined which segmental transmural threshold of scarring best predicted global LV recovery. Methods and Results: Fifty patients with reduced LV ejection fraction (EF) referred for CABG were recruited, and 33 included in this analysis. Patients underwent CMR to assess LV function and viability pre-operatively at 6 days and 6 months. Mean LVEF 38% ± 11, which improved to 43% ± 12 after surgery. 21/33 patients improved EF by ≥3% (EF before 38% ± 13, after 47% ± 13), 12/33 did not (EF before 39% ± 6, after 37% ± 8). The only independent predictor for global functional recovery after revascularisation was the number of viable+normal segments: Based on a segmental transmural viability cutoff of 50% LGE, number of viable segments, number of viable+normal segments, time between surgery and CMR scan, preoperative LVEF and ESVI) and late change in EF. Variables with p < 0.1 were then included in the multiple linear regression using an enter selection method to assess the best factors for predicting change in LV function. Receiver Operating Characteristic (ROC) analysis was performed to determine the number of viable segments, and the number of viable+normal segments, that best predicts recovery of global function, where improvement is defined as ≥3%[13] absolute change in LVEF.
Registration of segments
For visual assessment of transmural extent of scar and RWM, two models, based on either a 48 segment (6 slices × 8 segments) or the AHA 16 segment model (excluding segment 17 - apex) was used. The basal slice was defined as the first slice without LVOT in any phase of the cardiac cycle. Segment 1 was defined at the anterior insertion of the right ventricle into the interventricular septum. Registration of segments for LGECMR and regional wall motion scores was undertaken in a paired manner by a single observer 6 months prior to visual analysis. For the 16 segment AHA model, the mid-ventricular slice was defined as 20 mm below the base, on condition that it contained papillary muscle but no trabeculation, similarly the apical slice was defined as 20 mm below the mid ventricular slice on condition that it contained trabeculation but no papillary muscle. Statistical Analysis
There was an excess in myo
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