Survival Determinants and Improvement of Heart Failure Symptoms after Surgical Repair of Anteroapical Left Ventricular Aneurysms Guided with Multislice Computed Tomography

Objectives: Surgical ventricular repair (SVR) is an established treatment option in patients with heart failure (HF) due to left ventricular (LV) aneurysms. In this study we evaluated the postoperative improvement of HF symptoms and factors affecting survival after SVR using clinical criteria and morphological characteristics obtained with multislice computed tomography (MSCT).

Methods: 205 patients (11/2005–01/2016, m:w=151:54, median 63.4 years; mean NYHA class 3.03) with anteroapical LV aneurysm underwent SVR combined with coronary artery bypass grafting (77%), mitral valve repair/replacement (19%), and LV thrombectomy (19%). MSCT was performed in 160 patients before and 7 days after surgery. Endpoints in the survival analysis were death, implantation of LV assist device and heart transplantation. Median follow up time was 1528 days. MSCT characteristics for survival analysis were LV end diastolic and end systolic volume index (LVEDVI, LVESVI), LV ejection fraction (LVEF) and LV sphericity index (SI). NYHA class changes were analyzed in the survivor population.

Results: Thirty-day, 1-year, and 5-year survival rates were 92.6, 82.7, and 67.9%, respectively. After SVR there was significant reductions of LVEDVI from 146.6 ± 52.4 mL/m² to 97.3 ± 35.6 mL/m², p < 0.001 and LVESVI from 100.0 ± 49.6 mL/m² to 59.2 ± 33.4 mL/m², p < 0.001) and increase of LVEF from 34.1 ± 12.1% to 43.1 ± 13.9% (p < 0.001). Multivariable proportional hazard regression modeling showed an effect on survival of preoperative and achieved postoperative LVESVI and no effect of preoperative diastolic SI. On average a 50 mL/m² increase of preoperative LVESVI was associated with a 35% increase of the hazard of death (p = 0.043). Survival stratified by preoperative LVESVI resulted in following cut-off points: < 74 mL/m², 74 to 114 mL/m², and >114 mL/m². Also, achieved postoperative LVESVI was strongly predictive for all defined endpoints with following cut-off points: < 58 mL/m², 58 to 82 mL/m² and >82 mL/m². We demonstrated a strong reduction of NYHA class III–IV quota after surgery in survivors (95.1% preoperatively and 20.5% in the follow-up).

Conclusion: Surgical repair of anteroapical LV aneurysms can be performed with good mid-term survival and significant improvement of HF severity due to LV volume reduction and functional improvement. MSCT delivers important predictive parameters for survival. Based on the MSCT assessment we propose an algorithm for surgical planning in anterior LV aneurysms.