Geometry or function for the prediction of prognosis following revascularization in ischaemic cardiomyopathy: beyond the ejection fraction

I read with great interest the recent article in the Journal by Joshi et al.,1 regarding the prognostic value of improvement in ejection fraction (EF) following revascularization in patients with ischaemic cardiomyopathy (ICM). I wish to raise some points for consideration. Previous studies have shown the importance of the degree of left ventricular (LV) geometry and LV remodelling, both on the ability to recover global function and to inform prognosis. Schinkel et al.2 found that, in 118 ICM patients assessed before and after revascularization, patients with significant myocardial viability but in whom EF did not improve had significantly larger left ventricular end-systolic volumes (LVESV) than those in whom EF improvement was seen. ROC curve analysis indicated that an initial LVESV ≥140 mL accurately predicted lack of recovery of function. The same group later published data showing that this negatively affects outcome—indeed, they showed that patients with small ventricles and no viability had a lower event rate during follow-up (24%) than those with large ventricles and viable myocardium (38%).3 These findings were in keeping with those previously reported by Senior et al.,4 who found that in 70 ICM patients followed up for a mean of 3.5 years, the only multivariate predictor of survival patients was baseline LVESV—irrespective of whether patients were managed medically or revascularized. It is now believed that severely dilated ventricles—which have undergone severe remodelling—are unable to improve in function following revascularization, irrespective of the quantity of hibernating myocardium.5