Impact of coronary revascularisation on left ventricular remodelling in ischaemic cardiomyopathy with reduced ejection fraction

Background Left ventricular remodelling is a central mechanism driving disease progression and adverse outcomes in patients with ischaemic cardiomyopathy and reduced left ventricular ejection fraction. The extent to which coronary revascularisation promotes reverse remodelling beyond optimal medical therapy in routine clinical practice remains uncertain. Purpose To evaluate the impact of coronary revascularisation on left ventricular remodelling and functional recovery in patients with ischaemic cardiomyopathy and reduced ejection fraction. Methods This retrospective cohort study included 561 patients with ischaemic cardiomyopathy and left ventricular ejection fraction <40% treated between 2014 and 2024. Patients were managed with percutaneous coronary intervention plus optimal medical therapy (PCI+OMT, n=281) or optimal medical therapy alone (OMT, n=280) according to clinical decision-making. Transthoracic echocardiography was performed at baseline and during follow-up using standardised protocols. Changes in left ventricular ejection fraction, left ventricular end-diastolic volume and functional mitral regurgitation were assessed. Reverse remodelling was defined as a reduction in left ventricular end-diastolic volume >10%. Follow-up duration was 24 months. Results At 24 months, improvement in left ventricular systolic function was significantly greater in the PCI+OMT group compared with OMT alone (increase in ejection fraction +7.2±3.1 vs +1.9±2.8 percentage points; p<0.001). A greater reduction in left ventricular end-diastolic volume was observed after PCI+OMT (−18±10 mL vs −5±12 mL; p=0.01), with reverse remodelling occurring more frequently (46.3% vs 25.0%; p<0.001). The prevalence of functional mitral regurgitation ≥ grade II decreased markedly in the PCI+OMT group (from 62% to 24%) compared with OMT alone (from 28% to 21%; p<0.001). Conclusion In this real-world cohort of patients with ischaemic cardiomyopathy and reduced ejection fraction, coronary revascularisation in addition to optimal medical therapy was associated with significant reverse left ventricular remodelling, improved systolic function and reduction of functional mitral regurgitation at 24 months. These findings support an individualised approach to coronary revascularisation aimed at promoting structural and functional recovery of the left ventricle.