Relationship Between Transmural Extent of Necrosis and Quantitative Recovery of Regional Strains After Revascularization.

Gerber, Bernhard [UCL] Pasquet, Agnes [UCL] Darchis, Julie [UCL] Le Polain De Waroux, Jean-Benoît [UCL] Legros, Gabin [UCL] Pouleur, Anne-Catherine [UCL] Vancraeynest, David [UCL] Vanoverschelde, Jean-Louis [UCL]

OBJECTIVES: To better understand the quantitative relationship of recovery of regional and global dysfunction after revascularization in chronic infarcts with variable transmural extent of necrosis by delayed enhanced cardiac magnetic resonance. BACKGROUND: Studies relating transmurality of delayed enhanced magnetic resonance to functional recovery in dysfunctional myocardium using semiquantitative Likert scales have demonstrated the intermediate likelihood (50% probability) of recovery of dysfunction in subendocardial scars. METHODS: Forty-two patients with chronic left ventricular dysfunction due to coronary artery disease underwent tagged and delayed enhanced magnetic resonance before and 10 +/- 7 months after revascularization (coronary artery bypass graft: 35, percutaneous transluminal coronary angioplasty: 7). Left ventricular ejection fraction and regional mid-myocardial Eulerian radial thickening strain (Err) and mid-myocardial, subendocardial, and subepicardial Eulerian circumferential shortening strain (Ecc) strains were quantified in 16 segments per patient before and after revascularization and related to pre-operatively measured transmurality of necrosis. RESULTS: At baseline, 256 of 672 segments were dysfunctional, having <2 SD (i.e., >-10%) mid-myocardial Ecc. The magnitude of recovery of mid-myocardial Ecc (r = -0.33, p < 0.01) was inversely correlated with transmurality of necrosis before revascularization. Segments with <25% necrosis improved mid-myocardial Ecc and Err. No significant improvement of mid-myocardial Ecc or Err occurred when transmurality was >/=25%. However, subendocardial Ecc improved up to 75% transmural necrosis. Receiver-operator characteristic analysis determined optimal sensitivity (54%) and specificity (82%) for normalization of mid-myocardial Ecc (to <-10% Ecc) at a cutoff value of >/=18% transmural necrosis. Improvement of left ventricular ejection fraction (from 35 +/- 15% to 40 +/- 7%, p < 0.001) was best predicted (67% sensitivity, 58% specificity) by the presence of <4.5 dysfunctional segments with <75% transmural necrosis. CONCLUSIONS: The quantitative relationship between necrosis transmurality and improvement of regional and global dysfunction after revascularization is complex. Although improvement of recovery of regional mid-myocardial dysfunction after revascularization was observed only for scarring not exceeding 25% transmurality, global dysfunction significantly improved even when more extensive subendocardial scarring was revascularized.