Commentary: Let's start again!

Antonio Miceli, MD, PhD

In the next years, more patients will be referred for SVR as an indirect effect of COVID-19 for untreated myocardial infarction.

See Article page 1058.

Left ventricular aneurysm (LVA) is a late mechanical complication of myocardial infarction and is defined as an area of systolic dyskinesia with paradoxical bulging. The incidence of this complication is less than in the past (10%-35%) and currently affects approximately 5% of all patients with transmural myocardial infarction. This is probably the result of aggressive postischemic treatments, including percutaneous coronary intervention, angiotensin-converting enzyme inhibitors, and other medical therapies for advanced heart failure. LVA is often associated with arrhythmia, poor ejection fraction, and heart failure, and if left untreated, it is associated with poor survival at 5 years. Several left ventricular reconstruction techniques have been developed with the aim of restoring the left ventricular volume and shape, and encouraging results have been reported. Nevertheless, the number of these procedures has dramatically decreased in the last decade. Many factors such as early percutaneous treatment, surgical complexity, and poor long-term outcomes may have contributed to this decline. Most important, the Surgical Treatment of Ischemic Heart Failure trial failed to show any improvement in survival or ventricular function of adding surgical valve replacement (SVR) to coronary artery grafting in patients with left ventricular ejection fraction less than 35% and dominant anterior asynergy, although SVR achieved greater left ventricular end-systolic volume index reduction (19% vs 6%). A major criticism on this trial was the inadequate volume reduction, which left the patients in the 2 arms at the identical risk. In an insight of the Surgical Treatment of Ischemic Heart Failure trial, Michler and colleagues identified a 30% volume reduction threshold for better survival. In the current issue of the Journal, Stefanelli and colleagues add evidence on the importance of performing a left ventricular volume reduction greater than 35% for survival benefits. Better long-term results were reached in those patients receiving the modified SVR technique compared with the Dor technique. According to the authors, the preservation of left ventricular diastolic function without the use of circumference pure strings and pericardial patch, and the restoration of the elliptic geometry represent the key of success of this procedure. Overall early mortality was 1.6%, much lower than others with an overall survival of 68% at 5 years and 41% at 10 years. Nevertheless, the small sample size (represented by few patients at risk in Kaplan–Meier curve) and the inclusion of mitral valve treatment (potential impact on survival) represent major limits. In addition, this is a single surgeon experience, which may not be reproducible in other hands. Despite these limits, the authors present excellent timing in publishing this article. In my opinion, more SVR procedures will be performed in the next years. Data collected during the coronavirus disease 2019 (COVID-19) pandemic have shown an important reduction rate of hospital admission for acute coronary syndrome, especially after lockdown. , It is likely that patients avoid cardiovascular evaluation out of the fear of contracting COVID-19 in hospitals. As a consequence, LVA, ischemic mitral regurgitation, and heart failure will surge in the next years. The authors have demonstrated that LVA is safe and associated with early and long-term outcomes. Although the incidence of LVA has decreased over the time, in the next years more patients will be referred for SVR as an indirect effect of COVID-19 for untreated myocardial infarction. We have to prepare. Let's start again!