key: cord-0976685-w2dkwchs
authors: Miceli, Antonio
title: Commentary: Let’s start again!
date: 2020-05-27
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.05.047
sha: 216212c97f1f77e62f16edc2e18261a0d45a8da2
doc_id: 976685
cord_uid: w2dkwchs

nan

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

Left ventricular aneurysm (LVA) is a late mechanical complication of myocardial infarction and is defined as an area of systolic dyskinesia with paradoxical bulging. [1] . The incidence of this complication is much less than in past (10-35%) and

currently is about 5% of all patients with transmural MI. [2] . This is probably the result of the aggressive post-ischemic 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 [3] . Several left ventricular reconstruction (LVR) techniques have been developed with the aim of restoring the left ventricular volume and shape and encouraging results have been reported [4] . Nevertheless, the number of these procedures has dramatically reduced in the last decade. Many factors such as early percutaneous treatment, surgical complexity and the poor long-term outcomes may have contributed to this decline. Most importantly, the Surgical Treatment of Ischemic Heart Failure (STICH) trial failed to show any improvement in survival or ventricular function of adding SVR to coronary arterial grafting in patients with LVEF <35% and dominant anterior asinergy, even though SVR achieved greater LV end systolic volume index reduction (19% vs 6%) [5] . A major criticism on this trial was the inadequate volume reduction, which left the patients in the two arms at the identical risk. In an insight of the STICH trial, Michler et al identified a 30% volume reduction threshold for better survival [6] . In the current issue of the Journal, Stefanelli et al add evidence on the importance of performing a LV volume reduction >35% for survival benefits [7] . Interestingly, better long terms results were reached in those patients receiving the modified SVR technique compared to the Dor one.

According to authors, the preservation of left ventricular diastolic function without the use of circumference pure strings and pericardial patch as well as 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 [4] . Nevertheless, the small sample size (represented by few patients at risk in Kaplan Meyer 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, authors present an excellent timing in publishing this paper. In my opinion, more SVR procedures will be performed in the next years. Data collected during the COVID-19 pandemic have shown an important reduction rate of hospital admission for acute coronary syndrome, especially after lockdown [8, 9] . It is likely that patients avoid cardiovascular evaluation out of the fear of contracting COVID-19 in hospitals. As consequence, LVA, ischemic mitral regurgitation and heart failure will surge in the next years. In conclusion, authors have demonstrated that LVA is safe and associated with early and long-term outcomes. Although the incidence of LVA have reduced over the time, in the next years more patients will be referred for SVR as indirect effect of COVID-19 for untreated myocardial infarction. We have to prepare. Let's start again!

Mechanical complications of myocardial infarction. In: manual of cardiothoracic surgery

Myocardial abnormalities underlying persistent ST-segment elevation after anterior myocardial infarction

Surgical ventricular reconstruction for ischaemic heart failure: state of the art

Left ventricular reconstruction for post infarction left ventricular aneurysm. Review of surgical techniques

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Ambrogio Minimally Invasive Cardiothoracic Department Word Count: 539 Disclosures: No conflict of interest Correspondence