In a patient with NYHA class II heart failure, left bundle branch block, global left ventricular hypokinesia, ejection fraction about 35%, being evaluated for non‑cardiac surgery, does an akinetic septum alter pre‑operative and long‑term management decisions?

Does an Akinetic Septum Alter Management in This Patient?

An akinetic septum in this clinical context does not fundamentally alter the decision to proceed with noncardiac surgery, but it does signal important implications for both perioperative risk stratification and long-term cardiac management, particularly regarding potential cardiac resynchronization therapy (CRT) candidacy.

Perioperative Decision-Making

Proceeding with Surgery

• The presence of an akinetic septum alone does not contraindicate noncardiac surgery in this patient with NYHA class II heart failure, LBBB, and EF ~35% 1
• The decision to proceed with surgery should be based on the patient's functional capacity (≥4 METs), surgery-specific risk, and overall clinical stability rather than isolated regional wall motion abnormalities 1
• Preoperative stress testing indications remain unchanged by the presence of septal akinesis; the focus should be on detecting reversible ischemia in non-septal territories that would predict perioperative events 1

Understanding Septal Akinesis in LBBB Context

• Septal akinesis is an expected mechanical consequence of LBBB and does not necessarily indicate myocardial infarction or ischemia 2, 3, 4
• Fixed perfusion defects (including akinetic segments) have low positive predictive value for perioperative cardiac events but do predict long-term cardiac events 1
• The critical distinction is whether the akinetic septum represents infarcted myocardium versus LBBB-induced dyssynchrony 1, 2

Risk Stratification Implications

Perioperative Risk Assessment

• The patient's reduced LVEF (<35%) and symptomatic heart failure (NYHA II) are the primary perioperative risk factors, not the regional wall motion abnormality itself 1
• Severely decreased LVEF (<30%) is an independent contributor to perioperative outcome and long-term mortality risk 1
• If dobutamine stress echocardiography is performed, the presence of baseline akinetic segments should be distinguished from new stress-induced wall motion abnormalities, which indicate ischemia and carry greater perioperative risk 1

Functional Capacity Assessment

• The patient's functional capacity (ability to perform ≥4 METs of activity) is more predictive of perioperative risk than the presence of septal akinesis 1, 5
• Patients with good functional capacity can often proceed to intermediate-risk surgery despite structural abnormalities 5

Long-Term Management Considerations

CRT Candidacy Assessment

• The presence of an akinetic septum with preserved lateral wall function in a patient with LBBB, EF ~35%, and NYHA class II symptoms makes this patient a strong candidate for CRT evaluation 2
• Research demonstrates that LBBB-induced heart failure progresses through stages: initially with impaired septal function but preserved lateral wall function, followed by lateral wall dysfunction in advanced stages 2
• Lateral wall dysfunction signals the onset of progressive heart failure and represents an optimal timepoint for CRT intervention 2
• Patients with preserved lateral wall work at the time of CRT have significantly better outcomes, with 54% achieving normalized LVEF (≥50%) compared to only 13% in those with reduced lateral wall work 2

Echocardiographic Evaluation Needed

• Speckle-tracking echocardiography should be performed to assess lateral wall function and regional myocardial work 2, 6
• The severity of septal dysfunction does not directly correlate with global LV function in LBBB, but lateral wall function does 2, 3
• Mechanical dyssynchrony features including septal flash (present in 79% of LBBB patients) and apical rocking (65%) should be documented 4

Perioperative Medical Optimization

• Perioperative beta-blockade is recommended for this patient with known heart failure and clinical risk factors undergoing intermediate-risk surgery 1, 5
• Optimal medical therapy for heart failure with reduced ejection fraction should be confirmed and continued perioperatively 1
• Blood pressure control is critical, as hypertension is a primary modifiable risk factor in patients with ventricular dysfunction 1, 7

Critical Clinical Pitfalls

Common Errors to Avoid

• Do not interpret septal akinesis in LBBB as necessarily indicating prior myocardial infarction or requiring coronary revascularization before noncardiac surgery 1, 3
• Avoid delaying necessary noncardiac surgery solely based on the presence of regional wall motion abnormalities without evidence of active ischemia 1
• Do not overlook the opportunity to evaluate for CRT candidacy in this patient who meets criteria (LBBB, EF ≤35%, NYHA class II) 2

Distinguishing Ischemia from Dyssynchrony

• Fixed septal defects reflect either infarction or LBBB-induced dyssynchrony and have low predictive value for perioperative MI or cardiac death 1
• Reversible perfusion defects in non-septal territories are what predict perioperative events and should guide decision-making 1
• Patients with LBBB show perfusion and wall motion abnormalities involving the entire left ventricle, not just the septum 3

Algorithmic Approach

Preoperative Pathway

1. Assess functional capacity: Can the patient perform ≥4 METs of activity without symptoms? 1, 5
2. If functional capacity ≥4 METs: Proceed to surgery with perioperative beta-blockade 5
3. If functional capacity <4 METs or unknown: Consider stress testing to evaluate for reversible ischemia in non-septal territories 1
4. Optimize heart failure medical therapy regardless of surgical decision 1

Long-Term Pathway

1. Perform speckle-tracking echocardiography to assess lateral wall function and quantify mechanical dyssynchrony 2, 6
2. If lateral wall function is preserved: Strong CRT candidate with high likelihood of response 2
3. If lateral wall dysfunction is present: CRT still indicated but with lower expected response rate 2
4. Refer to electrophysiology for CRT evaluation given LBBB, EF ~35%, and NYHA class II symptoms 2

The akinetic septum in this patient represents an expected finding in LBBB rather than a contraindication to surgery, but it highlights the importance of comprehensive cardiac evaluation for potential CRT therapy to prevent progression to advanced heart failure 2, 3.