Previous anterior or posterior MI as evaluated by electrocardiogram, echocardiogram, or cardiac magnetic resonance (CMR). CMR is of great value to obtain a quantitative assessment and is preferred when available and not contraindicated. CMR is the most precise tool to obtain a complete knowledge of the characteristics of myocardium: It defines the presence of viable myocardium and the extension (transmural or not) of scarred tissue that must be excluded from the cavity.

LV end-systolic volume index (ESVI) >60 mL/m². When SVR is performed, the aim is to treat HF patients by reducing LV volume, which is the most powerful predictor of mortality in dilated ischemic cardiomyopathy. Patients with postoperative ventricular reduction of >30% will benefit from SVR according to all published series, but the most important thing in long-term survival is to achieve an ESVI of <60 mL/m². This observation is supported by the post hoc Surgical Treatment for Ischemic Heart Failure (STICH) trial subgroup analysis, in which the enhanced survival with coronary artery bypass grafting (CABG) plus SVR for patients who achieved an ESVI of 70 mL/m² or less is indicated. Moreover, it is strongly indicated by our data, that performing SVR before the patients have reached end-stage LV dilatation may maximize the benefit of treatment. Preoperative ESVI of 94 mL/m² can be considered a cut-off value to obtain an optimal residual volume of <60 mL/m². Conversely a higher preoperative ESVI leads to inadequate volume reduction and significantly lower survival rate. Clinical and echocardiographic follow-up of asymptomatic patients with initial signs of postinfarction LV dysfunction are suggested in order to detect early signs of deterioration, that is, LV progressive enlargement or decline in EF. In 2014 the Task Force on Myocardial Revascularization of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery suggested considering SVR during CABG procedure in patients with a large aneurysm if there is a risk of rupture or large thrombus formation (Class of Recommendation IIa; level of evidence C). Moreover, SVR may be considered in patients with a scarred left anterior descending (LAD) territory, especially if a postoperative LVESV index of <70 mL/m² can be predictably achieved (Class of Recommendation IIb; level of evidence B).

LV dysfunction with regional asynergy, which is either dyskinetic or akinetic. It has been demonstrated that the result of SVR is more strongly linked to the extent of asynergy than to the presence or absence of dyskinesia: Patients with large akinetic scars and severely depressed pump function benefit from surgery to the same extent as patients with large dyskinetic scars. Notably, particular attention should be given to cases of severe and diffuse LV asynergy in which SVR should be performed only if the remote zone maintains an adequate contractile reserve, demonstrated by functional and vitality tests (dobutamine echocardiography, CMR stress testing).

Predominant HF symptoms with advanced NYHA class (III/IV). It is suggested in the pertinent guidelines that patients with symptoms of HF, predominant over angina, may benefit more from SVR. The indication for SVR can be expanded to patients presenting with angina when surgical revascularization is needed and the previous conditions are present (enlarged LV, transmural myocardial scar).

Ventricular arrhythmias late after MI are a major cause of death particularly in patients with EF <35%. Because of the protective effect of revascularization on ventricular arrhythmias, patients with ischemic LV dysfunction (EF <35%) who are considered for primary preventive ICD implantation should be first evaluated for residual ischemia and for potential revascularization targets. Recent guidelines suggest SVR in addition to CABG if a large ventricular aneurysm is the origin of arrhythmias (Class of Recommendation IIa; level of evidence C).

Severe right ventricular dysfunction (RVD) as reflected by an impaired tricuspid annular plane systolic excursion (TAPSE) <16 mm emerged in a recent analysis of our group as a major predictor of late mortality or HF hospitalization after SVR. The patients of our series experienced higher postoperative low output syndrome with higher rate of inotropic support and IABP. The concomitant presence of advanced NYHA class strengthens the relationship between preoperative RVD and adverse outcome.

Severe type 2 pulmonary hypertension (PH). The presence of advanced PH reflects long-term exposure of pulmonary circulation to retrograde overload caused by systolic dysfunction, with or without MR. In these patients a variable pulmonary vasoreactive component can play a significant role reducing the reversibility of PH. Ideally, invasive hemodynamic evaluation of the right-sided circulation should be considered when out of proportion PH is suspected, in order to optimize presurgical treatment.

Restrictive diastolic pattern associated with high functional class and MR is a predictor of operative mortality. In our experience MR alone (>2+) did not increase the hospital mortality, conversely the risk is significant in presence of elevated LV end-diastolic pressures and consequent LA pressure (echocardiographic finding of diastolic dysfunction by early-to-late diastolic filling pressure [E/A] ratio >2.0), leading to congestive HF and severe functional impairment (NYHA class III/IV).