Objective: Advanced ischemic heart failure can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent heart failure have been identified, no plain predictor for identifying SVR patients with left ventricular damage beyond recovery is yet available. We tested echocardiographic wall motion score index (WMSI) as a predictor for mortality or poor functional result. Methods: One hundred and one patients electively operated between April 2002 and April 2007 were included for analysis. All patients had advanced ischemic heart failure (NYHA-class >= III and LVEF <= 35%). Mean logistic EuroSCORE was 10 +/- 8. All patients were evaluated at 1-year follow-up. Risk factors for poor outcome, defined as mortality or poor functional result (NYHA class >= III) at 1-year follow-up were identified by univariable logistic regression analysis. Preoperatively, a 16-segment echocardiographic WMSI was calculated and receiver operating characteristic curve analysis was used to identify cut-off values for WMSI in predicting poor outcome. Results: Early mortality was 9.9%, late mortality 6.6%. NYHA class improved from 3.2 +/- 0.4 to 1.5 +/- 0.7. At 1-year follow-up, 10 patients (12%) were in NYHA class III and the remaining patients were in NYHA class I or II (75 patients, 88%). WMSI was found to be the only statistically significant predictor for poor outcome (odds ratio 139, 95% confidence interval (CI) 17-1116, p < 0.0001). The optimal cut-off value for WMSI in predicting mortality or poor functional result was 2.19 with a sensitivity and specificity of 82% (95% CI 81.5-82.5% and 81.4-82.6%). The area under the curve was 0.94 (95% CI 0.90-0.99). Positive and negative predictive values were 67% and 92% respectively (95% CI 66.4-67.6% and 91.4-92.6%). Conclusions: Sufficient residual remote myocardium is necessary to recover from a SVR procedure and to translate the surgically induced morphological changes into a functional improvement. Preoperative WMSI is a surrogate measure of residual remote myocardial function and is a promising tool. for better patient selection to improve results after SVR procedures for advanced ischemic heart failure. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.