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Prognostic value of myocardial ischemia and viability in patients with chronic left ventricular ischemic dysfunction
A Pasquet1, A Robert, A M D'Hondt
1Divisions of Cardiology and Nuclear Medicine, University of Louvain Medical School, Brussels, Belgium.
Insights
Thallium scintigraphy and dobutamine echocardiography identify ischemic or viable myocardium, predicting survival after revascularization in patients with left ventricular dysfunction. These tests aid in selecting patients for improved cardiac outcomes.
Area of Science:
- Cardiology
- Nuclear Cardiology
- Echocardiography
Background:
- Thallium scintigraphy and dobutamine echocardiography predict contractile recovery post-revascularization in left ventricular (LV) dysfunction.
- Prognostic impact of these noninvasive methods for predicting outcomes remains uncertain.
Purpose of the Study:
- To evaluate the prognostic impact of thallium scintigraphy and dobutamine echocardiography in patients with coronary disease and LV dysfunction.
- To determine if identifying ischemic or viable myocardium influences long-term survival after revascularization.
Main Methods:
- Prospective study of 137 patients with coronary disease and LV dysfunction.
- Exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography performed to assess myocardial ischemia and viability.
- Patients underwent either revascularization (n=94) or medical treatment (n=43), with cardiac mortality as the primary endpoint over a mean 33-month follow-up.
Main Results:
- Long-term survival was associated with coronary disease extent, diabetes, treatment type, ischemic myocardium (thallium), and viable myocardium (both tests).
- Three-year survival was significantly higher in patients with ischemic or viable myocardium who underwent revascularization.
- Revascularization improved survival in all patients with 3-vessel or left main disease, particularly those with identified ischemic or viable myocardium.
Conclusions:
- Ischemic myocardium (thallium scintigraphy) and viable myocardium (dobutamine echocardiography) are independent predictors of mortality in LV ischemic dysfunction.
- These findings can assist in preoperative patient selection for revascularization procedures.
- Noninvasive imaging modalities play a crucial role in risk stratification and treatment planning for coronary artery disease.
Background:
Previous studies showed that thallium scintigraphy and dobutamine echocardiography were accurate, noninvasive ways of predicting contractile recovery after revascularization in patients with left ventricular (LV) dysfunction. However, the prognostic impact of such methods remains uncertain.
Methods And Results:
We prospectively studied 137 consecutive patients with coronary disease and LV dysfunction who underwent exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography to identify myocardial ischemia and viability. A total of 94 patients subsequently underwent revascularization, and 43 underwent medical treatment. The primary endpoint was cardiac mortality, and mean follow-up was 33+/-10 months. Twenty-four patients died of cardiac causes. By Cox's regression analysis, long-term survival was related to the extent of coronary disease, the presence of diabetes, type of treatment, the presence of ischemic myocardium as determined by thallium scintigraphy, and the presence of viable myocardium as determined by both tests. Three-year survival was greater in patients with ischemic myocardium (as determined by thallium scintigraphy) or viable myocardium (as determined by both tests) who underwent revascularization than in the other groups (P=0.018 with thallium; P<0.001 with dobutamine). Subgroup analyses indicated that among patients with 1- or 2-vessel disease, only those with ischemic or viable myocardium improved survival after revascularization, whereas in patients with 3-vessel or left main diseases, revascularization always improved survival, albeit more in the presence of ischemic or viable myocardium.
Conclusions:
Among the parameters commonly available in patients with LV ischemic dysfunction, the presence of ischemic myocardium (as determined by thallium scintigraphy) and that of viable myocardium (as determined by dobutamine echocardiography) are independent predictors of subsequent mortality. These observations may be useful in the preoperative selection of patients for revascularization.
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