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Surgical ventricular restoration: where do we go from here?
Constantine L Athanasuleas1, Gerald Buckberg
1Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA, cathanasuleas@uab.edu.
Insights
Surgical ventricular restoration (SVR) combined with bypass grafting did not improve survival in ischemic heart failure patients per the STICH trial. Discrepancies with observational data suggest trial conduct may have influenced outcomes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Research
Background:
- The Surgical Treatment for Ischemic Heart Failure (STICH) trial reported no survival benefit from adding surgical ventricular restoration (SVR) to coronary bypass grafting (CABG) in dilated ischemic cardiomyopathy.
- Contrasting observational studies show significant long-term survival (approx. 70%) and improved ventricular function with SVR.
- Discrepancies between trial and observational data warrant further investigation into trial methodology.
Purpose of the Study:
- To review the causes for the discrepancy between STICH trial results and observational data on surgical ventricular restoration (SVR) for ischemic heart failure.
- To identify potential patient subgroups who might benefit from SVR based on a re-analysis of STICH trial data.
- To address confounding factors in the STICH trial, such as unsuitable patient entry criteria and surgical approaches.
Main Methods:
- Review of existing literature comparing STICH trial outcomes with observational studies on SVR.
- Analysis of recent STICH subset data relating ventricular volumes to patient outcomes.
- Proposal for re-analyzing STICH data according to its original design parameters.
Main Results:
- The STICH trial did not demonstrate improved survival with SVR plus CABG for ischemic cardiomyopathy.
- Observational studies consistently report positive outcomes, including improved global ventricular function and high long-term survival rates with SVR.
- Potential confounding factors in the STICH trial include patient selection and surgical execution.
Conclusions:
- The methodology and patient selection in the STICH trial may have obscured the potential benefits of SVR in specific patient populations.
- Re-analysis of STICH data, focusing on the initial trial design, is recommended to identify patients who could benefit from SVR.
- Further research is needed to reconcile the conflicting findings and optimize SVR application in ischemic heart failure management.
Abstract:
The surgical treatment for ischemic heart failure (STICH) trial concluded that the addition of surgical ventricular restoration (SVR) to coronary bypass grafting did not lead to improved survival in patients with dilated ischemic cardiomyopathy. Observational studies at multiple centers over the last 15 years have shown consistent improvement in global ventricular function and approximately 70 % long-term survival. The causes of this discrepancy are reviewed here and likely relate to how the STICH trial was conducted. Recent subset analyses from the STICH investigators have provided some additional data relating ventricular volumes to outcomes. However, including patients with unsuitable entry criteria and operations confounds the data. We recommend an analysis of the STICH data based on the trial's initial design in order to determine if there are patients who may benefit by SVR.
