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Severity of Remodeling, Myocardial Viability, and Survival in Ischemic LV Dysfunction After Surgical
Robert O Bonow1, Serenella Castelvecchio2, Julio A Panza3
1Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Insights
End-systolic volume (ESV) and myocardial viability predict prognosis in ischemic cardiomyopathy. However, larger ESV did not alter the survival benefit of coronary artery bypass grafting (CABG) versus medical therapy in patients with viable myocardium.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Research
Background:
- Retrospective studies suggest left ventricular remodeling severity influences survival benefits of revascularization in ischemic cardiomyopathy.
- Previous research indicated coronary artery bypass grafting (CABG) may only benefit patients with viable myocardium and smaller end-systolic volumes (ESV).
- Prospective validation of the interaction between ESV, myocardial viability, and treatment outcomes is lacking.
Purpose of the Study:
- To prospectively test if end-systolic volume (ESV), a marker of left ventricular (LV) remodeling severity, modifies the relationship between myocardial viability and survival.
- To evaluate the impact of ESV and myocardial viability on the comparative effectiveness of CABG versus medical therapy in patients with LV systolic dysfunction.
Main Methods:
- Analysis of data from the prospective, randomized STICH trial (n=601) including patients with coronary artery disease and LV systolic dysfunction (ejection fraction ≤35%).
- Assessment of interactions between end-systolic volume index (ESVI), myocardial viability, and treatment assignment (CABG vs. medical therapy) on survival.
- Viability assessed using single-photon emission computed tomography or dobutamine echocardiography; median follow-up of 5.1 years.
Main Results:
- Higher mortality was observed in patients with larger ESVI and nonviable myocardium (p < 0.001).
- No significant interaction was found between ESVI, viability status, and treatment assignment (p = 0.491).
- The survival benefit of CABG compared to medical therapy was similar across different ESVI thresholds in patients with viable myocardium.
Conclusions:
- In ischemic cardiomyopathy, greater LV ESVI combined with lack of myocardial viability indicates a worse prognosis.
- The therapeutic effect of CABG relative to medical therapy was not influenced by the combined presence of high ESVI and nonviable myocardium.
- Lower ESV did not identify a subgroup of patients with viable myocardium who particularly benefit from CABG over medical therapy.
Objectives:
This study sought to test the hypothesis that end-systolic volume (ESV), as a marker of severity of left ventricular (LV) remodeling, influences the relationship between myocardial viability and survival in patients with coronary artery disease and LV systolic dysfunction.
Background:
Retrospective studies of ischemic LV dysfunction suggest that the severity of LV remodeling determines whether myocardial viability predicts improved survival with surgical compared with medical therapy, with coronary artery bypass grafting (CABG) only benefitting patients with viable myocardium who have smaller ESV. However, this has not been tested prospectively.
Methods:
Interactions of end-systolic volume index (ESVI), myocardial viability, and treatment with respect to survival were assessed in patients in the prospective randomized STICH (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease) trial of CABG versus medical therapy who underwent viability assessment (n = 601; age 61 ± 9 years; ejection fraction ≤35%), with a median follow-up of 5.1 years. Median ESVI was 84 ml/m(2). Viability was assessed by single-photon emission computed tomography or dobutamine echocardiography using pre-specified criteria.
Results:
Mortality was highest among patients with larger ESVI and nonviability (p < 0.001), but no interaction was observed between ESVI, viability status, and treatment assignment (p = 0.491). Specifically, the effect of CABG versus medical therapy in patients with viable myocardium and ESVI ≤84 ml/m(2) (hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.56 to 1.29) was no different than in patients with viability and ESVI >84 ml/m(2) (HR: 0.87; 95% CI: 0.57 to 1.31). Other ESVI thresholds yielded similar results, including ESVI ≤60 ml/m(2) (HR: 0.87; 95% CI: 0.44 to 1.74). ESVI and viability assessed as continuous rather than dichotomous variables yielded similar results (p = 0.562).
Conclusions:
Among patients with ischemic cardiomyopathy, those with greater LV ESVI and no substantial viability had worse prognosis. However, the effect of CABG relative to medical therapy was not differentially influenced by the combination of these 2 factors. Lower ESVI did not identify patients in whom myocardial viability predicted better outcome with CABG relative to medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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