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Published on: April 25, 2014
Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy
Julio A Panza1, Alicia M Ellis1, Hussein R Al-Khalidi1
1From Westchester Medical Center, New York Medical College, Valhalla (J.A.P.); Duke Clinical Research Institute, Durham, NC (A.M.E., H.R.A.-K., D.B.M., K.L.L.); Northwestern University, Chicago (T.A.H., R.O.B.); Cedars Sinai Medical Center (D.S.B.) and the University of Southern California (G.M.P.), Los Angeles; Mayo Clinic, Rochester, MN (J.K.O.); the National Heart, Lung, and Blood Institute, Bethesda, MD (G.S.); Medical University of Lodz, Lodz (L.C.), and Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze (T.K.) - both in Poland; University Hospital Favaloro Foundation, Buenos Aires (L.E.F.); Medical University of Vienna, Vienna (G.M.); Instituto Dante Pazzanese de Cardiologia, São Paulo (P.S.F.); National Heart Center, Singapore (R.-S.T.); MedStar Washington Hospital Center, Washington, DC (F.M.A.); Yale University School of Medicine, New Haven, CT (E.J.V.); and Montreal Heart Institute, Montreal (J.L.R.).
Insights
Coronary artery bypass grafting (CABG) reduces death in ischemic cardiomyopathy patients. Myocardial viability assessment did not predict long-term benefits of CABG, despite improving heart function.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Imaging
Background:
- The benefit of assessing myocardial viability to guide surgical revascularization in ischemic cardiomyopathy is debated.
- The link between improved left ventricular function post-revascularization and patient outcomes is unclear.
Purpose of the Study:
- To investigate the role of myocardial viability assessment in identifying patients with ischemic cardiomyopathy who may benefit from coronary artery bypass grafting (CABG).
- To determine the relationship between left ventricular function improvement and long-term outcomes after CABG.
Main Methods:
- 601 patients with coronary artery disease and low ejection fraction (<35%) underwent myocardial viability assessment (SPECT, dobutamine echo, or both).
- Patients were randomized to CABG plus medical therapy or medical therapy alone.
- Primary endpoint was all-cause mortality, with a median follow-up of 10.4 years.
Main Results:
- CABG plus medical therapy significantly reduced all-cause mortality compared to medical therapy alone (HR 0.73; 95% CI, 0.60-0.90).
- No significant interaction was found between myocardial viability and the survival benefit of CABG.
- Left ventricular ejection fraction improved only in patients with viable myocardium, irrespective of treatment, but this did not correlate with survival.
Conclusions:
- Myocardial viability assessment does not appear to be associated with long-term benefits of CABG in ischemic cardiomyopathy.
- While viable myocardium improves systolic function, this functional improvement does not translate to better long-term survival after revascularization.
Background:
The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear.
Methods:
Among 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years.
Results:
CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P = 0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death.
Conclusions:
The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595.).
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