Revascularization Strategies in Patients with Severe LV Dysfunction
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1 Revascularization Strategies in Patients with Severe LV Dysfunction Richard Lee, M.D., M.B.A. Saint Louis University The Center for Comprehensive Cardiovascular Care C4
2 Severe LV Dysfunction Defined as EF<35% (ACC)
3 Severe LV Dysfunction-My Definition Last Friday s case- CASE 1 65 year old Man admitted SOB NSTEMI trops peak at 4 Cr 1.1
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7 Course CABGx3, LIMA-LAD, SVG-OM, SVG- PDA Out of OR on 0.04 mcg/k/min epinephrine, 0.25 mcg/k/min milrinone, vaso levo Extubated POD 0, Floor POD 3, Home POD 7
8 Severe LV Dysfunction-My Definition Friday s case two weeks ago- CASE 2 59 year old Man admitted SOB NSTEMI- trops peak at 45 Cr 1.3
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12 Acute angioplasty of OM on Impella GI bleed-clipped Surgery after 2 weeks in bed CABGx3, LIMA-LAD, SVG-OM, SVG-PDA Difficult time off pump Extubated POD 3 HIT positive Reintubated POD4 Arrest with 20 min CPR POD 5 Open Chest, IABP placed, NO Closed POD 8 IABP out POD 9 Trach/peg, course evolving
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22 Patients randomized in STICH Revascularization Hypothesis 1212 Patients with myocardial viability test Patients with usable myocardial viability test Unusable test Timing Poor quality Patients with no myocardial viability test Patients with no usable myocardial viability test
23 Patients randomized in STICH Revascularization Hypothesis 1212 SPECT n=471 Dobutamine echo n= Patients with usable myocardial viability test Nonviable Patients with no usable myocardial viability test 487 Viable
24 Baseline Characteristics Patients With and Without Myocardial Viability Variable Viable (n=487) Non-Viable (n=114) P value Age 61 ± ± 9 NS Multivessel CAD 73% 73% NS Proximal LAD stenosis 64% 70% NS * Risk score 12.4 ± ± 9.3 NS Previous MI 76.6% 94.7% <0.001 LV ejection fraction (percent) 28 ± 8 23 ± 9 <0.001 LV end-diastolic volume index (ml/m 2 ) 117 ± ± 53 <0.001 LV end-systolic volume index (ml/m 2 ) 86 ± ± 50 <0.001 *Significant covariates in risk model: Age, renal function, heart failure, ejection fraction, CAD index, mitral regurgitation, stroke
25 Myocardial Viability and Mortality Mortality Rate Without viability With viability HR 95% CI P , Variables associated with mortality Chi-square p Risk score <0.001 LV ejection fraction <0.001 LV EDVI <0.001 LV ESVI <0.001 Myocardial viability Without viability With viability Years from Randomization
26 Myocardial Viability and Cardiovascular Mortality 1.0 Without viability Cardiovascular Mortality Rate With viability HR 95% CI P , Univariate Multivariable Chi-square p value Chi-square p value Without viability With viability Years from Randomization
27 Myocardial Viability and Mortality + CV Hospitalization 1.0 Without viability Mortality and CV Hospitalization Rate With viability HR 95% CI P ,0.44 <0.001 Univariate HR Multivariable 95% CI P Chi-square p value ,0.44 Chi-square <0.001 p value < Without viability With viability Years from Randomization
28 Patients with viability tests 601 Patients with myocardial viability Patients without myocardial viability MED CABG MED CABG 49.9% 50.1% 52.6% 47.4%
29 Baseline Characteristics Viable (n=487) Non-Viable (n=114) Variable MED (n=243) CABG (n=244) VariableP value MED (n=60) CABG (n=54) P value Age 60 ± ± Age 9 NS 62 ± 9 60 ± 9 NS Gender (% male) 84% 86% Gender (% NS male) 92% 93% NS Previous MI 78% 75% Previous MI NS 93% 96% NS Multivessel CAD 72% 73% MultivesselNS CAD 68% 78% NS Proximal LAD 65% 63% Proximal LAD NS 70% 70% NS * Risk score 11.9 ± ± Risk 903 score NS 13.7 ± ± 9.3 NS * LV EF (percent) 28 ± 8 27± LV 8 EF (percent) NS 23 ± 9 23 ± 9 NS LV EDVI (ml/m 2 ) 118 ± ± LV 35EDVI (ml/m NS 2 ) 151 ± ± 54 NS LV ESVI (ml/m 2 ) 86 ± ± LV 32ESVI (ml/m NS 2 ) 121 ± ± 51 NS * Significant covariates in risk model: Age, renal function, heart failure, ejection fraction, CAD index, MR, stroke
30 Myocardial Viability and Mortality Without Viability MED (33 deaths) CABG (25 deaths) With Viability MED (95 deaths) CABG (83 deaths) Mortality Rate MED CABG Years from Randomization Years from Randomization
31 Myocardial Viability and Mortality Without Viability MED (33 deaths) CABG (25 deaths) With Viability MED (95 deaths) CABG (83 deaths) Mortality Rate Years from Randomization Years from Randomization Subgroup Without viability N Deaths HR 95% CI , 1.18 Interaction P value With viability , CABG better MED better
32 Limitations Lack of viability data on all patients; patients represent a subpopulation of STICH Analysis limited to SPECT and DE, not PET or cardiac MRI Fundamental differences in viability information provided by SPECT and DE, and differences in analytic methods between the two methods
33 STICH Revascularization Hypothesis STICH results: demonstrate a significant association between myocardial viability and outcome, but this association is rendered non-significant when subjected to a multivariable analysis that includes other prognostic variables. fail to demonstrate a significant interaction between myocardial viability and medical versus surgical treatment with respect to mortality, whether assessed according to treatment assigned (intention to treat) or to the treatment actually received.
34 STICH Revascularization Hypothesis Implications of STICH: In patients with CAD and LV dysfunction, assessment of myocardial viability does not identify patients who will have the greatest survival benefit from adding CABG to aggressive medical therapy
35 Will CABG Benefits Anyone?
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43 Next Friday s Case?
44 What do I do now? Do I think I can survive the pt? - CRF Yes, LVD-yes, CRF +LVD = NO - Liver Dz =NO = No (usually) - RV alive? Do I think I will help the patient? - CHF? - Thick myocardium, no thin unless DOR - Not bedbound - Mentally intact
45 Revascularization Strategies in Patients with Severe LV Dysfunction Richard Lee, M.D., M.B.A. Saint Louis University The Center for Comprehensive Cardiovascular Care C4
46 Myocardial Viability and Mortality Variable No. Univariate Multivariable Chi-square p value Chi-square p value SPECT and/or DE SPECT alone DE alone
Rational use of imaging for viability evaluation
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