Prognostic value of myocardial viability recognized by low-dose dobutamine echocardiography in chronic ischemic left ventricular dysfunction

doi:10.1016/j.amjcard.2003.08.004

The American Journal of Cardiology

Volume 92, Issue 11, 1 December 2003, Pages 1263-1266

https://doi.org/10.1016/j.amjcard.2003.08.004 Get rights and content

Abstract

This study assesses the prognostic value of myocardial viability recognized as a contractile response to inotropic stimulation in patients with left ventricular (LV) dysfunction in a large-scale prospective, multicenter, observational study. Four hundred twenty-five patients (mean age 61 ± 10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction, and severe LV dysfunction (ejection fraction <35%; mean 28 ± 6%) were enrolled in the study. Each patient underwent low-dose dobutamine echocardiography (up to 10 μg/kg/min). Myocardial viability was identified as a rest–stress variation (Δ) in the wall motion score index (WMSI), in which each segment was scored from 1 = normal to 4 = dyskinetic in a 16-segment model of the left ventricle. Myocardial viability was identified as an improvement of ≥0.40 in WMSI. All patients were followed for a median of 3.1 years. One hundred eighty-eight were revascularized either by coronary artery bypass grafting (n = 118) or coronary angioplasty (n = 70). The only end point analyzed was cardiac death. In the revascularized group, cardiac death occurred in 4 of the 52 patients with and in 37 of the 136 patients without myocardial viability (7.7% vs 27.2%, p <0.003). Kaplan-Meier survival estimates showed a better outcome for those patients with compared to patients without myocardial viability who underwent coronary revascularization (90.1% vs 62%, p <0.0078). Thus, in severe LV ischemic dysfunction, myocardial viability by low-dose dobutamine echocardiography is associated with improved survival in revascularized patients.

Section snippets

Patients selection

The study population consisted of 425 consecutive patients enrolled from January 1, 1992 to December 31, 1999 in each of the participating centers and selected on the basis of the following criteria: (1) angiographically proven coronary artery disease (visually assessed >75% diameter reduction of ≥1 major coronary vessel on a coronary angiogram taken any time before study enrollment): (2) chronic ischemic disease (no acute myocardial infarction in the preceding 3 months to avoid a significant

Results

The main clinical and echocardiographic data are reported in Table 1. In 77 patients (18%), β-blocker therapy was not discontinued at time of testing.

Discussion

The results of the present study show that in revascularized patients with severe global LV dysfunction and chronic coronary artery disease, the presence and extent of myocardial viability, identified as inotropic reserve after low-dose dobutamine, are associated with a higher probability of survival. The higher the improvement of function, expressed by the delta low-dose WMSI, the better the impact of myocardial viability on survival. In the present population, ejection fraction was the only

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Utility of coronary revascularization in patients with ischemic left ventricular dysfunction
2024, Cardiovascular Revascularization Medicine
Revascularization in patients with left ventricular (LV) dysfunction has been a subject of ongoing uncertainty and conflicting results. This is further complicated by factors including viability, severity of LV dysfunction, and method of revascularization using percutaneous coronary intervention (PCI) versus coronary-artery bypass grafting (CABG).
The purpose of this meta-analysis is to evaluate the association of coronary revascularization with outcomes in patients with ischemic LV dysfunction.
A literature search was conducted for studies reporting on cardiovascular outcomes after revascularization compared to optimal medical therapy (OMT) in patients with ischemic LV dysfunction.
A total of 23 studies with 10,110 participants met inclusion criteria. Revascularization was significantly associated with lower all-cause mortality and CV mortality compared to OMT. The association was statistically significant regardless of severity of LV dysfunction or method of revascularization. Subgroup analysis demonstrated that revascularization was significantly associated with lower all-cause and CV mortality compared to OMT for patients with viable myocardium and mixed cohorts with variable viability, but not patients without viable myocardium. Revascularization was not associated with a significant difference in risk of heart failure (HF) hospitalization or acute myocardial infarction (AMI) compared to OMT.
Revascularization in patients with ischemic LV dysfunction is associated with lower risk of all-cause and CV mortality independent of severity of LV dysfunction or method of revascularization. Revascularization is not associated with lower risk of mortality in patients without evidence of viable myocardium and is not associated with lower risk of AMI or HF hospitalization.
Do Patients With Non-Viable Myocardium From Ischemic Cardiomyopathy Benefit From Revascularization? A Systematic Review And Meta-Analysis
2023, Cardiovascular Revascularization Medicine
Citation Excerpt :
Subgroup analyses were performed to assess the impact of imaging modality for the assessment of myocardial viability. Our search identified 12 eligible studies (Fig. 1) that included a total of 1363 patients with ischemic cardiomyopathy and non-viable myocardium, of whom 501 patients underwent revascularization and 862 patients received medical therapy alone [6,10–20]. Baseline characteristics are summarized in Table 1.
Myocardial viability assessment is used to select patients who will derive the greatest benefit from revascularization. It remains controversial whether revascularization only benefits patients with ischemic cardiomyopathy who have viable myocardium. The objective of this meta-analysis was to compare mortality between patients with ischemic cardiomyopathy and non-viable myocardium who underwent revascularization and those who underwent medical therapy alone.
The MEDLINE database was searched using PubMed to retrieve studies published up to December 2021. Inclusion criteria were 1. studies that evaluated the impact of revascularization (revascularization group) versus medical therapy alone (control group) following myocardial viability assessment; 2. patients who had coronary artery disease that was amenable to coronary artery bypass grafting or percutaneous coronary intervention; and 3. patients who had non-viable myocardium. The main outcome measure was all-cause mortality.
A total of 12 studies were included, evaluating 1363 patients with non-viable myocardium, of whom 501 patients underwent revascularization and 862 patients received medical therapy alone. There was a significant reduction in all-cause mortality (RR 0.76, 95 % CI: 0.62–0.93, I² = 0) in the revascularization group compared to the control group. There was no association between the type of viability imaging modality and the risk of all-cause mortality (P-interaction = 0.58).
The findings of this meta-analysis suggest a benefit from revascularization compared to medical therapy in patients with ischemic cardiomyopathy despite the lack of myocardial viability.
Improving Terminology to Describe Coronary Artery Procedures: JACC Review Topic of the Week
2021, Journal of the American College of Cardiology
Citation Excerpt :
The same considerations can be made for other trials similar to ISCHEMIA that reported similar results (21,24,27). Nonrandomized studies assessing myocardial perfusion and ischemia in patients with left ventricular dysfunction provide a mixed picture with respect to the effects on survival (and on recovery of function) (28–36). However, most of these studies are incomplete in reporting information on recovery of function, on survival or on subsequent myocardial infarction, and so mechanisms underlying the clinical outcomes are uncertain.
Coronary artery disease (CAD) is treated with medical therapy with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The latter 2 options are commonly referred to as “myocardial revascularization” procedures. We reason that this term is inappropriate because it is suggestive of a single treatment effect of PCI and CABG (ie, the reestablishment of blood flow to ischemic myocardium) and obscures key mechanisms, such as the improvement in coronary flow capability in the absence of ongoing ischemia, the reperfusion in the presence of ischemia, and the prevention of myocardial infarction from CAD progression. We review the current evidence on the topic and suggest the use of a purely descriptive terminology (“invasive treatment by PCI or CABG”) which has the potential to improve clinical decision making and guide future trial design.
Percutaneous Revascularization for Ischemic Ventricular Dysfunction: Rationale and Design of the REVIVED-BCIS2 Trial: Percutaneous Coronary Intervention for Ischemic Cardiomyopathy
2018, JACC: Heart Failure
Evaluate whether PCI in combination with optimal medical therapy (OMT) will reduce all-cause death and hospitalization for HF compared to a strategy of OMT alone.
Ischemic cardiomyopathy (ICM) is the most common cause of heart failure (HF) and is associated with significant mortality and morbidity. Surgical revascularization has been shown to improve long-term outcomes in some patients, but surgery itself carries a major early hazard. Percutaneous coronary intervention (PCI) may allow a better balance between risk and benefit.
REVIVED-BCIS2 is a prospective, multi-center, open-label, randomized controlled trial, funded by the National Institute for Health Research in the United Kingdom. Follow-up will be for at least 2 years from randomization. Secondary outcomes include left ventricular ejection fraction (LVEF), quality of life scores, appropriate implantable cardioverter defibrillator therapy and acute myocardial infarction. Patients with LVEF ≤35%, extensive coronary disease and demonstrable myocardial viability are eligible for inclusion and those with a myocardial infarction within 4 weeks, decompensated HF or sustained ventricular arrhythmias within 72 h are excluded. A trial of 700 patients has more than 85% power to detect a 30% relative reduction in hazard.
A total of 400 patients have been enrolled to date.
International guidelines do not provide firm recommendations on the role of PCI in managing severe ICM, because of a lack of robust evidence. REVIVED-BCIS2 will provide the first randomized data on the efficacy and safety of PCI in ICM and has the potential to inform guidelines pertaining to both revascularization and HF. (Study of Efficacy and Safety of Percutaneous Coronary Intervention to Improve Survival in Heart Failure [REVIVED-BCIS2]; NCT01920048) (REVascularisation for Ischaemic VEntricular Dysfunction; ISRCTN45979711)
Myocardial viability for decision-making concerning revascularization in patients with left ventricular dysfunction and coronary artery disease: A meta-analysis of non-randomized and randomized studies
2015, International Journal of Cardiology
Citation Excerpt :
On the basis of their title and abstract, 101 studies were retrieved as complete reports, of which 36 met the eligibility criteria. We included 32 non-randomized studies [9–40] (4328 patients) and 4 randomized studies [41–44] (1079 patients) in the analyses (Table 1). The mean duration of follow-up was 28.4 months for non-randomized studies and 45.6 months for randomized studies.
Myocardial viability tests have been proposed as a key factor in the decision-making process concerning coronary revascularization procedures in patients with left ventricular dysfunction and coronary artery disease (LVD–CAD).
We performed a systematic review and meta-analysis of studies that compared medical treatment with revascularization in patients with viable and non-viable myocardium and recorded mortality as outcome.
Thirty-two non-randomized (4328 patients) and 4 randomized (1079 patients) studies were analyzed. In non-randomized studies, revascularization provided a significant mortality benefit compared with medical treatment (p < 0.05). Since the heterogeneity was significant (p < 0.05) a viability subgroup analysis was performed, showing that revascularization provided a significant mortality benefit compared with medical treatment in patients with viable myocardium (p < 0.05) but not in patients without (p = 0.34). There was a significant subgroup effect (p < 0.05) related to the intensity of the effect, but not to the direction. In randomized studies, revascularization did not provide a significant mortality benefit compared with medical treatment in either patients with viable myocardium or those without (p = 0.21). There was no significant subgroup effect (p = 0.72). Neither non-randomized nor randomized studies demonstrated any significant difference in outcomes between patients with and without viable myocardium.
The available data are inconclusive regarding the usefulness of myocardial viability tests for the decision-making process concerning revascularization in LVD–CAD patients.
Patients with viable myocardium appear to benefit from revascularization, but similar benefits were observed in patients without viable myocardium. Moreover, a neutral or adverse effect of revascularization cannot be excluded in either group of patients.
Myocardial Viability: Comparison with Other Techniques. Comparison with Other Techniques.
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Coronary artery diseasePrognostic value of myocardial viability recognized by low-dose dobutamine echocardiography in chronic ischemic left ventricular dysfunction

Abstract

Section snippets

Patients selection

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Lancet

J Am Coll Cardiol

Am J Med

Coronary artery disease
Prognostic value of myocardial viability recognized by low-dose dobutamine echocardiography in chronic ischemic left ventricular dysfunction