Myocardial viability and long-term outcomes in ischemic cardiomyopathy

Julio A. Panza*, Alicia M. Ellis, Hussein R. Al-Khalidi, Thomas A. Holly, Daniel S. Berman, Jae K. Oh, Gerald M. Pohost, George Sopko, Lukasz Chrzanowski, Daniel B. Mark, Tomasz Kukulski, Liliana E. Favaloro, Gerald Maurer, Pedro S. Farsky, Ru San Tan, Federico M. Asch, Eric J. Velazquez, Jean L. Rouleau, Kerry L. Lee, Robert O. Bonow

*Corresponding author for this work

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Abstract

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.

Original languageEnglish (US)
Pages (from-to)739-748
Number of pages10
JournalNew England Journal of Medicine
Volume381
Issue number8
DOIs
StatePublished - Aug 22 2019

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Cardiomyopathies
Coronary Artery Bypass
Stroke Volume
Therapeutics
Left Ventricular Function
Cause of Death
Dobutamine
Group Psychotherapy
Single-Photon Emission-Computed Tomography
Echocardiography
Coronary Artery Disease
Myocardium
Confidence Intervals
Survival
Incidence

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Panza, Julio A. ; Ellis, Alicia M. ; Al-Khalidi, Hussein R. ; Holly, Thomas A. ; Berman, Daniel S. ; Oh, Jae K. ; Pohost, Gerald M. ; Sopko, George ; Chrzanowski, Lukasz ; Mark, Daniel B. ; Kukulski, Tomasz ; Favaloro, Liliana E. ; Maurer, Gerald ; Farsky, Pedro S. ; Tan, Ru San ; Asch, Federico M. ; Velazquez, Eric J. ; Rouleau, Jean L. ; Lee, Kerry L. ; Bonow, Robert O. / Myocardial viability and long-term outcomes in ischemic cardiomyopathy. In: New England Journal of Medicine. 2019 ; Vol. 381, No. 8. pp. 739-748.
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abstract = "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.",
author = "Panza, {Julio A.} and Ellis, {Alicia M.} and Al-Khalidi, {Hussein R.} and Holly, {Thomas A.} and Berman, {Daniel S.} and Oh, {Jae K.} and Pohost, {Gerald M.} and George Sopko and Lukasz Chrzanowski and Mark, {Daniel B.} and Tomasz Kukulski and Favaloro, {Liliana E.} and Gerald Maurer and Farsky, {Pedro S.} and Tan, {Ru San} and Asch, {Federico M.} and Velazquez, {Eric J.} and Rouleau, {Jean L.} and Lee, {Kerry L.} and Bonow, {Robert O.}",
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Panza, JA, Ellis, AM, Al-Khalidi, HR, Holly, TA, Berman, DS, Oh, JK, Pohost, GM, Sopko, G, Chrzanowski, L, Mark, DB, Kukulski, T, Favaloro, LE, Maurer, G, Farsky, PS, Tan, RS, Asch, FM, Velazquez, EJ, Rouleau, JL, Lee, KL & Bonow, RO 2019, 'Myocardial viability and long-term outcomes in ischemic cardiomyopathy', New England Journal of Medicine, vol. 381, no. 8, pp. 739-748. https://doi.org/10.1056/NEJMoa1807365

Myocardial viability and long-term outcomes in ischemic cardiomyopathy. / Panza, Julio A.; Ellis, Alicia M.; Al-Khalidi, Hussein R.; Holly, Thomas A.; Berman, Daniel S.; Oh, Jae K.; Pohost, Gerald M.; Sopko, George; Chrzanowski, Lukasz; Mark, Daniel B.; Kukulski, Tomasz; Favaloro, Liliana E.; Maurer, Gerald; Farsky, Pedro S.; Tan, Ru San; Asch, Federico M.; Velazquez, Eric J.; Rouleau, Jean L.; Lee, Kerry L.; Bonow, Robert O.

In: New England Journal of Medicine, Vol. 381, No. 8, 22.08.2019, p. 739-748.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Myocardial viability and long-term outcomes in ischemic cardiomyopathy

AU - Panza, Julio A.

AU - Ellis, Alicia M.

AU - Al-Khalidi, Hussein R.

AU - Holly, Thomas A.

AU - Berman, Daniel S.

AU - Oh, Jae K.

AU - Pohost, Gerald M.

AU - Sopko, George

AU - Chrzanowski, Lukasz

AU - Mark, Daniel B.

AU - Kukulski, Tomasz

AU - Favaloro, Liliana E.

AU - Maurer, Gerald

AU - Farsky, Pedro S.

AU - Tan, Ru San

AU - Asch, Federico M.

AU - Velazquez, Eric J.

AU - Rouleau, Jean L.

AU - Lee, Kerry L.

AU - Bonow, Robert O.

PY - 2019/8/22

Y1 - 2019/8/22

N2 - 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.

AB - 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.

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U2 - 10.1056/NEJMoa1807365

DO - 10.1056/NEJMoa1807365

M3 - Article

C2 - 31433921

AN - SCOPUS:85071285262

VL - 381

SP - 739

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JO - New England Journal of Medicine

JF - New England Journal of Medicine

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