Download We`ve known for decades that in patients with LV dysfunction

Farveh
Vakilian.M.D
OCT 2011
Revascularization in
HEART FAILURE
patients
We've known for decades that in patients
with LV dysfunction, ischemia is the major
cause of mortality, and that in patients with
ischemia, LV dysfunction is the major cause
of mortality.
• A 65 man came to your clinic with the
complain of dyspnea
• He has history of chest pain 2 months ago and CCU
admission,DM(+),HTN and other RF was (-)
• ECG:sinus rhythm,narrow complex,poor R
progression,ST changes anterior leads
• CXRay:Cardiomegaly,Hilar Congestion
• Echocardiography:LVEF:35%,RWMA(+) in LAD
territory,Mild RV Dysfunction,Normal PAP
• Whats the plan?
o Do you recommend angiography or you
prefer noninvasive imaging studies?
 A reasonable management strategy for patients
who present with heart failure secondary to
coronary artery disease (i.e., ischemic
cardiomyopathy) includes coronary angiography
 Viability studies are appropriate for those
patients with severe disease and adequate
surgical targets.
 If significant viability is present (≥25%), the
weight of currently available clinical evidence
suggests that CABG may improve survival and
quality of life over medical therapy alone
• SCA was done and he suffered 3VD
• You recommend him CABG but he
has some questions!!!???
Do I really need
the operation?
• Ischemic cardiomyopathy can be envisioned as
three interrelated pathophysiologic processes:
• Myocardial hibernation, defined as persistent
contractile dysfunction at rest, caused by reduced
coronary blood flow
• Myocardial stunning, viable myocardium but reversible
post ischemic contractile dysfunction caused by the
generation of oxygen-derived free radicals on
reperfusion and by a loss of sensitivity of contractile
filaments to calcium;
• Myocyte cell death, leading to ventricular remodeling
and contractile dysfunction
 Surgery might benefit these patients by
improving systolic function or perhaps improving
diastolic function, which had been inhibited by
myocardial stiffness caused by ischemia
• Much of the improvement will be from a benefit
on sudden cardiac death, or could it be that the
benefit is on recurrent infarction, which these
patients obviously cannot tolerate
• In a meta-analysis of 24 studies involving a
total of 3088 patients with ischemic
cardiomyopathy, revascularization decreased
the risk of death by 79.6% in patients with
evidence of viable myocardial tissue, yielding
an annual mortality of 3.2% compared with
16.0% for patients who did not undergo
revascularization
• Several clinical factors play a major role in the
decision-making process including:
 The presence of angina, severity of heart
failure symptoms, LV dimensions, degree of
hemodynamic compromise, and
comorbidities
• Other major technical issues to be considered
are:
 the adequacy of target vessels for
revascularization and an adequate conduit
strategy.
 The most important determinant, however,
is the extent of jeopardized but still viable
myocardium
• Current studies have suggested that for a significant
improvement in heart failure symptoms and LV
function as well as for improvement in survival to
occur after coronary revascularization, at least 25%
of the myocardium should be viable
Benefits of Coronary Artery Bypass Grafting
 Improved blood flow to hypoperfused but viable
myocardium, with a subsequent improvement in
LV function and clinical outcomes.
 Alleviation of ischemia may also lessen the
tendency toward proarrhythmias, thereby
reducing the incidence of sudden cardiac death.
 Coronary artery revascularization has the
potential to improve symptoms of heart failure,
LV function, and survival.
Improvement in Left Ventricular Function
A review of pooled viability data
demonstrated that significant viability (25% to
30%) predicted an improvement in LVEF.
Nuclear studies, PET, and dobutamine
echocardiography predict improvement of LV
function of approximately 8% to 10% when
viability of the myocardium is present
Symptomatic Improvement
• Several studies have reported marked
improvement in heart failure symptoms after
revascularization.
• Freedom from heart failure was 78% and 47%
at 1 and 5 years.
• Only 54% of patients were symptom free of
both angina and heart failure at follow-up
How much is the
risk?
The mortality and
morbidity!
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The perioperative risks in patients with severe LV
dysfunction range from 2% to nearly 10%,
depending on:
the availability of targets and their viability,
RV dysfunction,
Advanced heart failure symptoms (New York Heart
Association [NYHA] Class IV),
Increased LV end-diastolic pressure,
Comorbidities of advanced age,
Peripheral vascular disease,
chronic obstructive pulmonary disease
• Studies have indicated that for patients with
clinical heart failure, perioperative mortality
rates will range from approximately 2.6% to
8.7%,
• Depending on age and presence of one or
more comorbid conditions.
Several studies have shown that overall
survival and cardiac events (including cardiac
death, infarction, and hospitalization for
heart failure) are directly related to the
presence of myocardial viability in heart
failure patients.
• In the CABG Patch trial, patients without angina or
heart failure had a perioperative mortality of 1.3%.
• The mortality increased to 4.8% for patients with no
angina and mild heart failure, NYHA Class I or II, and
7.4% with no angina and NYHA Class III or IV heart
failure.
 Importantly, viability imaging was not used to
stratify these outcomes.
o For cardiogenic shock after myocardial infarction, the
results of emergent CABG are poor but still better
than medical therapy.
o The SHOCK Trial gave 1-year mortality after CABG of
42% and 56% for patients in cardiogenic shock.
o This is compared with 56% and 75% with medical
therapy alone
• Stabilization of the patients with the use of an
intra-aortic balloon pump decreased in-hospital
mortality but had no effect on 1-year survival.
 More recently, smaller experiences with
percutaneous partial pumps, such as the Impella
and TandemHeart devices, suggest that
perioperative mortality can be improved after
revascularization, but these results have not yet
been confirmed with a larger experience.
Does the EF
will be
changed post
operatively?
 The presence of hibernating or viable
myocardium is essential for improvement in LVEF
after surgical revascularization.
 Recovery of LV function after revascularization is
related to the degree of reversible myocardial
ischemia, severity of the LV dysfunction, LV
chamber dimensions, and LV geometry.
 There may be continuing improvements in LVEF
as late as 6 to 12 months after surgery
• A number of surgical approaches have emerged as
potentially beneficial in patients with ischemic HF.
• The goals of such procedures generally include:
 revascularization,
 reduction in “geometric” or functional mitral
regurgitation,
 restoration of a more normal LV geometry and
function.
 Surgical ventricular restoration(SVR) procedure is one
of the most extensively studied and applied
techniques
STICH, a prospective, randomized study
• 2800 patients randomized from 100 centers.
• Patients with LV dysfunction and coronary artery
disease amenable to CABG were randomized to a
combination of three different treatment strategies:
 CABG, CABG plus surgical ventricular
reconstruction (SVR), or intense medical
therapy.
 In STICH CABG was associated with an early risk of death as
a result of the surgical intervention itself, but this
disadvantage for surgery disappeared after two years post
procedure.
 Over a median follow-up of 56 months, 41% of the medicaltherapy group and 36% of the CABG group died ,the
difference was statistically significant following adjustment
for baseline characteristics (p=0.039).
 In the medical-therapy group, 68% of the patients died
from any cause or were hospitalized for cardiovascular
causes, compared with 58% of the CABG group (p<0.0001).
STICH trial
 The STICH trial was designed to compare coronary
bypass (CABG) alone vs. CABG plus surgical
ventricular reconstruction (SVR) in patients with left
ventricular (LV) dysfunction
 It reported that adding SVR to coronary bypass CABG
was not associated with a greater improvement in
symptoms, exercise tolerance, or reduced
intermediate mortality.
Surgical ventricular reconstruction is an
effective operation when performed by
properly trained surgeons in correctly
selected patients
• A randomized comparison of coronary artery bypass
graft (CABG) surgery and medical therapy alone in
1212 patients with coronary artery disease amenable
to CABG with a left ventricular ejection fraction under
35%.
Coronary-Artery Bypass Surgery in Patients
with Left Ventricular Dysfunction
The New England Journal of Medicine
april 28, 2011
Is there any other
options?
Can I do PCI? Isn
it better?
PCI in Heart Failure:
Early surgical or percutaneous intervention, as
compared with continued medical therapy,
significantly improves the survival of patients with
systolic heart failure, according to a retrospective
analysis
CREDO-Kyoto
PCI/CABG registry
Cohort-2:
CABG would still remain the standard treatment
option in patients with triple vessel disease,
particularly when their SYNTAX scores are high
 Findings from study show that PCI was associated
with a higher 3-year risk for this primary endpoint
(adjusted hazard ratio (HR) 1.47 [95% CI 1.13-1.92,
P=0.004]) and for MI (HR 2.39 [95% CI 1.31-4.36,
P=0.004]), as compared with CABG.
 The risk for cardiac death was not significantly
different (HR 1.30 [95% CI 0.81-2.07, P=0.28]), but
the risk for all-cause death was significantly higher
after PCI (HR 1.62 [95% CI 1.16-2.27, P=0.005]).
Results also showed that the cumulative incidence of
the primary endpoint was comparable between the
PCI and CABG groups in patients with low (<23) and
intermediate (23-32) SYNTAX scores
in patients with high SYNTAX scores (≥33) was
markedly higher after PCI than after CABG (15.8%
and 12.5%, P=0.25, 18.8% and 16.7%, P=0.24, and
27.0% and 16.4%, P=0.004, respectively).
• The study population consisted of 2981 patients with
triple vessel disease (PCI 1825 patients, and CABG
1156 patients
• Anatomic complexities of coronary artery disease
were assessed by using the SYNTAX score to ensure
comparability between the PCI and CABG groups (in
an observational study)
• A composite of all-cause death, myocardial
infarction (MI) and stroke was primarily studied.
o The SYNTAX score is the sum of the points assigned
to each individual lesion identified in the coronary
tree with >50% diameter narrowing in vessels
>1.5mm diameter.
o The coronary tree is divided into 16 segments
according to the AHA classification
(ACC/AHA) guidelines for CABG in patients
with poor LV function
Recommend Surgery as :
• Class I indication for those patients with left main or
equivalent disease,
• Class IIa for patients with viable noncontracting
muscle
• Class III for those without evidence of ischemia or
viability
• "The take-home message is that:
I. the STICH trial supports bypass surgery on top of
best medical therapy vs medical therapy alone to
reduce cardiovascular morbidity and mortality
II. many patients who are now treated for heart failure
should be evaluated for CAD, because [coronary
disease] does not present the same way in every
patient
"Heart failure without angina shouldn't exclude
patients from an angiographic evaluation."