CLINICAL STUDY: LV FUNCTION FOLLOWING REVASCULARIZATION
Positron emission tomography and recovery following revascularization (PARR-1): the importance of scar and the development of a prediction rule for the degree of recovery of left ventricular function
Rob S. B. Beanlands, MD, FACC, FRCP(C)*,*,
Terrence D. Ruddy, MD, FACC, FRCP(C)*,
Robert A. deKemp, PhD*,
Robert M. Iwanochko, MD, FRCP(C) ,
Geoffrey Coates, MD, FRCP(C) ,
Michael Freeman, MD, FACC, FRCP(C),
Claude Nahmias, PhD,
Paul Hendry, MD, FRCS(C)*,
Robert J. Burns, MD, FACC, FRCP(C),
Andre Lamy, MD, FRCP(C) ,
Lynda Mickleborough, MD, FRCP(C),
William Kostuk, MD, FACC, FRCP(C)||,
Ernest Fallen, MD, FACC, FRCP(C),
Graham Nichol, MD, MPH, FRCP(C)¶ PARR Investigators
* Cardiac PET Centre, Divisions of Cardiology and Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Divisions of Cardiology and Cardiac Surgery, Toronto Hospital Western and General Divisions and St. Michael’s Hospital, University of Toronto Health Sciences Network, Toronto, Ontario, Canada
E. S. Garnett Memorial PET Centre, Department of Radiology, McMaster University and Department of Nuclear Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
Divisions of Cardiology and Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
|| Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
¶ Cardiovascular Outcomes Related to Economics Group, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
Manuscript received February 15, 2002;
revised manuscript received May 24, 2002,
accepted June 24, 2002.
* Reprint requests and correspondence: Dr. Rob S. B. Beanlands, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada.
rbeanlands{at}ottawaheart.ca
OBJECTIVES: The aim of this study was to determine whether the extent of viability or scar is important in the amount of recovery of left ventricular (LV) function, and to develop a model for predicting recovery after revascularization that could be tested in a randomized trial.
BACKGROUND: F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) is used to define viable myocardium in patients with coronary artery disease (CAD) and severe LV dysfunction and to guide revascularization decisions. Whether this approach improves clinical outcomes has not been tested in a randomized trial. Before doing so, an objective model for prediction of recovery is required.
METHODS: A total of 82 patients with CAD and an ejection fraction (EF)  35% had FDG PET perfusion imaging before revascularization. Complete follow-up was available on 70 patients (86%). Patients had radionuclide angiograms at baseline and three months post-revascularization.
RESULTS: Diabetes (p = 0.029), time to operation (p = 0.008), and scar score (p = 0.001) were significant independent predictors of the change in EF. Previous coronary artery bypass graft confounded the effect of age. There was a significant interaction between the perfusion tracer used and mismatch score (p = 0.02). The multivariable prediction model incorporating PET and clinical variables had a goodness of fit with p = 0.001. Across tertiles of scar scores (I, small: 0% to 16%; II, moderate: 16% to 27.5%; III, large: 27.5% to 47%), the changes in EFs were 9.0 ± 1.9%, 3.7 ± 1.6%, and 1.3 ± 1.5% (p = 0.003: I vs. III), respectively.
CONCLUSIONS: In patients with severe LV dysfunction, the amount of scar was a significant independent predictor of LV function recovery after revascularization. A combination of PET and clinical parameters predicts the degree of recovery. This model is being applied in a large randomized controlled trial to determine the effectiveness of therapy guided by FDG PET.
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Abbreviations and Acronyms
| | CAD | | coronary artery disease | | EF | | ejection fraction | | FDG | | F-18-fluorodeoxyglucose | | LV | | left ventricle/ventricular | | PET | | positron emission tomography | | RNA | | radionuclide angiogram/angiography | | SPECT | | single photon emission computed tomography | | Tc | | technetium |
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