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CLINICAL RESEARCH: MYOCARDIAL VIABILITY AND PROGNOSIS

Incremental value of myocardial viability for prediction of Long-Term prognosis in surgically revascularized patients with left ventricular dysfunction

Stephen Sawada, MD, FACC^*,*, Ashutosh Bapat, MD^*, Dev Vaz, MD^*, Juan Weksler, MD^*, Naomi Fineberg, PhD^*, Adam Greene, MD, FACC^*, Irmina Gradus-Pizlo, MD, FACC^* and Harvey Feigenbaum, MD, FACC^*

^* Department of Medicine of Indiana University School of Medicine, Indianapolis, Indiana, USA
Krannert Institute of Cardiology, Indianapolis, Indiana, USA

^* Reprint requests and correspondence: Dr. Stephen Sawada, 1801 North Senate Boulevard, M.P.C. II, Suite D4082, Indianapolis, Indiana 46202, USA.
ssawada{at}iupui.edu

OBJECTIVES: We assessed the incremental long-term prognostic value of myocardial viability in surgically revascularized (CABG) patients with left ventricular (LV) dysfunction.

BACKGROUND: Clinical factors, medical therapy, the degree of LV dysfunction, and stress-induced ischemia may affect the relative prognostic value of myocardial viability.

METHODS: Patients with coronary disease and ventricular dysfunction (mean ejection fraction 33% by echocardiography, 25% by angiography) were studied with dobutamine echocardiography. Follow-up (mean –4.9 years) was obtained in 95 patients (85% triple-vessel disease) who underwent CABG.

RESULTS: The use of angiotensin-converting enzyme inhibitors, advanced heart failure, rest, low- and peak-dose wall motion scores were univariate predictors of cardiac death. The extent of contractile reserve and ischemia were not predictive. Low-dose score was the strongest multivariate predictor of death (p < 0.001, hazard ratio 6.7). A biphasic response predicted better survival (p = 0.045, hazard ratio 0.5). Five-year survival was better in those with extensive (low-dose score <2.00) versus intermediate (score 2.00 to 2.49) amounts of viable myocardium (p = 0.019). Patients with the least viability (score 2.5) had the worst outcome (p = 0.0001 vs. those with low-dose score <2.00; p = 0.05 vs. those with score 2.00 to 2.49). In stepwise multivariate analysis, low-dose score added incremental prognostic value (p = 0.024) to clinical information and rest score.

CONCLUSIONS: Low-dose score, representing the extent of viable myocardium, has incremental prognostic value as a predictor of long-term outcome in CABG patients with LV dysfunction.

Abbreviations and Acronyms   ACEI = angiotensin-converting enzyme inhibitor   CABG = coronary artery bypass grafting   CAD = coronary artery disease   CHF = congestive heart failure   DobE = dobutamine echocardiography   EF = ejection fraction   LV = left ventricle/ventricular

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