Ischaemic cardiomyopathy revascularisation how when and why

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Ischaemic cardiomyopathy revascularisation how when and why

  1. 1. ISCHAEMIC CARDIOMYOPATHYREVASCULARISATION-HOW WHEN AND WHY? Dr. DEV PAHLAJANI (MD,FACC,FSCAI) HOD INTERVENTIONAL CARDIOLOGY BREACH CANDY HOSPITAL AND CONSULTANT CARDIOLOGIST NANAVATI HOSPITAL MUMBAI
  2. 2. Congestive Heart Failure in IndiaPrevalence: 18.8 million (1.76% of population)Incidence: 1.57 million per year (0.15%)
  3. 3. Etiology of CHFUnited States:o Ischemic (50%)o Idiopathic (50%)Indiao Rheumatic heart disease (52.8%)o Ischemic/ hypertensive (27.2%)
  4. 4. Duke CVD Data-chnge Unadjusted survival curves for CABG versus medical therapyA, overall; B, 1-vessel disease; C, 2-vessel disease; D, 3-vessel disease Am. J. Cardiol 2002, 90, 101
  5. 5. Ischaemic CardiomyopathyOlder population• Usually MV Disease• DM, CRF• Poor LV function• Increased LV volumes• Regional wall motion abnormalities• Multiple infarcts, Earlier procedures• Conduction defects, Arrythmias• PVD and Cer. Vascular Disease
  6. 6. Ischaemic Cardiomyopathy : Selection Criteria Duke CVD Data Bank 75 % ≥ Diameter stenosis in major coronary Artery EF < 40 % NYHA Symptoms Class II or More Stitch Trial Patient with CAD EF < 35 %
  7. 7. Factors Contributing to Left Ventricular Remodeling,Progression of Left Ventricular Systolic Dysfunction and Heart Failure Cardiovascular Systemic and Other nonmyocardial factors factors Coronary artery Renin-angiotensin- disease extent aldosterone system endothelial function Sympathetic nervous system Arrhythmias Vasodilators Myocardial factors Mitral valve function Natriuretic peptides Ventricular synchrony Cytokines Remote myocardium Diastolic function Diabetes mellitus and Scar tissue metabolic syndrome Hibernation Sleep apnea Ischemia / stunning Renal disease Apoptosis Environmental LV remodeling Age Hypertrophy Progression of LV systolic dysf. Heart failure
  8. 8. Dukes : CVD Data : Ischemic Cardiomyopathty – Observational Data Duke Cardiac Catherizations Patients (taking first CHF ≥ 2 July 1969 – February catheterizations) 1994 n = 4129 N=3630 N = 54,498 63 patients deleted from analysis Ejection Medical fraction < 40 % lost, or died within N=1052 mean time to CABG N=1454 N=1391 CABG N = 339 Am. J. Cardiol 2002, 90, 101
  9. 9. Viability Vs Hibernation Are They Same ?Viable myocardium = Hibernating myocardium
  10. 10. Myocardial ViabilityDysfunctional myocardium subtended by disease coronary artery with limited or absent scarring that hasPOTENTIAL FOR FUNCTIONAL RECOVERY
  11. 11. Hibernation Myocardium State of myocardial hypocontractilityduring chronic hypoperfusion in the presence of completely viable myocardium which functionally upon
  12. 12. Duke CVD Data-chnge Unadjusted survival curves for CABG versus medical therapyA, overall; B, 1-vessel disease; C, 2-vessel disease; D, 3-vessel disease Am. J. Cardiol 2002, 90, 101
  13. 13. Duke Data Ischaemic Cardiomyopathy CABG better MED betterEF ≤ 25 % > 25 % Age ≤ 65 > 65 NYHA II III IV AnginaNo Angina 0 0.5 1 1.5 Am. J. Cardiol 2002, 90, 101
  14. 14. Duke CVD Data Ischaemic Cardiomyopathy Adjusted Cox Proportional-hazards Survival Estimates* Medical Therapy CABG1-year survival 74 % 83 %5-year survival 37 % 61 %10-year survival 13 % 42 %*p<0.0001, for all comparisons. Weighted average of 1-, 2-, and 3-vessel disease usedto calculate the 1-, 5-, and 10-year survival estimates Am. J. Cardiol 2002, 90, 101
  15. 15. Relative Risk of Mortality for Coronary Artery Bypass Grafting Compared With Medical Therapy In Moderate to Severe LeftVentricular Systolic Dysfunction, ranked in order of Study Quality Study Follow-up Favors Favors Medical (year) Surgery Treatment Duke 5 Coronary Artery 3 Surgery Study Mayo 2 University of Albama 5 St. Luke’s Milwaukee 6 Vanderbilt 2 Duke 1 0.24 0.50 0.75 1 2
  16. 16. Coronary Artery Occlusion Outcomes Incomplete or short Complete and Complete and short duration prolonged Normal structure & function Stunning Low- ATP Ischemia Contractile failure Myocardial Hibernation infarctionInfluenced By Collaterals and Ischemic Preconditioning
  17. 17. Myocardial Tissue
  18. 18. Surgical Revascularization Hypothesis STITCH N ENG J MED 2011Primary Hypothesis: In patients with HF, LVD and CAD amenable to surgical revascularization, CABG added to intensive medical therapy (MED) will decrease all-cause mortality compared to MED alone. Secondary hypothesis: Presence and extent of dysfunctional but viable myocardium, as defined by radionuclide imaging, dobutamine stress echocardiography, or both, will identify patients with greatest survival advantage of MED + CABG compared with MED alone.
  19. 19. Important Inclusion Criteria LVEF ≤ 0.35 within 3 months of trial entry CAD suitable for CABG MED eligible – Absence of left main CAD as defined by an intraluminal stenosis of ≥ 50% – Absence of CCS III angina or greater (angina markedly limiting ordinary activity)
  20. 20. Major Exclusion Criteria Recent acute MI (within 30 days) Cardiogenic shock (within 72 hours of randomization) Plan for percutaneous intervention Aortic valve disease requiring valve repair or replacement History of more than 1 prior CABG Non-cardiac illness with a life expectancy of less than 3 years or imposing substantial operative mortality
  21. 21. STICH Revascularization Randomized MED only 602 1212 Randomized CABGHF, LVD and CAD 610amenable to CABG
  22. 22. STITCH TRIAL N. Eng. J. Med 2011, 364, 1607- 1616
  23. 23. Has CABG no role in Ischemic HF ?“We were unable to show a significant benefit forCABG in our primary analysis, but if you dive deeper,the data are much more supportive of bypasssurgery,” -Dr Eric J. Velazquez, M.D.
  24. 24. N. Eng. J. Med 2011, 364-1604 N Engl J Med 2011; 364:1607-1616
  25. 25. N Engl J Med 2011; 364:1607-1616
  26. 26. Patients with viability tests 601Patients with Patients myocardial without viability 487 114 myocardial viability 243 244 60 54 MED CABG MED CABG 49.9% 50.1% 52.6% 47.4%
  27. 27. STICH ViabilityViability testing was optional at enrolling sites and was not a prerequisite for enrollment. Dobutamine echo SPECT protocols: protocols: • Thallium-201 stress- • Staged increase in redistribution- dobutamine starting reinjection at 5 μg/kg/min • Thallium-201 rest- redistribution • Nitrate-enhanced Tc- 99m perfusion imaging
  28. 28. N. Eng. J. Med 2011, 364-1617
  29. 29. STICH ViabilityImplications: In patients with CAD and LV dysfunction, assessment of myocardial viability does not identify patients who will have the greatest survival benefit from adding CABG to aggressive medical therapy
  30. 30. Myocardial viability testing and impact of revascularization on Prognosis in patients with coronary artery disease and left ventricular dysfunction: A meta analysisKevin C. Allman , MB,BS,FRACP,FACC, * Leslee J. Shaw, PhD, Rory Hachamovitch, MD,FACC, James E. Udelson, MD,FACC Conrod, Australia, Atlanta, Georgia and Boston, Massachusetts JACC,2002.VOL .39. No. 7
  31. 31. Myocardial Viability : Meta-Analysis Allman et al -79.6 % 20 23.0 % x2=147 16Death rate (%/yr) p<0.0001 x2=1.43 15 p<0.23 10 7.7 6.2 5 3.2 0 Revasc. Medical Revasc. Medical Viable Non-Viable JACC Vol. 39, No. 7, 2002 April 3, 2002:1151-8
  32. 32. Predicted Reduction in Death Rate With Revascularization Allman et al 0 -25 -50 Viable -75 Non-Viable -100 25 30 35 40 45 Left Ventricular EF % Relation between left ventricular ejection fraction (EF) and predicted change in mortality for patients with viable (circles) versus nonviable (triangles) myocardium based on the results of meta-regression. This demonstrates increasing potential for improved survival with lower left ventricular EF in patients with viable myocardium, p < 0.0001 (broken plot line), but not in those without viability, p = 0.11 JACC Vol. 39, No. 7, 2002 April 3, 2002:1151-8
  33. 33. Myocardial Hibernation : SCD G. HeuschSymptomatic stimulationAcute ischemiaMicroembolization ?Acute inflammation TRIGGER Structural remodeling interstitial fibrosis myocyte hypertrophy Altered innervation Electrical remodeling altered conduction ? SUBSTRATE Elements of the arrhythmogenic substrate and triggers for arrhythmia in hibernating myocardium
  34. 34. Ischaemic Cardiomyopathy Prognosis AfterRevascularization Relation With Improvement IN LVEF & Viability – Rizello Y et al Heart 2009, 95, 1273• 97 Consecutive patients• LVEF < 40 % CAD• Symptoms of Heart failure and or angina• Radionuclear ventriculography and Dobutamine Stress• Echo before Revascularization• After Revascularization : Group I – Viable patient with improved EF Group II – Viable patients with no Improvement in EF Group III – No viability
  35. 35. Kaplan-Meir curves showing the cardiac event rate in the three groups of patients 40 Log-rank P-value 0.01 Group 3Cardiac death rate (%) 30 Non viable 20 Group 2 Viable No Improvement LVEF 10 Group 1 0 Viable 0 1 2 3 4 Improvement LVEF Follow up (years)
  36. 36. Time Course of Functional Recovery After Revasc. – 26 Patients3 WMS210 Stunning Hibernation Nontransm scar Transm scar Baseline 3 Months 14 Months Circulation September 18, 2001
  37. 37. Effect of Revascularisation On Long Term Survival In Ischaemic LV Dysfunction and Viability SAWAD et al Am. J. Cardiol 2010, 106, 187 274 Patients : Mean LVEF 32 % Viability In ≥ 25 % Myocardium by DSE Primary End Point Cardiac Death 130 : Revascularization : Mean Survival 5.9 years 144 : Medical Treatment : Mean Survival 3.3 years P=0.0001
  38. 38. Markers of Hibernating MyocardiumModalities and Targets Metabolism Perfusion Nonviability Scar Contractile ReserveCMR - + + +CT - + + -Echocardiography - + (+) +PET + + - -SPECT + + - + Assessment of Detection of Exact localization Assessment of functional blood flow and size of contractile function integrity of toward the necrosis/fibrosis myocardial cells myocardium
  39. 39. Algorithm to Assess Hibernating Myocardium With CMR Wall Motion Abnormalities At Rest – CHR in the Presence of Coronary Artery Disease LGE Revascularization Transmurality > 50 % < 50 % Medical LDDSMR Therapy Medical Therapy Revascularization
  40. 40. Dobutamine Study Echo In 128 Patients : Ischaemic Cardiomyopathy - EF 31 % CR-patients 30 25 p = 0.015 Cardiac death rate (%) 20 15 CR+patients 10 5 0 0 365 730 1095 1460 1825 Follow up (days) Heart 2006, Rizzella V et al
  41. 41. Results of Studies That Evaluated the Improvement in Function on a Segmental Basis Sensitivity Specificity PPV NPVCMR Contrast enhanced 97 68 73 93 Dobutamine stress 94 90 86 92 Total 94 87 84 87Conventional nuclear 99mTc-sestambi 96 55 87 80 SPECT FDG 89 86 --- --- 201TI rest, reinjection Total 86 63 69 85 89 68 73 84Echocardiography DSE 76 81 66 89 DSE SRI 82 80 --- --- End-diastolic wall thickness Total 94 48 53 93 78 78 64 90PET PET-FDG67,70,75,79-81 89 57 73 90 Total 89 57 73 90
  42. 42. REHEAT : Revascularization In Ischaemic Heart Failure Trial Non Randomised case controlled 141 patients : LVEF < 40 % + CAD Primary Outcome : Improvement in LVEF Secondary Outcome : In-Hospital Major Adverse Events
  43. 43. Scheme of enrolling and follow-up of patients included in the study. N=141 patients included Into the study N=55 N=54 N=32 patients allocated to patients allocated topatients allocated to PCI group CABG group Registry group 30-day Follow-up 30-day Follow-up N=50 N=55 (2 deaths before CABG 2 deaths after CABG up to 30 days) 12-month Follow-up N=54 12-month Follow-up (1 death after 3 months follow-up) N=50
  44. 44. Results  30 Days MACE  CABG – 40.7 %  PCI 9 % p=0.0003  Improvement in EF  CABG – 6 %  PCI – 4.4 % Functional Status Long-term Freedom From Angina  CABG was better p = 0.0013
  45. 45. 42 40 p=0.99 38 PCI p<0.01 CABGLVEF (%) 36 34 p=0.38 p<0.01 32 30 28 EFO EF12
  46. 46. 65 60 PCILVEDD (mm) p=0.86 CABG 55 p=0.78 p=0.37 50 p=0.86 45 40 Baseline after 12 months
  47. 47. 50 p=0.62 45 PCILVESD (mm) zp=0.94 p=0.99 CABG p=0.98 40 35 30 Baseline after 12 months
  48. 48. Symptoms and/or signs of congestive heart failure with abnormal left ventricular function (clinical examination and echocardiography) CAD CAD Assess myocardial viability Investigate alternative with technique available aetiologies (DCM, valve diseases etc.No evidence of viability Presence of significant viabilityor viability < 25 % of LV in segments subtended by stenotic coronaries Medical treatment Coronary revascularization CRT, ICD, LVAD by PCI or CABG
  49. 49. TAKE HOME MESSAGE• Ischemic cardiomypathy has high mortality with medical Treatment• Improved survival with CABG? PCI• Effort should be made to detect viable muscle• De,spect,cmr should be performed to detect viable muscle

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