CABG in ischemic cardiomyopathy

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CABG in ischemic cardiomyopathy

  1. 1. Ischemic Cardiomyopathy
  2. 2. Ischemic Cardiomyopathy “The most common cause of heart failure in developed countries.” He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001; 161:996.
  3. 3. Definition of Ischemic Cardiomyopathy “Impairment of left ventricular function that results from coronary artery disease”
  4. 4. Pathogenesis Irreversible loss of myocardium from prior MI with ventricular remodeling AND Partially reversible loss of contractility due to reduced function of ischemic but still viable myocardium (Hibernating Myocardium)
  5. 5. Hibernating Myocardium “Contractile dysfunction in viable myocardium that improves after revascularization or perhap medical therapy” Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. J Am Coll Cardiol. 2005 Aug 16;46(4):567-74.
  6. 6. http://www.britannica.com/blogs/wp-content/uploads/2011/05/dormouse.jpg
  7. 7. “No randomized trials of revascularization in patients with coronary artery disease with decrease LVEF” “Multiple observational study suggesting improvement in outcome with CABG”
  8. 8. Current Recommendation for CABG in patient with poor LV function
  9. 9. 1. Significant left main disease 2. Left main equivalent disease ( ≥ 70 % stenosis of proximal LAD and Proximal LCX) 3. Proximal LAD stenosis with two or three vessel disease
  10. 10. Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction (STICH trial)
  11. 11. STICH = Surgical Treatment for Ischemic Heart Failure
  12. 12. Methods
  13. 13. Study Design • Non-blinded, Randomized study. • Sponsored by NHLBI and Abbott Laboratories • Design to have 90% power to detect a 25% reduction in mortality with CABG as compared with medical therapy alone
  14. 14. Study Patients • CAD amenable to CABG • EF of 35% or less
  15. 15. Study Procedures • CABG is performed by cardiac surgeon in whom have operative death rate less than 5% • Patients are followed at 30 days, every 4 months then every 6 months on next year
  16. 16. Primary Outcome • Rate of death from any cause
  17. 17. Secondary Outcome • “Rate of death from CVS cause” • “Rate of death from any cause or hospitalization from cardiovascular cause”
  18. 18. Statistical Analysis • Intention to treat analysis • Kaplan Meier method • As treated analysis
  19. 19. Result
  20. 20. Study Population • 1212 Patients from 22 countries • 602 has medial therapy • 610 has CABG + Medical Therapy
  21. 21. CABG group 610 Patients 529 (95%) got surgery 63 also got mitral valve repair Medical Group 602 Patients 100 (17%) end up getting surgery 1. Progressive symptoms 2. Acute decompensation 3. Family ‘s decision 4. Physician’s decision
  22. 22. Follow-up • 5 of 1212 patients were loss to follow up. • Median length of follow-up is 56 months
  23. 23. Outcome Medical Therapy CABG Rate of death from any cause 41 % 36 % Primary Outcome Hazard Ratio with CABG 0.86 P Value 0.12
  24. 24. Secondary Outcome Outcome Medical Therapy CABG Hazard Ratio Death from cardiovascular cause 33 % 28 % 0.81 (0.66-1.00) Death from any cause or admit for HF 54 % 48 % 0.84 (0.71-0.98)
  25. 25. As-treated analysis CABG 620 Patients including cross over Medical Management 592 Patients
  26. 26. As-treated analysis
  27. 27. Limitations • Non blinded study has an effect on non fatal outcome • Trial was design to detect 25% reduction in mortality with CABG • Limited power and limited duration of follow- up

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