How to assess reversible ischemia in lv dysfunction

1. Andres.Iniguez.Romo@sergas.es
Dr. Andrés Iñiguez
How to assess reversible
ischemia in LV Dysfunction ?

2. Speaker's name: Andrés Iñiguez
 I do not have any potential conflict of interest related to
the issue of this presentation.
q I have the following potential conflicts of interest to report:
Honorarium:
Institutional grant/research support:
Consultant:
Employment in industry:
Owner of a healthcare company:
Stockholder of a healthcare company:
Other(s):
Conflict of Interest

3. SEC 2015-2017
1 Introduction
Revascularization & Left Ventricular Dysfunction
2 LV Dysfunction and Revascularization
- CABG / PCI
3 New Onset CHF and Revascularization
4 LVD and haemodynamic support

4. SEC 2015-2017
1 Introduction
Revascularization & Left Ventricular Dysfunction

5. SEC 2015-2017Revascularization & Left Ventricular Dysfunction
ü The optimal treatment for patients with severe coronary
artery disease (CAD) and reduced LV function remains
controversial.
ü The impact of having revascularization by CABG or PCI on
survival in patients with left ventricular (LV) dysfunction,
particularly severe LV dysfunction, remains a subject of
considerable debate and uncertainty.

6. SEC 2015-2017
Still remain questions to be solved
Revascularization & Left Ventricular Dysfunction
ü In how many P. with CHF/severe LV dysfunction:
- we know their coronary anatomy ?.
- we know status of myocardial viability ?.
ü How many P. with CHF/severe LV dysfunction &
severe coronary artery disease:
- being revascularized (CABG-PCI) ?.
ü What is the prognosis of P. with CHF / severe LV
dysfunction according to subgroups ? :
- Revascularized vs non revascularized.
- Complete Revasc. Vs. Incomplete Revasc.
- With Myocadial Viability Vs. Absence of Viability.

7. SEC 2015-2017Revascularization & Left Ventricular Dysfunction
2 LV Dysfunction and Revascularization
- CABG / PCI

8. Impact of Revascularization by CABG on LVEF

9. Patients with Impaired Left Ventricular Function
Improvement of LVEF postCABG
Med Arh. 2014 Oct; 68(5): 332-334
40 P.
LVEF <35%
Basal1m. post
Impact of Revascularization by CABG on LVEF

10. Revascularization & Left Ventricular Dysfunction
The updated 2014 European guidelines for
myocardial revascularization continue to recommend
that CABG surgery in patients with LV dysfunction be
considered in the presence of viable myocardium.
(Eur Heart J. 2014;35:2541-619)
The European guidelines for management of heart
failure do not recommend CABG (class III) surgery in
patients with LV dysfunction without angina and
without myocardial viability.
(Eur Heart J. 2012;33:1787-847)

11. Revascularization & Left Ventricular Dysfunction

12. Revascularization & Left Ventricular Dysfunction

13. CABG Vs PCI Revascularization &
Left Ventricular Dysfunction
Am J Cardiol 2014;114:988e 996
(NO LVEF)

14. Am J Cardiol 2014;114:988e 996
Cardiac Death
CABG Vs PCI Revascularization &
Left Ventricular Dysfunction

15. Am J Cardiol 2014;114:988e 996
Readmission for Heart Failure
CABG Vs PCI Revascularization &
Left Ventricular Dysfunction

16. ü (STICH) trial emerges as the first and only prospective
randomized trial designed to determine the impact of
CABG when it is added to evidence-based medical
therapy in patients with CAD and an EF 35%.
ü The STICH trial investigated 2 hypotheses:
a) Survival is enhanced with CABG plus evidence-based medical
therapy compared with medical therapy alone in patients with
ischemic heart failure (the revascularization hypothesis); and
a) CABG plus surgical ventricular reconstruction (SVR) provides a
survival advantage compared with CABG alone, in patients with
an EF<35% undergoing revascularization who have dominant
LV anterior akinesia or dyskinesia (the SVR hypothesis).
Velazquez EJ, et al. N Engl J Med. 2011;364:1607-16.
CABG Revascularization Vs. Medical Therapy &
Left Ventricular Dysfunction

17. Velazquez EJ, et al. N Engl J Med. 2011;364:1607-16.
The primary outcome was all-cause
mortality.
The principal result was the lack of significant difference in all-cause
mortality between the 2 groups during the 56-month mean follow-up period,
with 41% and 36% mortality in those assigned to medical
therapy and CABG, respectively.
Bonow RO, et al. N Engl J Med. 2011;364:1617-25.
CABG Revascularization Vs. Medical Therapy &
Left Ventricular Dysfunction

18. Velazquez EJ, et al. N Engl J Med. 2011;364:1607-16.
The primary outcome was all-cause
mortality.
The principal result was the lack of significant difference in all-cause
mortality between the 2 groups during the 56-month mean follow-up period,
with 41% and 36% mortality in those assigned to medical
therapy and CABG, respectively.
It is at all ?
Bonow RO, et al. N Engl J Med. 2011;364:1617-25.
CABG Revascularization Vs. Medical Therapy &
Left Ventricular Dysfunction

19. Velazquez EJ, et al. N Engl J Med. 2011;364:1607-16.
STICH substudy.
(601 of the 1212 patients imaged with single-photon emission tomography or low-dose
dobutamine echocardiography to determine the magnitude of viable myocardium)
- Patients with predominately viable myocardium had
reduced mortality compared with those with predominately
nonviable myocardium: 37% versus 51%, respectively, over
a median 5.1-year follow-up period.
Bonow RO, et al. N Engl J Med. 2011;364:1617-25.
CABG Revascularization Vs. Medical Therapy &
Left Ventricular Dysfunction
The primary outcome was all-cause
mortality.
The principal result was the lack of significant difference in all-cause
mortality between the 2 groups during the 56-month mean follow-up period,
with 41% and 36% mortality in those assigned to medical
therapy and CABG, respectively.

20. Complete Vs. Incomplete Revascularization &
Left Ventricular Dysfunction

21. Complete Vs. Incomplete Revascularization &
Left Ventricular Dysfunction

22. J Korean Med Sci 2014; 29: 1501-1506
92,7 %
82,5 %
54,9 %
65,3 %
Complete Vs. Incomplete Revascularization &
Left Ventricular Dysfunction

23. Revascularization & Left Ventricular Dysfunction
European Heart Journal (2014) 35, 3004–3012

24. Revascularization & Left Ventricular Dysfunction
European Heart Journal (2014) 35, 3004–3012
A strong relationship between LV function and mortality.
A worse LV function independently predicting 30-day and
long-term mortality outcomes across all indications for PCI.
There is a differential impact of LV function on mortality
outcomes across different indications for PCI, with the
greatest adverse prognostic association between worse LV
function and mortality outcomes observed in patients
undergoing PCI in the STEMI setting.

25. Revascularization & Left Ventricular Dysfunction
European Heart Journal (2014) 35, 3004–3012
Elective PCI NSTEMI PCI STEMI PCI

26. Revascularization & Left Ventricular Dysfunction
Catheterization and Cardiovascular Interventions
DOI: 10.1002/ccd.25732
The impact of LV dysfunction on mortality is attenuated
across all age groups (even after adjustments).
The attenuation is related to the increased prevalence of
comorbid conditions and adverse procedural characteristics
in the elderly cohort, but may be related to incident frailty
which increases with age, and is a strong independent
predictor of worse outcomes post PCI, which may serve to
further diminish the importance of LV function on prognosis
in such elderly patients.

27. Catheterization and Cardiovascular Interventions
DOI: 10.1002/ccd.25732
Prognosis of LVEF after PCI Revascularization & Age

28. SEC 2015-2017Revascularization & Left Ventricular Dysfunction
3 New Onset CHF and Revascularization

29. ü Patients presenting with CHF had consistently higher mortality
rates than those without (irrespective of revascularization
procedures) both in the hospital and from discharge to 6 months
after hospitalization.
Steg PG et al. Circulation 2004;109:494-9.
Relevance of New Onset Left Ventricular Dysfunction

30. ü New-Onset Acute Heart Failure in Patients with Acute Myocardial
infarction Underwent Successful Revascularization
6 Months Mortality rates
Steg PG et al. Circulation 2004;109:494-9.
GRACE: 1778 patients (13%) had HF (Killip class II or III) at hospital admission.
Recent & New Onset Left Ventricular Dysfunction
x4

31. 7,064 AMI patients with Killip class I at admission underwent successful PCI
from KAMIR between Oct. 2005 and Jan. 2008
Keun-Ho Park and KAMIR investigators
Death
No AHF
6,944 (98.3%)
New–onset AHF
120 (1.7%)
Relevance of New Onset Left Ventricular Dysfunction

32. SEC 2015-2017Revascularization & Left Ventricular Dysfunction
4 LVD and haemodynamic support

33. Hemodynamic Support PCI in P. with Left Ventricular Dysfunction
J Interven Cardiol 2015;28:32–40
Improvement of
Hemodynamic Conditions

34. J Interven Cardiol 2015;28:32–40
Improvement of
Global Adverse Events
Hemodynamic Support PCI in P. with Left Ventricular Dysfunction

35. J Interven Cardiol 2015;28:32–40
Hemodynamic Support PCI in P. with Left Ventricular Dysfunction
No Improvement in Death rate

36. Conclusions
① Complete Myocardial Revascularization should be recommended in patients
with LV dysfunction in presence of viable myocardium.
② A strong relationship exists between LV function and mortality. A worse LV
function independently predict 30-day and long-term mortality outcomes
across all indications for PCI, with the greatest adverse prognostic association
in patients undergoing PCI in the STEMI setting.
③ Impact of LV dysfunction on mortality is attenuated across all age groups. The
attenuation may be related to the increased prevalence of comorbid
conditions, adverse procedural characteristics, and frailty in the elderly cohort
which may serve to further diminish the importance of LV function on
prognosis in such elderly patients.
④ Patients presenting with new onset CHF had consistently higher mortality rates
than those without (irrespective of revascularization procedures) both in the
hospital and at mid-term after hospitalization.
⑤ Use of hemodynamic support techniques during revascularization may improve
hemodynamic conditions, but will not modify short or late death rate.

37. Thanks