title: Severity of Remodeling, Myocardial Viability, and Survival in Ischemic LV Dysfunction After Surgical Revascularization.
abstract: OBJECTIVE
  This study sought to test the hypothesis that end-systolic volume (ESV), as a marker of severity of left ventricular (LV) remodeling, influences the relationship between myocardial viability and survival in patients with coronary artery disease and LV systolic dysfunction.
  
  
  BACKGROUND
  Retrospective studies of ischemic LV dysfunction suggest that the severity of LV remodeling determines whether myocardial viability predicts improved survival with surgical compared with medical therapy, with coronary artery bypass grafting (CABG) only benefitting patients with viable myocardium who have smaller ESV. However, this has not been tested prospectively.
  
  
  METHODS
  Interactions of end-systolic volume index (ESVI), myocardial viability, and treatment with respect to survival were assessed in patients in the prospective randomized STICH (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease) trial of CABG versus medical therapy who underwent viability assessment (n = 601; age 61 ± 9 years; ejection fraction ≤35%), with a median follow-up of 5.1 years. Median ESVI was 84 ml/m(2). Viability was assessed by single-photon emission computed tomography or dobutamine echocardiography using pre-specified criteria.
  
  
  RESULTS
  Mortality was highest among patients with larger ESVI and nonviability (p < 0.001), but no interaction was observed between ESVI, viability status, and treatment assignment (p = 0.491). Specifically, the effect of CABG versus medical therapy in patients with viable myocardium and ESVI ≤84 ml/m(2) (hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.56 to 1.29) was no different than in patients with viability and ESVI >84 ml/m(2) (HR: 0.87; 95% CI: 0.57 to 1.31). Other ESVI thresholds yielded similar results, including ESVI ≤60 ml/m(2) (HR: 0.87; 95% CI: 0.44 to 1.74). ESVI and viability assessed as continuous rather than dichotomous variables yielded similar results (p = 0.562).
  
  
  CONCLUSIONS
  Among patients with ischemic cardiomyopathy, those with greater LV ESVI and no substantial viability had worse prognosis. However, the effect of CABG relative to medical therapy was not differentially influenced by the combination of these 2 factors. Lower ESVI did not identify patients in whom myocardial viability predicted better outcome with CABG relative to medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address: r-bonow@northwestern.edu.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Bonow
authors.affiliation: IRCCS Policlinico San Donato, Milan, Italy.
authors.forename: Serenella
authors.initials: S
authors.lastname: Castelvecchio
authors.affiliation: Westchester Medical Center, Valhalla, New York.
authors.forename: Julio A
authors.initials: JA
authors.lastname: Panza
authors.affiliation: Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Duke University, Durham, North Carolina.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.affiliation: Montefiore Medical Center, New York, New York.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Michler
authors.affiliation: Duke University, Durham, North Carolina.
authors.forename: Lilin
authors.initials: L
authors.lastname: She
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Holly
authors.affiliation: National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Patrice
authors.initials: P
authors.lastname: Desvigne-Nickens
authors.affiliation: Dedinje Cardiovascular Institute, Belgrade, Serbia.
authors.forename: Dragana
authors.initials: D
authors.lastname: Kosevic
authors.affiliation: Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
authors.forename: Miroslaw
authors.initials: M
authors.lastname: Rajda
authors.affiliation: Medical University of Lodz, Lodz, Poland.
authors.forename: Lukasz
authors.initials: L
authors.lastname: Chrzanowski
authors.affiliation: Medical University of Silesia, Katowice, Poland.
authors.forename: Marek
authors.initials: M
authors.lastname: Deja
authors.affiliation: Duke University, Durham, North Carolina.
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Lee
authors.affiliation: Auckland City Hospital, Auckland, New Zealand.
authors.forename: Harvey
authors.initials: H
authors.lastname: White
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: Jae K
authors.initials: JK
authors.lastname: Oh
authors.affiliation: University of Jena, Jena, Germany.
authors.forename: Torsten
authors.initials: T
authors.lastname: Doenst
authors.affiliation: University of Florida, Gainesville, Florida.
authors.forename: James A
authors.initials: JA
authors.lastname: Hill
authors.affiliation: Université de Montréal, Montréal, Québec, Canada.
authors.forename: Jean L
authors.initials: JL
authors.lastname: Rouleau
authors.affiliation: IRCCS Policlinico San Donato, Milan, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Menicanti
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D025401:Echocardiography, Stress; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D020127:Recovery of Function; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D014022:Tissue Survival; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome; D014481:United States; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling
keywords: coronary artery bypass surgery; coronary artery disease; heart failure; myocardial viability