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

Sawada, Stephen; Bapat, Ashutosh; Vaz, Dev; Weksler, Juan; Fineberg, Naomi S.; Greene, Adam; Gradus‐Pizlo, Irmina; Feigenbaum, Harvey

doi:10.1016/j.jacc.2003.07.026

Cited by 57 publications

(8 citation statements)

References 27 publications

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“…Because the prognosis of patients with subendocardial infarction is better than that with transmural infarction, assessment of the transmurality of myocardial necrosis and ischemia is an important clinical issue for patients with acute myocardial infarction or with chronic myocardial ischemia (22,27). However, it has been difficult to make a diagnosis of subendocardial infarction by two-dimensional echocardiography.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of transmural distribution of viable muscle by myocardial strain profile and dobutamine stress echocardiography

Maruo

Nakatani²,

Jin³

et al. 2007

American Journal of Physiology-Heart and Circulatory Physiology

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bution of viable myocardium in the ischemic myocardium has not been quantified and fully elucidated. To address this issue, we evaluated transmural myocardial strain profile (TMSP) in dogs with myocardial infarction using a newly developed tissue strain imaging. TMSP was obtained from the posterior wall at the epicardial left ventricular short-axis view in 13 anesthetized open-chest dogs. After control measurements, the left circumflex coronary artery was occluded for 90 min to induce subendocardial infarction (SMI). Subsequently, latex microbeads (90 m) were injected in the same artery to create transmural infarction (TMI). In each stage, measurements were done before and after dobutamine challenge (10 g ⅐ kg Ϫ1 ⅐ min Ϫ1 for 10 min) to estimate transmural myocardial viability. Strain in the subendocardium in the control stage increased by dobutamine (from 53.6 Ϯ 17.1 to 73.3 Ϯ 21.8%, P Ͻ 0.001), whereas that in SMI and TMI stages was almost zero at baseline and did not increase significantly by dobutamine [from 0.8 Ϯ 8.8 to 1.3 Ϯ 7.0%, P ϭ not significant (NS) for SMI, from Ϫ3.9 Ϯ 5.6 to Ϫ1.9 Ϯ 6.0%, P ϭ NS for TMI]. Strain in the subepicardium increased by dobutamine in the control stage (from 23.9 Ϯ 6.1 to 26.3 Ϯ 6.4%, P Ͻ 0.05) and in the SMI stage (from 12.4 Ϯ 7.3 to 27.1 Ϯ 8.8%, P Ͻ 0.005), whereas that in the TMI stage did not change (from Ϫ1.0 Ϯ 7.8 to Ϫ0.7 Ϯ 8.3%, P ϭ NS). In SMI, the subendocardial contraction was lost, but the subepicardium showed a significant increase in contraction with dobutamine. However, in TMI, even the subepicardial increase was not seen. Assessment of transmural strain profile using tissue strain imaging was a new and useful method to estimate transmural distribution of the viable myocardium in myocardial infarction. myocardial infarction; strain; viability; echocardiography IT IS WELL KNOWN that myocardial contraction has transmural heterogeneity. Several experimental studies confirmed that the subendocardium contributes greater to overall myocardial thickening than the subepicardium (6, 25). On the other hand, when a reduction of coronary blood flow occurs, a severe reduction of perfusion and kinesis occurs in the subendocardium, but only a trivial reduction can be detected in the subepicardium (5, 31). After a long period of ischemia, myocardial necrosis progresses from the endocardium to the epicardium (8, 13).Myocardial strain reflects regional myocardial function. With the recent advancement of tissue Doppler echocardiography, myocardial strain can be obtained noninvasively (3, 33) and has been reported to be useful to quantify regional myocardial systolic function in ischemic heart disease (9, 11, 24, 29, 36). The recently developed myocardial strain imaging system provides us myocardial strain in each wall layer and shows its distribution in a form of transmural myocardial strain profile (TMSP; see Ref. 1). Thus combination of TMSP and dobutamine stress echocardiography (DSE), which has been used for the assessment of myocardial viability (18), is expected to demonstr...

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Section: Discussionmentioning

confidence: 99%

Evaluation of transmural distribution of viable muscle by myocardial strain profile and dobutamine stress echocardiography

Maruo

Nakatani²,

Jin³

et al. 2007

American Journal of Physiology-Heart and Circulatory Physiology

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“…4 The most important factor for successful surgical recovery may be the viability of revascularized myocardium. [11][12][13][14] Therefore, preoperative investigations should include transthoracic echocardiography to grossly evaluate ventricular function, and nuclear studies or dobutamine stress echocardiography to identify the reversibility of myocardial ischemia. In addition, coronary angiography is needed to define the affected territory.…”

Section: Discussionmentioning

confidence: 99%

Clinical Results of Coronary Revascularization in Left Ventricular Dysfunction

Lee

Chang

Yoo

et al. 2007

Circ J

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DefinitionsThe number of diseased vessels was defined as the number of the 3 major coronary perfusion territories affected. Perioperative insertion of an intra-aortic balloon pump (IABP) was defined as a procedure for improving hemodynamics in the presence of cardiogenic shock. Postoperative cerebrovascular accident (CVA) was defined as a focal or global neurological deficit confirmed by a neurologist.

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“…They reported that the presence of myocardial viability was associated with a favourable outcome after revascularisation, whereas ischaemia was not predictive of prognosis. 27 In particular, WMSI during low dose dobutamine (a measure of myocardial viability) was predictive of outcome after revascularisation, whereas WMSI during high dose dobutamine (a measure of ischaemia) was not predictive. 27 …”

Section: Previous Studiesmentioning

confidence: 92%

“…Data on the relative prognostic value of viability and ischaemia in patients undergoing revascularisation are scant. [24][25][26][27] Pasquet et al 24 showed that the presence of viability (indicated by CR during low dose DSE), but not ischaemia, was a strong predictor of good outcome after revascularisation. Similarly, Sicari et al 25 26 showed that the greater the extent of viability, the lower the likelihood of cardiac death.…”

Section: Previous Studiesmentioning

confidence: 99%

Long term prognostic value of myocardial viability and ischaemia during dobutamine stress echocardiography in patients with ischaemic cardiomyopathy undergoing coronary revascularisation

Rizzello

Poldermans

Schinkel

et al. 2006

Heart

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Objective: To evaluate the relative merits of viability and ischaemia for prognosis after revascularisation. Methods: Low-high dose dobutamine stress echocardiography (DSE) was performed before revascularisation in 128 consecutive patients with ischaemic cardiomyopathy (mean (SD) left ventricular ejection fraction (LVEF) 31 (8)%). Viability (defined as contractile reserve (CR)) and ischaemia were assessed during low and high dose dobutamine infusion, respectively. Cardiac death was evaluated during a five year follow up. Clinical, angiographic, and echocardiographic data were analysed to identify predictors of events. Results: Univariable predictors of cardiac death were the presence of multivessel disease (hazard ratio (HR) 0.21, p , 0.001), baseline LVEF (HR 0.90, p , 0.0001), wall motion score index (WMSI) at rest (HR 4.02, p = 0.0006), low dose DSE (HR 7.01, p , 0.0001), peak dose DSE (HR 4.62, p , 0.0001), the extent of scar (HR 1.39, p , 0.0001), and the presence of CR in > 25% of dysfunctional segments (HR 0.34, p = 0.02). The best multivariable model to predict cardiac death included the presence of multivessel disease, WMSI at low dose DSE, and the presence of CR in > 25% of the severely dysfunctional segments (HR 9.62, p , 0.0001). Inclusion of ischaemia in the model did not provide additional predictive value. Conclusion: The findings of the present study illustrate that in patients with ischaemic cardiomyopathy, the extent of viability (CR) is a strong predictor of long term prognosis after revascularisation. Ischaemia did not add significantly in predicting outcome. P atients with chronic coronary artery disease and left ventricular (LV) dysfunction who undergo revascularisation are a high risk population. The prognosis is strongly related to the severity of LV dysfunction with a higher annual mortality among patients with impaired LV function.

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

Abstract: 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.

Cited by 57 publications

References 27 publications

Evaluation of transmural distribution of viable muscle by myocardial strain profile and dobutamine stress echocardiography

Evaluation of transmural distribution of viable muscle by myocardial strain profile and dobutamine stress echocardiography

Clinical Results of Coronary Revascularization in Left Ventricular Dysfunction

Long term prognostic value of myocardial viability and ischaemia during dobutamine stress echocardiography in patients with ischaemic cardiomyopathy undergoing coronary revascularisation

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