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Stiegel L, Visperas A, Piuzzi NS, Klika A. Exploring Differences in Screening and Enrollment Metrics in Orthopaedic Clinical Trials. J Knee Surg 2024; 37:492-497. [PMID: 37734404 DOI: 10.1055/a-2179-8281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
The success of any clinical trial relies heavily on patient recruitment and retention. The purpose of this study was to review screening and enrollment metrics for orthopaedic clinical trials, comparing different patient populations to determine common challenges to recruitment and differences in rates of enrollment. Screening logs and study trackers were manually reviewed for four clinical trials at a single academic institution and included randomized controlled trials (RCTs) and an observational study. Data extracted from these documents included the number of patients screened, number excluded and reasons for exclusion, number enrolled, number of withdrawn and reason. Of the four trials reviewed, the point-of-care diagnostic test had the highest number of patients excluded and the lowest patient refusal rate. Refusal rates were highest in the venous thromboembolism prophylaxis study and enrollment rates were the lowest in the RCT of drug treatments and the highest rate in the observational study. The success of the trial relies on the ability to recruit patients and factors need to be considered when recruiting participants including sample size requirements and inclusion and exclusion criteria. These data provide some insights into the patient recruitment experience at our institution with different patient populations and study types, highlighting key points to be aware of when planning for an orthopaedic clinical trial.
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Affiliation(s)
- Laura Stiegel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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2
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Gaudino M, Castelvecchio S, Rahouma M, Robinson NB, Audisio K, Soletti GJ, Cancelli G, Tam DY, Garatti A, Benedetto U, Doenst T, Girardi LN, Michler RE, Fremes SE, Velazquez EJ, Menicanti L. Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial. J Thorac Cardiovasc Surg 2024; 167:713-722.e7. [PMID: 35599207 DOI: 10.1016/j.jtcvs.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/28/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data. METHODS Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality. RESULTS The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001). CONCLUSIONS Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Derrick Y Tam
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Garatti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric J Velazquez
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Lorenzo Menicanti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Fu G, Zhou Z, Jian B, Huang S, Feng Z, Liang M, Liu Q, Huang Y, Liu K, Chen G, Wu Z. Systolic blood pressure time in target range and long-term outcomes in patients with ischemic cardiomyopathy. Am Heart J 2023; 258:177-185. [PMID: 36925271 DOI: 10.1016/j.ahj.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/13/2022] [Accepted: 12/25/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND The relationship between the degree of systolic blood pressure (SBP) control and outcomes remains unclear in patients with ischemic cardiomyopathy (ICM). Current control metrics may not take into account the potential effects of SBP fluctuations over time on patients. METHODS This study was a post-hoc analysis of the surgical treatment of ischemic heart failure trial which enrolled 2,136 participants with ICM. Our SBP target range was defined as 110 to 130 mm Hg and the time in target range (TTR) was calculated by linear interpolation. RESULTS A total of 1,194 patients were included. Compared with the quartile 4 group (TTR 77.87%-100%), the adjusted hazard ratios and 95% confidence intervals of all-cause mortality were 1.32 (0.98-1.78) for quartile 3 group (TTR 54.81%-77.63%), 1.40 (1.03-1.90) for quartile 2 group (TTR 32.59%-54.67%), and 1.53 (1.14-2.04) for quartile 1 group (TTR 0%-32.56%). Per 29.28% (1-SD) decrement in TTR significantly increased the risk of all-cause mortality (1.15 [1.04-1.26]). Similar results were observed in the cardiovascular (CV) mortality and the composite outcome of all-cause mortality plus CV rehospitalization, and in the subgroup analyses of either coronary artery bypass grafting or medical therapy, and different baseline SBP. CONCLUSIONS In patients with ICM, the higher TTR was significantly associated with decreased risk of all-cause mortality, CV mortality and the composite outcome of all-cause mortality plus CV rehospitalization, regardless of whether the patient received coronary artery bypass grafting or medical therapy, and the level of baseline SBP. TTR may be a surrogate metric of long-term SBP control in patients with ICM.
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Affiliation(s)
- Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bohao Jian
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zicong Feng
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Quan Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Kaizheng Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guangxian Chen
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Perioperative changes in left ventricular systolic function following surgical revascularization. PLoS One 2022; 17:e0277454. [PMID: 36355812 PMCID: PMC9648779 DOI: 10.1371/journal.pone.0277454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Nearly 1/3rd of patients undergoing coronary artery bypass graft surgery (CABG) have left ventricular systolic dysfunction. However, the extent, direction and implications of perioperative changes in left ventricular ejection fraction (LVEF) have not been well characterized in these patients. Methods We studied the changes in LVEF among 549 patients with left ventricular systolic dysfunction (LVEF <50%) who underwent CABG as part of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Patients had pre- and post-CABG (4 month) LVEF assessments using identical cardiac imaging modality, interpreted at a core laboratory. An absolute change of >10% in LVEF was considered clinically significant. Results Of the 549 patients (mean age 61.4±9.55 years, and 72 [13.1%] women), 145 (26.4%) had a >10% improvement in LVEF, 369 (67.2%) had no change and 35 (6.4%) had >10% worsening of LVEF following CABG. Patients with lower preoperative LVEF were more likely to experience an improvement after CABG (odds ratio 1.36; 95% CI 1.21–1.53; per 5% lower preoperative LVEF; p <0.001). Notably, incidence of postoperative improvement in LVEF was not influenced by presence, nor absence, of myocardial viability (25.5% vs. 28.3% respectively, p = 0.67). After adjusting for age, sex, baseline LVEF, and NYHA Class, a >10% improvement in LVEF after CABG was associated with a 57% lower risk of all-cause mortality (HR: 0.43, 95% CI: 0.26–0.71). Conclusions Among patients with ischemic cardiomyopathy undergoing CABG, 26.4% had >10% improvement in LVEF. An improvement in LVEF was more likely in patients with lower preoperative LVEF and was associated with improved long-term survival.
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Gaudino M, Castelvecchio S, Rahouma M, Robinson NB, Audisio K, Soletti GJ, Garatti A, Benedetto U, Girardi LN, Menicanti L. Results of surgical ventricular reconstruction in a specialized center and in comparison to the STICH trial: Rationale and study protocol for a patient-level pooled analysis. J Card Surg 2021; 36:689-692. [PMID: 33438823 DOI: 10.1111/jocs.15315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Post-infarction left ventricular remodeling is associated with increased mortality in patients with ischemic heart disease. Surgical ventricular reconstruction (SVR) in addition to coronary artery bypass grafting (CABG) has been proposed to reduce left ventricular volume and improve clinical outcomes. The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that the addition of SVR to CABG did not reduce the rates of death or rehospitalization in the 5 years after surgery compared to CABG alone. Like all randomized trials, STICH has limitations and it has been hypothesized that it may have underestimated the treatment effect of SVR. The aim of this study is to evaluate the results of SVR in one of the largest contemporary single-center series and to compare the results with those of the STICH trial using individual patient's data. METHODS AND ANALYSIS Individual data of patients who underwent SVR with or without CABG will be obtained from San Donato University Hospital in Milan. Using multivariable Cox regression analysis, significant prognostic indicators in this cohort will be identified. We will then compare the San Donato cohort to individual patient's data from the SVR arm of Hypothesis 2 of the STICH trial and from both arms of the STICH Extended Study (STICHES). To reduce confounders, propensity score adjustment will be used for this comparison. The primary endpoint will be all-cause mortality. Data will be merged and analyzed independently at Weill Cornell Medicine in New York.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Andrea Garatti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lorenzo Menicanti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Hamilton NN, Tedde ML, Wolosker N, Aguiar WWS, Ferreira HPDC, Oliveira HAD, Lima AMR, Westphal FL, Oliveira MVBD, Riuto FDO, Pereira STLF, Rezende GC, Valero CEB, Pego-Fernandes PM. A prospective controlled randomized multicenter study to evaluate the severity of compensatory sweating after one-stage bilateral thoracic sympathectomy versus unilateral thoracic sympathectomy in the dominant side. Contemp Clin Trials Commun 2020; 19:100618. [PMID: 32715152 PMCID: PMC7369506 DOI: 10.1016/j.conctc.2020.100618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/27/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the contribution that unilateral thoracic sympathectomy in dominant side or two-stage bilateral thoracic sympathectomy can have as strategies to reduce the incidence of compensatory sweating after sympathectomy for palmar hyperhidrosis. METHODS This is a prospective, controlled, randomized multicenter trial of 200 participants with palmar hyperhidrosis, which will be randomized into two arms: (a) one-stage bilateral thoracic sympathectomy (control arm); or (b) unilateral thoracic sympathectomy in dominant side (intervention arm). At six months the participants submitted to unilateral procedure can make the contralateral surgery if they wanted it, creating a third group called two-stage bilateral sympathectomy. Participants will be evaluated for the degree of sweating by the Hyperhidrosis Disease Severity Scale (HDSS) and of quality of life questionnaires. RESULTS 96 participants out of the 200 proposed have been included so far, with 48 participants randomized to each arm. From the sample 61 (63.5%) are female, with a mean age of 24 (20-32) years. There were exclusive palmar hiperhydrosis in 14 cases (14.5%), palmar and plantar hyperhidrosis in 36 (37.5%) cases, palmar and axillar hyperhidrosis in 12 (12,5%) cases and palmar-axillary-plantar hyperhidrosis in 34 (35,4%) cases. The age at the beginning of the disease was childhood (78%), with mean of time of disease 15 (11-22) years. CONCLUSIONS If one or both hypothesis: (a) unilateral sympathectomy in dominant hand is a satisfactory treatment; b) two-stage bilateral sympathectomy causes less compensatory sweating than in one stage are confirmed there is a chance that surgical therapy for palmar hyperhidrosis can be changed for better.
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Affiliation(s)
- Niura Noro Hamilton
- Heart Institute (InCor) Hospital das Clinicas, University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-900, Sao Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815, 01327-001, São Paulo, SP, Brazil
| | - Miguel Lia Tedde
- Heart Institute (InCor) Hospital das Clinicas, University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-900, Sao Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815, 01327-001, São Paulo, SP, Brazil
| | - Nelson Wolosker
- Hospital das Clinicas, University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 255, 05403-000, São Paulo, SP, Brazil
| | | | | | | | | | - Fernando Luiz Westphal
- Hospital da Universidade Federal do Amazonas, Av. Gen. Rodrigo Octávio, 6200, 69080-900, Manaus, AM, Brazil
| | - Marina Varela Braga de Oliveira
- Hospital das Clinicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, 30130-100, Belo Horizonte, MG, Brazil
| | - Fabio de Oliveira Riuto
- Hospital da Universidade Federal da Grande Dourados, R. Ivo Alves da Rocha, 558, 79823-501, Dourados, MS, Brazil
| | | | - Guilherme Cançado Rezende
- Hospital Universitário de Brasília, Setor de Grandes Áreas Norte, 605, 70840-040, Brasília, DF, Brazil
| | | | - Paulo M. Pego-Fernandes
- Heart Institute (InCor) Hospital das Clinicas, University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-900, Sao Paulo, SP, Brazil
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Kim KH, She L, Lee KL, Dabrowski R, Grayburn PA, Rajda M, Prior DL, Desvigne-Nickens P, Zoghbi WA, Senni M, Stefanelli G, Beghi C, Huynh T, Velazquez EJ, Oh JK, Lin G. Incremental prognostic value of echocardiography of left ventricular remodeling and diastolic function in STICH trial. Cardiovasc Ultrasound 2020; 18:17. [PMID: 32466790 PMCID: PMC7257201 DOI: 10.1186/s12947-020-00195-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/27/2020] [Indexed: 11/10/2022] Open
Abstract
Aims We sought to determine which echocardiographic markers of left ventricular (LV) remodeling and diastolic dysfunction can contribute as incremental and independent prognostic information in addition to current clinical risk markers of ischemic LV systolic dysfunction in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Methods and results The cohort consisted of 1511 of 2136 patients in STICH for whom baseline transmitral Doppler (E/A ratio) could be measured by an echocardiographic core laboratory blinded to treatment and outcomes, and prognostic value of echocardiographic variables was determined by a Cox regression model. E/A ratio was the most significant predictor of mortality amongst diastolic variables with lowest mortality for E/A closest 0.8, although mortality was consistently low for E/A 0.6 to 1.0. Mortality increased for E/A < 0.6 and > 1.0 up to approximately 2.3, beyond which there was no further increase in risk. Larger LV end-systolic volume index (LVESVI) and E/A < 0.6 and > 1.0 had incremental negative effects on mortality when added to a clinical multivariable model, where creatinine, LVESVI, age, and E/A ratio accounted for 74% of the prognostic information for predicting risk. LVESVI and E/A ratio were stronger predictors of prognosis than New York Heart Association functional class, anemia, diabetes, history of atrial fibrillation, and stroke. Conclusions Echocardiographic markers of advanced LV remodeling and diastolic dysfunction added incremental prognostic value to current clinical risk markers. LVESVI and E/A ratio outperformed other markers and should be considered as standard in assessing risks in ischemic heart failure. E/A closest to 0.8 was the most optimal filling pattern.
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Affiliation(s)
- Kyung-Hee Kim
- Division of Cardiovascular Diseases, Sejong General Hospital, Bucheon, South Korea.,Division of Cardiovascular Diseases, Echocardiography Core Laboratory, Mayo Clinic, Gonda 6 South, 200 First St SW, Rochester, MN, USA
| | - Lilin She
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | | | - Miroslaw Rajda
- Capital Health Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | | | | | - William A Zoghbi
- Cardiovascular Imaging Institute, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | | | | | - Cesare Beghi
- Ospedale di Circolo, University of Insubria, Varese, Italy
| | - Thao Huynh
- Montreal General Hospital, McGill Health University Center, Montreal, Canada
| | | | - Jae K Oh
- Division of Cardiovascular Diseases, Echocardiography Core Laboratory, Mayo Clinic, Gonda 6 South, 200 First St SW, Rochester, MN, USA
| | - Grace Lin
- Division of Cardiovascular Diseases, Echocardiography Core Laboratory, Mayo Clinic, Gonda 6 South, 200 First St SW, Rochester, MN, USA.
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Andersson B, She L, Tan RS, Jeemon P, Mokrzycki K, Siepe M, Romanov A, Favaloro LE, Djokovic LT, Raju PK, Betlejewski P, Racine N, Ostrzycki A, Nawarawong W, Das S, Rouleau JL, Sopko G, Lee KL, Velazquez EJ, Panza JA. The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial. Eur Heart J 2019; 39:3464-3471. [PMID: 30113633 DOI: 10.1093/eurheartj/ehy438] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/06/2018] [Indexed: 12/11/2022] Open
Abstract
Aims Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Bert Andersson
- Department of Cardiology, Blå Stråket 3, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lilin She
- Duke Clinical Research Institute, 2400 Pratt Street Durham, NC, USA
| | - Ru-San Tan
- National Heart Centre, 5 Hospital Drive, Singapore
| | - Panniyammakal Jeemon
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India, and Centre for Chronic Disease Control, New Delhi, India
| | - Krzysztof Mokrzycki
- Department of Cardiac Surgery, SPSK-2, Pomeranian Medical University, Powstanców Wielkopolskich 72, Szczecin, Poland
| | - Matthias Siepe
- Klinik für Herz- und Gefässchirurgie, Universitäts Herzzentrum Freiburg Bad Krozingen, Südring 15, Bad Krozingen, Germany
| | - Alexander Romanov
- Arrhythmia Department and Electrophysiology Laboratory, State Research Institute of Circulation Pathology, Rechkunovskaya 15, Novosibirsk, Russia
| | - Liliana E Favaloro
- Hospital Universitario Fundación Favaloro, Av. Belgrano 1782 (C1093AAS), Ciudad Autónoma de Buenos Aires, Argentina
| | - Ljubomir T Djokovic
- Dedinje Cardiovascular Institute, Heroja Milana Tepica br. 1, Belgrade, Serbia
| | - P Krishnam Raju
- Care Hospitals, Care op center, Road Number 10, Zahara Nagar, Banjara Hills, Hyderabad, Telangana, India
| | - Piotr Betlejewski
- Klinika Kardiochirurgii, Instytut Kardiologii, Wilenska 44, Gdansk, Poland
| | - Normand Racine
- Université de Montréal, Montréal Heart Institute, 5000 Belanger est, Montreal, Québec, Canada
| | - Adam Ostrzycki
- National Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Weerachai Nawarawong
- Department of Surgery, Chiang Mai University, Su Thep, Mueang Chiang Mai District, Chiang Mai, Thailand
| | - Siuli Das
- Centre for Chronic Disease Conrol, C1/52 2nd Floor, Safdarjung Development Area, New Delhi, India
| | - Jean L Rouleau
- Université de Montréal, Montréal Heart Institute, 5000 Belanger est, Montreal, Québec, Canada
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, 6701 Rockledge Dr, Bethesda, MD, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, 2400 Pratt Street Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Velazquez
- Duke Clinical Research Institute, 2400 Pratt Street Durham, NC, USA.,Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Julio A Panza
- Cardiology, Westchester Medical Center and WMC Health Network, New York Medical College, 100 Woods Road, Macy Pavilion, Room 100 Valhalla, NY, USA
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Bouabdallaoui N, Stevens SR, Doenst T, Petrie MC, Al-Attar N, Ali IS, Ambrosy AP, Barton AK, Cartier R, Cherniavsky A, Demondion P, Desvigne-Nickens P, Favaloro RR, Gradinac S, Heinisch P, Jain A, Jasinski M, Jouan J, Kalil RAK, Menicanti L, Michler RE, Rao V, Smith PK, Zembala M, Velazquez EJ, Al-Khalidi HR, Rouleau JL. Society of Thoracic Surgeons Risk Score and EuroSCORE-2 Appropriately Assess 30-Day Postoperative Mortality in the STICH Trial and a Contemporary Cohort of Patients With Left Ventricular Dysfunction Undergoing Surgical Revascularization. Circ Heart Fail 2019; 11:e005531. [PMID: 30571194 DOI: 10.1161/circheartfailure.118.005531] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The STICH trial (Surgical Treatment for Ischemic Heart Failure) demonstrated a survival benefit of coronary artery bypass grafting in patients with ischemic cardiomyopathy and left ventricular dysfunction. The Society of Thoracic Surgeons (STS) risk score and the EuroSCORE-2 (ES2) are used for risk assessment in cardiac surgery, with little information available about their accuracy in patients with left ventricular dysfunction. We assessed the ability of the STS score and ES2 to evaluate 30-day postoperative mortality risk in STICH and a contemporary cohort (CC) of patients with a left ventricle ejection fraction ≤35% undergoing coronary artery bypass grafting outside of a trial setting. METHODS AND RESULTS The STS and ES2 scores were calculated for 814 STICH patients and 1246 consecutive patients in a CC. There were marked variations in 30-day postoperative mortality risk from 1 patient to another. The STS scores consistently calculated lower risk scores than ES2 (1.5 versus 2.9 for the CC and 0.9 versus 2.4 for the STICH cohort), and underestimated postoperative mortality risk. The STS and ES2 scores had moderately good C statistics: CC (0.727, 95% CI: 0.650-0.803 for STS, and 0.707, 95% CI: 0.620-0.795 for ES2); STICH (0.744, 95% CI: 0.677-0.812, for STS and 0.736, 95% CI: 0.665-0.808 for ES2). Despite the CC patients having higher STS and ES2 scores than STICH patients, mortality (3.5%) was lower than that of STICH (4.8%), suggesting a possible decrease in postoperative mortality over the past decade. CONCLUSIONS The 30-day postoperative mortality risk of coronary artery bypass grafting in patients with left ventricular dysfunction varies markedly. Both the STS and ES2 score are effective in evaluating risk, although the STS score tend to underestimate risk. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Nadia Bouabdallaoui
- Departments of Medicine, ontreal Heart Institute, University of Montreal, Canada (N.B., J.L.R.)
| | - Susanna R Stevens
- M. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.R.S.)
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Germany (T.D., P.H.)
| | - Mark C Petrie
- Department of Cardiology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (M.C.P.)
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P., N.A.-A, A.K.B.)
| | - Nawwar Al-Attar
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P., N.A.-A, A.K.B.)
| | - Imtiaz S Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin CV Institute, University of Calgary, Canada (I.S.A.)
| | - Andrew P Ambrosy
- Department of Medicine, Duke University School of Medicine, Durham, NC. (A.P.A., E.J.V.)
| | - Anna K Barton
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P., N.A.-A, A.K.B.)
| | - Raymond Cartier
- Cardiac Surgery, ontreal Heart Institute, University of Montreal, Canada (R.C.)
| | | | - Pierre Demondion
- Department of Cardiac Surgery, La Pitié Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, France (P.D.)
| | | | - Robert R Favaloro
- Department of Cardiac Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina (R.R.F.)
| | - Sinisa Gradinac
- Dedinje Cardiovascular Institute, University of Belgrade School of Medicine, Serbia (S.G.)
| | - Petra Heinisch
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Germany (T.D., P.H.)
| | - Anil Jain
- Department of Cardiac Surgery, SAL Hospital and Medical Institute, Ahmedabad, India (A.J.)
| | - Marek Jasinski
- Department of Cardiac Surgery, Wroclaw Medical University, Poland (M.J.)
| | - Jerome Jouan
- Department of Cardiovascular Surgery, Georges Pompidou European Hospital and University Paris-Descartes, Sorbonne Paris-Cité, France (J.J.)
| | - Renato A K Kalil
- Postgraduate Program, Instituto de Cardiologia/FUC and UFCSPA, Porto Alegre, Brazil (R.A.K.K.)
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy (L.M.)
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY (R.E.M.)
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Institute, University Health Network, University of Toronto, Canada (V.R.)
| | - Peter K Smith
- Department of Surgery, Duke University School of Medicine, Durham, NC. (P.K.S.)
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Poland Medical University of Silesia in Katowice, Poland (M.Z.)
| | - Eric J Velazquez
- Department of Medicine, Duke University School of Medicine, Durham, NC. (A.P.A., E.J.V.)
| | - Hussein R Al-Khalidi
- Departments of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC. (H.R.A.-K.)
| | - Jean L Rouleau
- Departments of Medicine, ontreal Heart Institute, University of Montreal, Canada (N.B., J.L.R.)
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Fogel DB. Factors associated with clinical trials that fail and opportunities for improving the likelihood of success: A review. Contemp Clin Trials Commun 2018; 11:156-164. [PMID: 30112460 PMCID: PMC6092479 DOI: 10.1016/j.conctc.2018.08.001] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/19/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
Clinical trials are time consuming, expensive, and often burdensome on patients. Clinical trials can fail for many reasons. This survey reviews many of these reasons and offers insights on opportunities for improving the likelihood of creating and executing successful clinical trials. Literature from the past 30 years was reviewed for relevant data. Common patterns in reported successful trials are identified, including factors regarding the study site, study coordinator/investigator, and the effects on participating patients. Specific instances where artificial intelligence can help improve clinical trials are identified.
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11
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Ramakrishna H, Gutsche JT, Patel PA, Evans AS, Weiner M, Morozowich ST, Gordon EK, Riha H, Bracker J, Ghadimi K, Murphy S, Spitz W, MacKay E, Cios TJ, Malhotra AK, Baron E, Shaefi S, Fassl J, Weiss SJ, Silvay G, Augoustides JGT. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2016. J Cardiothorac Vasc Anesth 2016; 31:1-13. [PMID: 28041810 DOI: 10.1053/j.jvca.2016.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/11/2022]
Affiliation(s)
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam S Evans
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, FL
| | - Menachem Weiner
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | | | - Emily K Gordon
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hynek Riha
- Cardiothoracic Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Joseph Bracker
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - Sunberri Murphy
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Warren Spitz
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Elvera Baron
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - Shahzad Shaefi
- Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Harvard Medical School, Boston, MA
| | - Jens Fassl
- Cardiovascular and Thoracic Section, Department of Anesthesia and Intensive Care Medicine, University of Basel, Basel, Switzerland
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Silvay
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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12
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Greene SJ, Hernandez AF, Sun JL, Metra M, Butler J, Ambrosy AP, Ezekowitz JA, Starling RC, Teerlink JR, Schulte PJ, Voors AA, Armstrong PW, O’Connor CM, Mentz RJ. Influence of Clinical Trial Site Enrollment on Patient Characteristics, Protocol Completion, and End Points. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.116.002986. [DOI: 10.1161/circheartfailure.116.002986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 08/08/2016] [Indexed: 12/12/2022]
Abstract
Background—
Most international acute heart failure trials have failed to show benefit with respect to key end points. The impact of site enrollment and protocol execution on trial performance is unclear.
Methods and Results—
We assessed the impact of varying site enrollment volume among all 7141 acute heart failure patients from the ASCEND-HF trial (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure). Overall, 398 sites enrolled ≥1 patient, and median enrollment was 12 patients (interquartile range, 5–23). Patients from high enrolling sites (>60 patients/site) tended to have lower ejection fraction, worse New York Heart Association functional class, and lower utilization of guideline-directed medical therapy but fewer comorbidities and lower B-type natriuretic peptide level. Every 10 patient increase (up to 100 patients) in site enrollment correlated with lower likelihood of protocol noncompletion (odds ratio, 0.93; 95% confidence interval [CI], 0.89–0.98). After adjustment, increasing site enrollment predicted higher risk of persistent dyspnea at 6 hours (per 10 patient increase: odds ratio 1.02; 95% CI, 1.01–1.03) but not at 24 hours (odds ratio, 0.99; 95% CI, 0.98–1.00). Higher site enrollment was independently associated with lower risk of 30-day death or rehospitalization (per 10 patient increase: odds ratio, 0.98, 95% CI, 0.96–0.99) but not 180-day mortality (hazard ratio, 0.99; 95% CI, 0.98–1.01). The influence of increasing site enrollment on clinical end points varied across geographic regions with strongest associations in Latin America and Asia-Pacific (all interaction
P
<0.01).
Conclusions—
In this large, acute heart failure trial, site enrollment correlated with protocol completion and was independently associated with trial end points. Individual and regional site performance present challenges to be considered in design of future acute heart failure trials.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00475852.
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Affiliation(s)
- Stephen J. Greene
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Adrian F. Hernandez
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Jie-Lena Sun
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Marco Metra
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Javed Butler
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Andrew P. Ambrosy
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Justin A. Ezekowitz
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Randall C. Starling
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - John R. Teerlink
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Phillip J. Schulte
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Adriaan A. Voors
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Paul W. Armstrong
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Christopher M. O’Connor
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Robert J. Mentz
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
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Temizturk Z, Azboy D, Atalay A, Atalay H, Dogan OF. The Effects of Levosimendan and Sodium Nitroprusside Combination on Left Ventricular Functions After Surgical Ventricular Reconstruction in Coronary Artery Bypass Grafting Patients. Open Cardiovasc Med J 2016; 10:138-47. [PMID: 27583039 PMCID: PMC4994121 DOI: 10.2174/1874192401610010138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 04/10/2016] [Accepted: 04/15/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of our study was to research the effects of levosimendan (LS) and sodium nitroprusside (SNP) combination on systolic and diastolic ventricular function after coronary artery bypass grafting (CABG) who required endoventricular patch repair (EVPR). PATIENTS AND METHODS We studied 70 patients with ischemic dilated cardiomyopathy. LS and SNP combination was administered in 35 patients (study group, SG). In the remaining patients, normal saline solution was given (placebo group, PG). Levosimendan (10µgr/kg) started 4 h prior to operation and we stopped LS before the initiation of extracorporeal circulation (ECC). During the rewarming period, we started again levosimendan (10µgr/kg) in combination with SNP (0.1-0.2 µgr/kg/min). If mean blood pressure decreased by more than 25% compared with pre-infusion values, for corrected of mean arterial pressure, the volume loading was performed using a 500 ml ringer lactate. Hemodynamic variables, inotrophyc requirement, and laboratory values were recorded. RESULTS Five patients died (7.14%) post-surgery (one from SG and 4 from PG) due to low cardiac out-put syndrome (LOS). At the postoperative period, cardiac output and stroke volume index was higher in SG (mean±sd;29.1±6.3 vs. 18.4±4.9 mL/min(-1)/m(-2) (P<0.0001)). Stroke volume index (SVI) decreased from 29±10mL/m(2) preoperatively to 22±14mL/m(2) in the early postoperative period in group 1. This difference was statistically significant (P=0.002). Cardiac index was higher in SG (320.7±37.5 vs. 283.0±83.9 mL/min(-1)/m-(2) (P=0.009)). The postoperative inotrophyc requirement was less in SG (5.6±2.7 vs. 10.4±2.0 mg/kg, P< 0.008), and postoperative cardiac enzyme levels were less in SG (P< 0.01). Ten patients (28.5%) in SG and 21 patients (60%) in PG required inotrophyc support (P<0.001). We used IABP in eight patients (22.8%) in SG and 17 patients (48.5%) in CG (P=0.0001). CONCLUSION This study showed that LS and SNP combination impressive increase in left ventricular systolic and diastolic functions including LVEF. The use of this combination achieved more less inotrophics and IABP requirement. We therefore suggest preoperative and peroperative levosimendan and SNP combination.
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Affiliation(s)
| | - Davut Azboy
- Elazig Education and Training Hospital, Elazig, Turkey
| | | | - Hakan Atalay
- Private Mersin Middle East Hospital, Mersin, Turkey
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14
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Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, Oh JK, She L, Moore VL, Desvigne-Nickens P, Sopko G, Rouleau JL. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med 2016; 374:1511-20. [PMID: 27040723 PMCID: PMC4938005 DOI: 10.1056/nejmoa1602001] [Citation(s) in RCA: 634] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear. METHODS From July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years. RESULTS A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test). CONCLUSIONS In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595.).
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Affiliation(s)
- Eric J Velazquez
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Kerry L Lee
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert H Jones
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Hussein R Al-Khalidi
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - James A Hill
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Julio A Panza
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert E Michler
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Robert O Bonow
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Torsten Doenst
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Mark C Petrie
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Jae K Oh
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Lilin She
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Vanessa L Moore
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Patrice Desvigne-Nickens
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - George Sopko
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
| | - Jean L Rouleau
- From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.)
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Wrobel K, Stevens SR, Jones RH, Selzman CH, Lamy A, Beaver TM, Djokovic LT, Wang N, Velazquez EJ, Sopko G, Kron IL, DiMaio JM, Michler RE, Lee KL, Yii M, Leng CY, Zembala M, Rouleau JL, Daly RC, Al-Khalidi HR. Influence of Baseline Characteristics, Operative Conduct, and Postoperative Course on 30-Day Outcomes of Coronary Artery Bypass Grafting Among Patients With Left Ventricular Dysfunction: Results From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial. Circulation 2015; 132:720-30. [PMID: 26304663 DOI: 10.1161/circulationaha.114.014932] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with severe left ventricular dysfunction, ischemic heart failure, and coronary artery disease suitable for coronary artery bypass grafting (CABG) are at higher risk for surgical morbidity and mortality. Paradoxically, those patients with the most severe coronary artery disease and ventricular dysfunction who derive the greatest clinical benefit from CABG are also at the greatest operative risk, which makes decision making regarding whether to proceed to surgery difficult in such patients. To better inform such decision making, we analyzed the Surgical Treatment for Ischemic Heart Failure (STICH) CABG population for detailed information on perioperative risk and outcomes. METHODS AND RESULTS In both STICH trials (hypotheses), 2136 patients with a left ventricular ejection fraction of ≤35% and coronary artery disease were allocated to medical therapy, CABG plus medical therapy, or CABG with surgical ventricular reconstruction. Relationships of baseline characteristics and operative conduct with morbidity and mortality at 30 days were evaluated. There were a total of 1460 patients randomized to and receiving surgery, and 346 (≈25%) of these high-risk patients developed a severe complication within 30 days. Worsening renal insufficiency, cardiac arrest with cardiopulmonary resuscitation, and ventricular arrhythmias were the most frequent complications and those most commonly associated with death. Mortality at 30 days was 5.1% and was generally preceded by a serious complication (65 of 74 deaths). Left ventricular size, renal dysfunction, advanced age, and atrial fibrillation/flutter were significant preoperative predictors of mortality within 30 days. Cardiopulmonary bypass time was the only independent surgical variable predictive of 30-day mortality. CONCLUSIONS CABG can be performed with relatively low 30-day mortality in patients with left ventricular dysfunction. Serious postoperative complications occurred in nearly 1 in 4 patients and were associated with mortality. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Krzysztof Wrobel
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Susanna R Stevens
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert H Jones
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Craig H Selzman
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Andre Lamy
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Thomas M Beaver
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Ljubomir T Djokovic
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Nan Wang
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Eric J Velazquez
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - George Sopko
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Irving L Kron
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - J Michael DiMaio
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert E Michler
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Kerry L Lee
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Michael Yii
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Chua Yeow Leng
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Marian Zembala
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Jean L Rouleau
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Richard C Daly
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Hussein R Al-Khalidi
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.).
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16
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Bonow RO, Castelvecchio S, Panza JA, Berman DS, Velazquez EJ, Michler RE, She L, Holly TA, Desvigne-Nickens P, Kosevic D, Rajda M, Chrzanowski L, Deja M, Lee KL, White H, Oh JK, Doenst T, Hill JA, Rouleau JL, Menicanti L. Severity of Remodeling, Myocardial Viability, and Survival in Ischemic LV Dysfunction After Surgical Revascularization. JACC Cardiovasc Imaging 2015; 8:1121-1129. [PMID: 26363840 PMCID: PMC4633018 DOI: 10.1016/j.jcmg.2015.03.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/23/2015] [Accepted: 03/05/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES 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).
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Affiliation(s)
- Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | | | | | | | | | - Lilin She
- Duke University, Durham, North Carolina
| | - Thomas A Holly
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Miroslaw Rajda
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Marek Deja
- Medical University of Silesia, Katowice, Poland
| | | | | | - Jae K Oh
- Mayo Clinic, Rochester, Minnesota
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17
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MacDonald MR, She L, Doenst T, Binkley PF, Rouleau JL, Tan RS, Lee KL, Miller AB, Sopko G, Szalewska D, Waclawiw MA, Dabrowski R, Castelvecchio S, Adlbrecht C, Michler RE, Oh JK, Velazquez EJ, Petrie MC. Clinical characteristics and outcomes of patients with and without diabetes in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Eur J Heart Fail 2015; 17:725-34. [PMID: 26011509 DOI: 10.1002/ejhf.288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/12/2015] [Accepted: 04/07/2015] [Indexed: 11/11/2022] Open
Abstract
AIMS Hypothesis 1 of the Surgical Treatment for Ischemic Heart Failure (STICH) trial enrolled 1212 patients with an LVEF of ≤35% and CAD amenable to coronary artery bypass grafting (CABG). Patients were randomized to CABG and optimal medical therapy (MED) or MED alone. The objective was to assess whether or not patients with diabetes mellitus (DM) enrolled in the STICH trial would have greater benefit from CABG than patients without DM. METHODS AND RESULTS The characteristics and clinical outcomes of patients with and without DM randomized to CABG and MED or MED alone were compared. DM was present in 40%. At baseline, patients with DM had more triple vessel CAD, higher LVEF, and smaller left ventricular volumes. In patients with DM, the primary outcome of all-cause mortality occurred in 39% of patients in the MED group and 39% in the CABG group [hazard ratio (HR) with CABG 0.96, 95% confidence interval (CI) 0.73-1.26]. In patients without DM, the primary outcome occurred in 41% of patients in the MED group and 32% in the CABG group (HR with CABG 0.80, 95% CI 0.63-1.02). While numerically it would appear that the treatment effect of CABG is blunted in patients with DM, there was no significant interaction between DM and treatment group on formal statistical testing. CONCLUSIONS Patients with DM enrolled in the STICH trial had more triple vessel disease, smaller hearts, and higher LVEF than those without DM. CABG did not exert greater benefit in patients with DM.
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Affiliation(s)
| | - Lilin She
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Philip F Binkley
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jean L Rouleau
- Montréal Heart Institute, Université de Montréal, Canada
| | | | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Alan B Miller
- Department of Cardiology, University of Florida, Jacksonville, FL, USA
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dominika Szalewska
- Department of Rehabilitation, Medical University of Gdansk, Gdansk, Poland
| | - Myron A Waclawiw
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Christopher Adlbrecht
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Robert E Michler
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, NY, USA
| | - Jae K Oh
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric J Velazquez
- Department of Medicine-Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Mark C Petrie
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, and University of Glasgow, Glasgow, UK
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18
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Holly TA, Bonow RO, Arnold JMO, Oh JK, Varadarajan P, Pohost GM, Haddad H, Jones RH, Velazquez EJ, Birkenfeld B, Asch FM, Malinowski M, Barretto R, Kalil RAK, Berman DS, Sun JL, Lee KL, Panza JA. Myocardial viability and impact of surgical ventricular reconstruction on outcomes of patients with severe left ventricular dysfunction undergoing coronary artery bypass surgery: results of the Surgical Treatment for Ischemic Heart Failure trial. J Thorac Cardiovasc Surg 2014; 148:2677-84.e1. [PMID: 25152476 DOI: 10.1016/j.jtcvs.2014.06.090] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/19/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone. METHODS Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria. RESULTS At 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality. CONCLUSIONS In patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.
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19
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Exercise capacity and mortality in patients with ischemic left ventricular dysfunction randomized to coronary artery bypass graft surgery or medical therapy: an analysis from the STICH trial (Surgical Treatment for Ischemic Heart Failure). JACC-HEART FAILURE 2014; 2:335-43. [PMID: 25023813 DOI: 10.1016/j.jchf.2014.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 02/09/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The objective of this study was to assess the prognostic significance of exercise capacity in patients with ischemic left ventricular (LV) dysfunction eligible for coronary artery bypass graft surgery (CABG). BACKGROUND Poor exercise capacity is associated with mortality, but it is not known how this influences the benefits and risks of CABG compared with medical therapy. METHODS In an exploratory analysis, physical activity was assessed by questionnaire and 6-min walk test in 1,212 patients before randomization to CABG (n = 610) or medical management (n = 602) in the STICH (Surgical Treatment for Ischemic Heart Failure) trial. Mortality (n = 462) was compared by treatment allocation during 56 months (interquartile range: 48 to 68 months) of follow-up for subjects able (n = 682) and unable (n = 530) to walk 300 m in 6 min and with less (Physical Ability Score [PAS] >55, n = 749) and more (PAS ≤55, n = 433) limitation by dyspnea or fatigue. RESULTS Compared with medical therapy, mortality was lower for patients randomized to CABG who walked ≥300 m (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.59 to 0.99; p = 0.038) and those with a PAS >55 (HR: 0.79; 95% CI: 0.62 to 1.01; p = 0.061). Patients unable to walk 300 m or with a PAS ≤55 had higher mortality during the first 60 days with CABG (HR: 3.24; 95% CI: 1.64 to 6.83; p = 0.002) and no significant benefit from CABG during total follow-up (HR: 0.95; 95% CI: 0.75 to 1.19; p = 0.626; interaction p = 0.167). CONCLUSIONS These observations suggest that patients with ischemic left ventricular dysfunction and poor exercise capacity have increased early risk and similar 5-year mortality with CABG compared with medical therapy, whereas those with better exercise capacity have improved survival with CABG. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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20
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Moe GW, Ezekowitz JA, O'Meara E, Howlett JG, Fremes SE, Al-Hesayen A, Heckman GA, Ducharme A, Estrella-Holder E, Grzeslo A, Harkness K, Lepage S, McDonald M, McKelvie RS, Nigam A, Rajda M, Rao V, Swiggum E, Virani S, Van Le V, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Giannetti N, Haddad H, Isaac DL, Kouz S, Leblanc MH, Liu P, Ross HJ, Sussex B, White M. The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization. Can J Cardiol 2013; 30:249-63. [PMID: 24480445 DOI: 10.1016/j.cjca.2013.10.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 12/25/2022] Open
Abstract
The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.
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Affiliation(s)
- Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Steve E Fremes
- Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Abdul Al-Hesayen
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anique Ducharme
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Adam Grzeslo
- Joseph Brant Memorial Hospital, Burlington, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Serge Lepage
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael McDonald
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert S McKelvie
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Anil Nigam
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Miroslaw Rajda
- QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivek Rao
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Vy Van Le
- Centre Hospitalier Universitaire de l'Université de Montréal, Québec, Canada
| | - Shelley Zieroth
- Cardiac Sciences Program, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | | | | | | | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, and Université Laval, Québec, Canada
| | | | - Peter Liu
- Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J Ross
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Sussex
- Health Sciences Centre, St John's, Newfoundland, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
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Allman KC. Noninvasive assessment myocardial viability: current status and future directions. J Nucl Cardiol 2013; 20:618-37; quiz 638-9. [PMID: 23771636 DOI: 10.1007/s12350-013-9737-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 12/22/2022]
Abstract
Observations of reversibility of cardiac contractile dysfunction in patients with coronary artery disease and ischemia were first made more than 40 years ago. Since that time a wealth of basic science and clinical data has been gathered exploring the mechanisms of this phenomenon of myocardial viability and relevance to clinical care of patients. Advances in cardiac imaging techniques have contributed greatly to knowledge in the area, first with thallium-201 imaging, then later with Tc-99m-based tracers for SPECT imaging and metabolic tracers used in conjunction with positron emission tomography (PET), most commonly F-18 FDG in conjunction with blood flow imaging with N-13 ammonia or Rb-82 Cl. In parallel, stress echocardiography has made great progress also. Over time observational studies in patients using these techniques accumulated and were later summarized in several meta-analyses. More recently, cardiac magnetic resonance imaging (CMR) has contributed further information in combination with either late gadolinium enhancement imaging or dobutamine stress. This review discusses the tracer and CMR imaging techniques, the pooled observational data, the results of clinical trials, and ongoing investigation in the field. It also examines some of the current challenges and issues for researchers and explores the emerging potential of combined PET/CMR imaging for myocardial viability.
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Affiliation(s)
- Kevin C Allman
- Department of PET and Nuclear Medicine, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.
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Panza JA, Holly TA, Asch FM, She L, Pellikka PA, Velazquez EJ, Lee KL, Borges-Neto S, Farsky PS, Jones RH, Berman DS, Bonow RO. Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2013; 61:1860-70. [PMID: 23500234 PMCID: PMC3755503 DOI: 10.1016/j.jacc.2013.02.014] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/30/2013] [Accepted: 02/03/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The study objectives were to test the hypotheses that ischemia during stress testing has prognostic value and identifies those patients with coronary artery disease (CAD) with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass grafting (CABG) compared with medical therapy. BACKGROUND The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction (EF) is largely unknown. METHODS The STICH (Surgical Treatment for IsChemic Heart Failure) trial randomized patients with CAD and EF ≤35% to CABG or medical therapy. In the current study, we assessed the outcomes of those STICH patients who underwent a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN testing if the summed difference score (difference in tracer activity between stress and rest) was ≥4 or if ≥2 of 16 segments were ischemic during DSE. Clinical endpoints were assessed by intention to treat during a median follow-up of 56 months. RESULTS Of the 399 study patients (51 women, mean EF 26 ± 8%), 197 were randomized to CABG and 202 were randomized to medical therapy. Myocardial ischemia was induced during stress testing in 256 patients (64% of the study population). Patients with and without ischemia were similar in age, multivessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p = NS). There was no difference between patients with and without ischemia in all-cause mortality (hazard ratio: 1.08; 95% confidence interval: 0.77 to 1.50; p = 0.66), cardiovascular mortality, or all-cause mortality plus cardiovascular hospitalization. There was no interaction between ischemia and treatment for any clinical endpoint. CONCLUSIONS In CAD with severe LV dysfunction, inducible myocardial ischemia does not identify patients with worse prognosis or those with greater benefit from CABG over optimal medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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Affiliation(s)
- Julio A Panza
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC 20010, USA.
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Doenst T, Cleland JGF, Rouleau JL, She L, Wos S, Ohman EM, Krzeminska-Pakula M, Airan B, Jones RH, Siepe M, Sopko G, Velazquez EJ, Racine N, Gullestad L, Filgueira JL, Lee KL. Influence of crossover on mortality in a randomized study of revascularization in patients with systolic heart failure and coronary artery disease. Circ Heart Fail 2013; 6:443-50. [PMID: 23515275 DOI: 10.1161/circheartfailure.112.000130] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To assess the influence of therapy crossovers on treatment comparisons and mortality at 5 years in patients with ischemic heart disease and heart failure randomly assigned to medical therapy alone (MED) or to MED and coronary artery bypass graft (CABG) surgery in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. METHODS AND RESULTS The influence of early crossover (within the first year after randomization) on 5-year mortality was assessed using time-dependent multivariable Cox models. CABG was performed in 65/602 patients (10.8%) assigned to MED, and 55/610 patients (9.0%) assigned to CABG received MED only. Common reasons for crossover from MED to CABG were progressive symptoms or acute decompensation. MED-assigned patients who underwent CABG had lower 5-year mortality than those who received MED only (25% vs 42%; hazard ratio, 0.50; 95% confidence interval, 0.30-0.85; P=0.008).The main reason for crossover from CABG to MED was patient/family decision. Five patients did not undergo their assigned CABG within a year but died before receiving surgery without status change. They were deemed crossover to MED. The CABG-to-MED crossover population had higher 5-year mortality compared with those treated with CABG per-protocol (59% vs 33%; hazard ratio, 2.01; 95% confidence interval, 1.36-2.96; P<0.001). CABG was associated with lower mortality compared with MED in per-protocol and several time-dependent analyses (all P<0.05). CONCLUSIONS CABG reduced mortality in both the per-protocol and crossover STICH patient populations. Crossover from assigned therapy, therefore, diminished the impact of CABG on survival in STICH when analyzed by intention to treat. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, University of Jena, Jena, Germany.
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Suma H, Anyanwu AC. Current Status of Surgical Ventricular Restoration for Ischemic Cardiomyopathy. Semin Thorac Cardiovasc Surg 2012; 24:294-301. [DOI: 10.1053/j.semtcvs.2013.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2013] [Indexed: 11/11/2022]
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Deja MA, Grayburn PA, Sun B, Rao V, She L, Krejca M, Jain AR, Leng Chua Y, Daly R, Senni M, Mokrzycki K, Menicanti L, Oh JK, Michler R, Wróbel K, Lamy A, Velazquez EJ, Lee KL, Jones RH. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation 2012; 125:2639-48. [PMID: 22553307 DOI: 10.1161/circulationaha.111.072256] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether mitral valve repair during coronary artery bypass grafting (CABG) improves survival in patients with ischemic mitral regurgitation (MR) remains unknown. METHODS AND RESULTS Patients with ejection fraction ≤35% and coronary artery disease amenable to CABG were randomized at 99 sites worldwide to medical therapy with or without CABG. The decision to treat the mitral valve during CABG was left to the surgeon. The primary end point was mortality. Of 1212 randomized patients, 435 (36%) had none/trace MR, 554 (46%) had mild MR, 181 (15%) had moderate MR, and 39 (3%) had severe MR. In the medical arm, 70 deaths (32%) occurred in patients with none/trace MR, 114 (44%) in those with mild MR, and 58 (50%) in those with moderate to severe MR. In patients with moderate to severe MR, there were 29 deaths (53%) among 55 patients randomized to CABG who did not receive mitral surgery (hazard ratio versus medical therapy, 1.20; 95% confidence interval, 0.77-1.87) and 21 deaths (43%) among 49 patients who received mitral surgery (hazard ratio versus medical therapy, 0.62; 95% confidence interval, 0.35-1.08). After adjustment for baseline prognostic variables, the hazard ratio for CABG with mitral surgery versus CABG alone was 0.41 (95% confidence interval, 0.22-0.77; P=0.006). CONCLUSION Although these observational data suggest that adding mitral valve repair to CABG in patients with left ventricular dysfunction and moderate to severe MR may improve survival compared with CABG alone or medical therapy alone, a prospective randomized trial is necessary to confirm the validity of these observations. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Marek A Deja
- Medical University of Silesia, Katowice, Poland.
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Deja MA, Grayburn PA, Sun B, Rao V, She L, Krejca M, Jain AR, Leng Chua Y, Daly R, Senni M, Mokrzycki K, Menicanti L, Oh JK, Michler R, Wróbel K, Lamy A, Velazquez EJ, Lee KL, Jones RH. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation 2012. [PMID: 22553307 DOI: 10.1161/circul ationaha.111.072256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Whether mitral valve repair during coronary artery bypass grafting (CABG) improves survival in patients with ischemic mitral regurgitation (MR) remains unknown. METHODS AND RESULTS Patients with ejection fraction ≤35% and coronary artery disease amenable to CABG were randomized at 99 sites worldwide to medical therapy with or without CABG. The decision to treat the mitral valve during CABG was left to the surgeon. The primary end point was mortality. Of 1212 randomized patients, 435 (36%) had none/trace MR, 554 (46%) had mild MR, 181 (15%) had moderate MR, and 39 (3%) had severe MR. In the medical arm, 70 deaths (32%) occurred in patients with none/trace MR, 114 (44%) in those with mild MR, and 58 (50%) in those with moderate to severe MR. In patients with moderate to severe MR, there were 29 deaths (53%) among 55 patients randomized to CABG who did not receive mitral surgery (hazard ratio versus medical therapy, 1.20; 95% confidence interval, 0.77-1.87) and 21 deaths (43%) among 49 patients who received mitral surgery (hazard ratio versus medical therapy, 0.62; 95% confidence interval, 0.35-1.08). After adjustment for baseline prognostic variables, the hazard ratio for CABG with mitral surgery versus CABG alone was 0.41 (95% confidence interval, 0.22-0.77; P=0.006). CONCLUSION Although these observational data suggest that adding mitral valve repair to CABG in patients with left ventricular dysfunction and moderate to severe MR may improve survival compared with CABG alone or medical therapy alone, a prospective randomized trial is necessary to confirm the validity of these observations. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Marek A Deja
- Medical University of Silesia, Katowice, Poland.
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Influence of global region on outcomes in heart failure β-blocker trials. J Am Coll Cardiol 2011; 58:915-22. [PMID: 21851879 DOI: 10.1016/j.jacc.2011.03.057] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/17/2011] [Accepted: 03/29/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We sought to describe the United States and the rest of the world (ROW) outcomes from the major β-blocker heart failure (HF) trials. BACKGROUND HF trials have demonstrated differences in outcomes by geographic region. METHODS Randomized, double-blind, placebo-controlled studies that evaluated β-blockers in HF patients, had a primary endpoint of mortality, and enrolled U.S. patients were included. Relative risk (RR) was calculated for patients enrolled in the United States and ROW. Meta-analysis of the combined mortality rates was performed using the Cochran-Mantel-Haenszel statistic, stratified by study. RESULTS A total of 8,988 patients were enrolled in the MERIT-HF (Metoprolol Controlled-Release Randomized Intervention Trial in Heart Failure), COPERNICUS (Carvedilol Prospective Randomized Cumulative Survival trial), and BEST (β-Blocker Evaluation of Survival Trial) combined; 4,198 (46.7%) were from the United States. In the U.S. cohort, the RR reduction for each β-blocker was of smaller magnitude than in the overall cohort and no longer significant, whereas in the ROW subgroup, the mortality benefit for β-blockade persisted. In the pooled analysis (n = 11,635), the RR of death was reduced by 23% (p < 0.001) with β-blockade compared with placebo. In contrast, the mortality reduction associated with β-blockade in the U.S. cohort was small and not statistically significant (RR: 0.92, 95% confidence interval [CI]: 0.82 to 1.02, p = 0.11). The survival benefit persisted in the ROW cohort (RR: 0.64, 95% CI: 0.56 to 0.72, p < 0.001). CONCLUSIONS Among patients enrolled in the United States, β-blockade was associated with a lower magnitude of survival benefit, whereas the ROW response was similar to the total study population. This geographic difference in treatment response may be a reflection of population differences, genetics, cultural or social differences in disease management, or low power and statistical chance.
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Abstract
The STICH trial showed that CABG surgery does not necessarily improve cardiovascular outcomes in patients with coronary artery disease and left ventricular dysfunction who are receiving optimal medical therapy. However, surgical revascularization should still be considered if the coronary artery disease is severe and viable myocardium can be identified.
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Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, Ali IS, Pohost G, Gradinac S, Abraham WT, Yii M, Prabhakaran D, Szwed H, Ferrazzi P, Petrie MC, O'Connor CM, Panchavinnin P, She L, Bonow RO, Rankin GR, Jones RH, Rouleau JL. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011; 364:1607-16. [PMID: 21463150 PMCID: PMC3415273 DOI: 10.1056/nejmoa1100356] [Citation(s) in RCA: 884] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
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Affiliation(s)
- Eric J Velazquez
- Division of Cardiovascular Medicine, Duke University Medical Center, Durham, NC, USA.
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Bonow RO, Maurer G, Lee KL, Holly TA, Binkley PF, Desvigne-Nickens P, Drozdz J, Farsky PS, Feldman AM, Doenst T, Michler RE, Berman DS, Nicolau JC, Pellikka PA, Wrobel K, Alotti N, Asch FM, Favaloro LE, She L, Velazquez EJ, Jones RH, Panza JA. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 2011; 364:1617-25. [PMID: 21463153 PMCID: PMC3290901 DOI: 10.1056/nejmoa1100358] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
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Affiliation(s)
- Robert O Bonow
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave., Suite 1006, Chicago, IL 60611, USA.
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Almenar L, Díaz Molina B, Comín Colet J, Pérez de la Sota E. [Heart failure and heart transplant]. Rev Esp Cardiol 2011; 64 Suppl 1:42-9. [PMID: 21276489 DOI: 10.1016/s0300-8932(11)70006-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The mission of the Heart Failure and Transplantation Section of the Spanish Society of Cardiology is to study, to promote interest in, and to disseminate information about all aspects of myocardial dysfunction and heart transplantation. Heart failure is a highly prevalent condition that consumes a substantial proportion of healthcare resources. Consequently, there is considerable interest in the disorder. Numerous lines of clinical and preclinical research are actively being pursued and new ways of increasing knowledge about the disease are constantly being explored. The aim of this article was to describe the most recent developments concerning heart failure and its treatment. Firstly, the latest publications on chronic heart failure are analyzed. Then, there is a review of the most recent studies on resynchronization therapy and of clinical trials on acute heart failure. Thirdly, new developments in right heart dysfunction and pulmonary hypertension, and the findings of the Spanish Pulmonary Hypertension Registry are discussed. Finally, the latest information on ventricular assist devices and heart transplantation is presented. In addition, the most important data obtained from official transplantation registries (i.e. the Spanish Heart Transplantation Registry and the Spanish Post-Heart Transplantation Tumor Registry) are reviewed.
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Bibliography--Editors' selection of current word literature. Coron Artery Dis 2010; 21:486-8. [PMID: 21076239 DOI: 10.1097/mca.0b013e328341d225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zembala M, Michler RE, Rynkiewicz A, Huynh T, She L, Lubiszewska B, Hill JA, Jandova R, Dagenais F, Peterson ED, Jones RH. Clinical characteristics of patients undergoing surgical ventricular reconstruction by choice and by randomization. J Am Coll Cardiol 2010; 56:499-507. [PMID: 20670761 PMCID: PMC2936491 DOI: 10.1016/j.jacc.2010.03.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 02/03/2010] [Accepted: 03/02/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of this study was to confirm the generalizability of the conclusions of the STICH (Surgical Treatment for Ischemic Heart Failure) trial. BACKGROUND Surgical ventricular reconstruction (SVR) added to coronary artery bypass grafting (CABG) did not decrease death or cardiac hospitalization in STICH patients randomized to CABG with (n = 501) or without (n = 499) SVR. METHODS Baseline clinical characteristics of 1,000 STICH SVR hypothesis patients and 1,036 STICH-eligible Society of Thoracic Surgeons (STS) National Cardiac Database patients undergoing CABG plus SVR were entered into a multivariate model equation to predict a mortality that placed these 2,036 patients in 1 of 32 risk at randomization (RAR) groups. The number of patients in each RAR group profiled the risk of STICH treatment arms and of STICH and STS STICH-eligible patients. RESULTS That 85% of the 1,000 STICH patients known to have no significant differences in baseline characteristics between the 2 treatment arms shared the same RAR group suggests that the RAR methodology has sufficient accuracy to compare RAR profiles of STICH and STS patients. RAR group was shared by 1,522 of 2,036 STICH and STS STICH-eligible patients (75%) who underwent CABG plus SVR. Differences in baseline characteristics responsible for more low-risk STICH patients and more high-risk STS patients were modest. Cox proportional hazard ratios of 1,000 STICH patients in 3 RAR groups suggested by STICH and STS RAR differences showed no differential treatment effect on survival across the low-, intermediate-, and high-risk groups. CONCLUSIONS The STICH conclusion of no benefit from adding SVR to CABG applies to a broad spectrum of CABG-eligible patients with ischemic cardiomyopathy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease; NCT00023595).
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Affiliation(s)
- Marian Zembala
- Department of Cardiac Surgery and Transplantation, Silesian Center for Heart Diseases/Medical University of Silesia, Zabrze-Katowice, Poland
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Shroyer ALW, Collins JF, Grover FL. Evaluating Clinical Applicability. J Am Coll Cardiol 2010; 56:508-9. [DOI: 10.1016/j.jacc.2010.03.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
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