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Varma PK, Radhakrishnan RM, Gopal K, Krishna N, Jose R. Selecting the appropriate patients for coronary artery bypass grafting in ischemic cardiomyopathy-importance of myocardial viability. Indian J Thorac Cardiovasc Surg 2024; 40:341-352. [PMID: 38681722 PMCID: PMC11045715 DOI: 10.1007/s12055-023-01671-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 05/01/2024] Open
Abstract
Patients who undergo coronary artery bypass graft (CABG) surgery in ischemic cardiomyopathy have a survival advantage over medical therapy at 10 years. The survival advantage of CABG over medical therapy is due to its ability to reduce future myocardial infarction, and by conferring electrical stability. The presence of myocardial viability does not provide a differential survival advantage for CABG over medical therapy. Presence of angina and inducible ischemia are also less predictive of outcome. Moreover, CABG is associated with significant early mortality. Hence, careful patient selection is more important for reducing the early mortality and improving the long-term outcome than relying on results of myocardial viability. Younger patients with good exercise tolerance benefit the most, while patients who are frail and patients with renal dysfunction and dysfunctional right ventricle seem to have very high operative mortality. Elderly patients, because of poor life expectancy, do not benefit from CABG, but the age cutoff is not clear. Patients also need to have revascularizable targets, but this decision is often based on experience of the surgical team and heart team discussion. These recommendations are irrespective of the myocardial viability tests. Optimal medical treatment remains the cornerstone for management of ischemic cardiomyopathy.
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Affiliation(s)
- Praveen Kerala Varma
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Rohik Micka Radhakrishnan
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Kirun Gopal
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Rajesh Jose
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
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Acerbo V, Cesaro A, Scherillo G, Signore G, Rotolo FP, De Michele G, Scialla F, Raucci G, Panico D, Fimiani F, Moscarella E, Gragnano F, Calabrò P. Understanding the role of coronary artery revascularization in patients with left ventricular dysfunction and multivessel disease. Heart Fail Rev 2023; 28:1325-1334. [PMID: 37493869 PMCID: PMC10575800 DOI: 10.1007/s10741-023-10335-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
Coronary artery disease (CAD) is the most common cause of heart failure with reduced ejection fraction (HFrEF). Advances and innovations in medical therapy have been shown to play a crucial role in improving the prognosis of patients with CAD and HFrEF; however, mortality rate in these patients remains high, and the role of surgical and/or percutaneous revascularization strategy is still debated. The Surgical Treatment for Ischemic Heart Failure (STICH) trial and the Revascularization for Ischemic Ventricular Dysfunction (REVIVED) trial have attempted to provide an answer to this issue. Nevertheless, the results of these two trials have generated further uncertainties. Their findings do not provide a definitive answer about the ideal clinical phenotype for surgical or percutaneous coronary revascularization and dispute the historical dogma on myocardial viability and the theory of myocardial hibernation, raising new questions about the proper selection of patients who are candidates for coronary revascularization. The aim of this review is to provide an overview on the actual available evidence of coronary artery revascularization in patients with CAD and left ventricular dysfunction and to suggest new insights on the proper selection and management strategies in this high-risk clinical setting.
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Affiliation(s)
- Vincenzo Acerbo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Gianmaria Scherillo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Giovanni Signore
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Francesco Paolo Rotolo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Gianantonio De Michele
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Francesco Scialla
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Giuseppe Raucci
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Domenico Panico
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Fabio Fimiani
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Division of Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, Caserta, Italy
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Velagaleti RS, Vetter J, Parker R, Kurgansky KE, Sun YV, Djousse L, Gaziano JM, Gagnon D, Joseph J. Change in Left Ventricular Ejection Fraction With Coronary Artery Revascularization and Subsequent Risk for Adverse Cardiovascular Outcomes. Circ Cardiovasc Interv 2022; 15:e011284. [PMID: 35411780 PMCID: PMC10103079 DOI: 10.1161/circinterventions.121.011284] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Coronary revascularization is recommended to treat ischemic cardiomyopathy. However, the relations of revascularization-associated ejection fraction (EF) change to subsequent outcomes have not been elucidated. METHODS In 10 071 veterans (mean age 67 years; 1% women; 15% non-White) who underwent a first percutaneous coronary intervention (PCI) or coronary artery bypass grafting between January 1, 1995, and December 31, 2010, and had prerevascularization and postrevascularization EF measured, we calculated delta-EF (postprocedure EF-preprocedure EF). We related delta-EF as a continuous measure and as categories (≤-5, -5<delta-EF<0, delta-EF=0, 0<delta-EF<5, and delta-EF≥5) to death (using Cox regression) and heart failure hospitalization days (using negative binomial regression) in multivariable-adjusted models, for total sample, and PCI and coronary artery bypass grafting strata. RESULTS Over follow-up (mean/maximum 5/14 years) 56% died. Each 5% improvement in delta-EF was associated with statistically significant reductions in death and heart failure hospitalization days of 5% (95% CI, 3%-7%) and 10% (95% CI, 5%-15%), respectively, in the total sample and 6% (95% CI, 4%-8%) and 10% (95% CI, 5%-16%), respectively, in the PCI subgroup. Patients in the highest delta-EF category had 27% (95% CI, 19%-34%) lower mortality (30% [95% CI, 21%-37%] lower in PCI stratum) and ≈40% lower heart failure hospitalization days in total sample and PCI stratum, compared with those in the lowest category. Relations of delta-EF and outcomes in coronary artery bypass grafting subgroup did not reach statistical significance. CONCLUSIONS Revascularization-associated EF improvement was associated with significant reductions in mortality and heart failure hospitalization burden, particularly in the PCI subgroup.
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Affiliation(s)
- Raghava S Velagaleti
- Cardiology Section, Department of Medicine (R.S.V., J.J.), VA Boston Healthcare System
| | - Joy Vetter
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Rachel Parker
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Katherine E Kurgansky
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Yan V Sun
- Emory School of Public Health, Atlanta, GA (Y.V.S.).,Atlanta VA Healthcare System, Decatur, GA (Y.V.S.)
| | - Luc Djousse
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System.,Division of Aging (L.D., J.M.G.), Brigham and Women's Hospital, Boston, MA
| | - J Michael Gaziano
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System.,Division of Aging (L.D., J.M.G.), Brigham and Women's Hospital, Boston, MA
| | - David Gagnon
- Massachusetts VA Epidemiology Research and Information Center (J.V., R.P., K.E.K., L.D., J.M.G., D.G.), VA Boston Healthcare System
| | - Jacob Joseph
- Cardiology Section, Department of Medicine (R.S.V., J.J.), VA Boston Healthcare System.,Division of Cardiovascular Medicine (J.J.), Brigham and Women's Hospital, Boston, MA
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4
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Zenati MA, Bhatt DL. Real-world revascularization therapy in heart failure: It's a jungle out there! J Thorac Cardiovasc Surg 2018; 156:1422-1423. [PMID: 29778338 DOI: 10.1016/j.jtcvs.2018.04.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Marco A Zenati
- Division of Cardiothoracic Surgery, Veterans Affairs Boston Healthcare System, Boston, Mass; Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Mass
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