Predicting revascularization outcome in patients with coronary artery disease and left ventricular dysfunction (data from the SEMINATOR study)

Abstract

A main goal of revascularization in patients with chronic ischemic cardiomyopathy is to improve global left ventricular (LV) function. This study aimed to verify whether it is possible to predict an increase in LV ejection fraction (EF) after revascularization on the basis of the extent of LV asynergy, myocardial viability, and revascularization completeness. We studied 77 patients with chronic LV ischemic dysfunction using baseline resting and nitrateenhanced technetium-99m sestamibi single-photon emission computed tomography. Regional wall motion and global LVEF were assessed with echocardiography before and after revascularization, which was complete in 51 patients and incomplete in 26. The number of viable asynergic segments included in revascularized coronary artery territories was the strongest predictor of significant (>5 EF U) functional improvement in univariate discriminant analysis. According to multivariate stepwise discriminant analysis, this parameter, together with the number of baseline asynergic segments, allowed the detection of patients with significant LVEF improvement with 75% accuracy. With use of a multivariate regression model, including the 2 mentioned variables, the measure of postrevascularization LVEF increase could be accurately quantified (R 2 0.43, p <0.000001). In conclusion, this study suggests that the severity of baseline asynergy, the extent of myocardial viability, and the completeness of revascularization are the main determinants of postrevascularization functional recovery in patients with LV ischemic dysfunction, and that on the basis of these variables it is possible to predict the measure of LVEF increase. ᮊ2002 by Excerpta Medica, Inc. V iable dysfunctional myocardium is expected to recover after coronary revascularization. 1,2Therefore, imaging methods that detect myocardial viability are currently used in patients with chronic coronary artery disease and left ventricular (LV) dysfunction to orient the therapeutic choices. [3][4][5][6][7][8][9] In these patients, the goal of treatment is to improve global LV function, and possibly heart failure symptoms and prognosis.2,10 -13 Thus, it would be important to predict the functional gain in the individual patient. A relation exists between extent of viable myocardium and improvement in global LV ejection fraction (EF). 4,8,9,12,14 -17 However, other variables should be considered, such as baseline extent of asynergy, amount of viable myocardium within the dysfunctional area, coronary artery status, and feasibility of a complete revascularization. Few data exist on the ability of viability imaging to quantify the degree of global functional improvement that should be expected. The aim of the SEstaMIbi with Nitrate Administration To predict the Outcome of Revascularization (SEMINATOR) study was to evaluate patients with chronic coronary artery disease and moderate-tosevere LV dysfunction submitted to the best possible revascularization procedure on the basis of their coronary artery status in order to identify which parame...

Clinical trials report

“…Sciagra et al [2] found that the severity of baseline asynergy, the extent of myocardial viability, and completeness of revascularization are the main variables in predicting postoperative increases in LV ejection fraction. Using SPECT imaging, Morse et al [3] showed that survival is more favorable for surgically revascularized patients with ischemic LV dysfunction and myocardial viability, confirming the previous study by Pagley et al [4], which identified patients more likely to benefit from surgical revascularization based on 201 Tl scintigraphy.…”

The Current and Future Role of Percutaneous Coronary Intervention in Patients with Coronary Artery Disease

“…The improvement in prognosis is most likely due to relieving ischemia, thus preventing further injury to viable myocardium and some improvement in global left ventricular (LV) function. The extent to which LV function improves is dependent on the amount of viable myocardium 32–34 and the completeness of revascularization 35 . Revascularization should not be delayed in patients with viable myocardium as it is associated with a high mortality and lack of improvement in LV function 36…”

“…The extent to which LV function improves is dependent on the amount of viable myocardium [32][33][34] and the completeness of revascularization. 35 Revascularization should not be delayed in patients with viable myocardium as it is associated with a high mortality and lack of improvement in LV function. 36 Optimal revascularization in patients with impaired LV systolic function has not received proper attention and is in great need of review.…”