The Occluded Artery Trial (OAT) Viability Ancillary Study (OAT-NUC): Influence of infarct zone viability on left ventricular remodeling after percutaneous coronary intervention versus optimal medical therapy alone

Abstract

Background The Occluded Artery Trial (OAT) showed no difference in outcomes between percutaneous coronary intervention (PCI) vs. optimal medical therapy (MED) in patients with persistent total occlusion of the infarct related artery (IRA) 3–28 days post-MI. Whether PCI may benefit a subset of patients with preservation of infarct zone (IZ) viability is unknown. Methods and Results The OAT nuclear ancillary study hypothesized that; 1) IZ viability influences left ventricular (LV) remodeling, and that 2) PCI as compared to MED attenuates adverse remodeling in post-MI patients with preserved viability. Enrolled were 124 OAT patients, who underwent resting nitroglycerin-enhanced 99mTc sestamibi SPECT prior to OAT randomization, with repeat imaging at 1 year. All images were quantitatively analyzed for infarct size, IZ viability, LV volumes and function in a core lab. At baseline, mean infarct size was 26%±18 of the LV, mean IZ viability was 43%±8 of peak uptake, and the majority (70%) of patients had at least moderately retained IZ viability. There were no significant differences in 1-year EDV or ESV change between those with severely reduced vs. moderately retained IZ viability, or when compared by treatment assignment PCI vs. MED. In multivariable models, increasing baseline viability independently predicted improvement in EF (p=0.005). There was no interaction between IZ viability and treatment assignment for any measure of LV remodeling. Conclusions In the contemporary era of optimal medical therapy, PCI of the IRA compared to medical therapy alone does not impact LV remodeling irrespective of IZ viability.

Late percutaneous coronary intervention for an occluded infarct-related artery in patients with preserved infarct zone viability: A pooled analysis of cardiovascular magnetic resonance studies

“…showed that 31% of patients did not have a preserved viability (severely reduced viability group) defined as at least 40% of the marker uptake [23].…”

Current state of myocardial revascularization in patients with severe left ventricular systolic dysfunction

“…Напротив, у пациентов с преимущественно рубцовыми изменениями на блюдается неблагоприятное ремоделирование ЛЖ, проявляющееся в увеличении конечносистоличе ского и конечнодиастолического объемов. Udelson et al [43] в исследовании Occluded Artery Trial (OAT) проанализировали подгруппу, включавшую 124 пациента с окклюзиями коронарных артерий, прошедших ОФЭКТ с технецием и нитроглицери новой пробой перед рандомизацией и через один год наблюдения. Через год не было выявлено до стоверных различий в изменении конечнодиасто лического или конечносистолического объема у пациентов со значительно или умеренно сниженной жизнеспособностью миокарда, а также различий при сравнении результатов в зависимости от вида проведенного лечения (ангиопластика или только медикаментозная терапия).…”

Revascularization of chronic total occluded coronary arteries: probable benefits and possible harms

“…In this study, 1212 patients with an ejection fraction of less than 35% and coronary artery disease were randomized to undergo CABG alongside optimal medical therapy (OMT) or OMT alone [16]. The 5 year follow up of this study, published in 2011, involving patients with ICM, did not demonstrate an overall mortality benefit with revascularization in comparison to medical treatment alone for ischemic patients [16].…”

“…In this study, 1212 patients with an ejection fraction of less than 35% and coronary artery disease were randomized to undergo CABG alongside optimal medical therapy (OMT) or OMT alone [16]. The 5 year follow up of this study, published in 2011, involving patients with ICM, did not demonstrate an overall mortality benefit with revascularization in comparison to medical treatment alone for ischemic patients [16]. However, surprisingly, the ten year follow up of this largest completed trial to date, involving patients with ICM, published in 2016, showed a mortality rate of 58.9% (359 patients) in the CABG group and of 66.1% (398 patients) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; P=0.02 by log-rank test) [17].…”