1. Revascularization in HEART FAILURE patients Farveh Vakilian.M.D OCT 2011

2. We've known for decades that in patients with LV dysfunction, ischemia is the major cause of mortality, and that in patients with ischemia, LV dysfunction is the major cause of mortality.

3. A 65 man came to your clinic with the complain of dyspnea He has history of chest pain 2 months ago and CCU admission,DM(+),HTN and other RF was (-) ECG:sinus rhythm,narrow complex,poor R progression,ST changes anterior leads

4. CXRay:Cardiomegaly,Hilar Congestion Echocardiography:LVEF:35%,RWMA(+) in LAD territory,Mild RV Dysfunction,Normal PAP Whats the plan? o Do you recommend angiography or you prefer noninvasive imaging studies?

5.  A reasonable management strategy for patients who present with heart failure secondary to coronary artery disease (i.e., ischemic cardiomyopathy) includes coronary angiography  Viability studies are appropriate for those patients with severe disease and adequate surgical targets.  If significant viability is present (≥25%), the weight of currently available clinical evidence suggests that CABG may improve survival and quality of life over medical therapy alone

6. SCA was done and he suffered 3VD You recommend him CABG but he has some questions!!!???

7. Do I really need the operation?

8. Ischemic cardiomyopathy can be envisioned as three interrelated pathophysiologic processes: Myocardial hibernation, defined as persistent contractile dysfunction at rest, caused by reduced coronary blood flow Myocardial stunning, viable myocardium but reversible post ischemic contractile dysfunction caused by the generation of oxygen-derived free radicals on reperfusion and by a loss of sensitivity of contractile filaments to calcium; Myocyte cell death, leading to ventricular remodeling and contractile dysfunction

9.  Surgery might benefit these patients by improving systolic function or perhaps improving diastolic function, which had been inhibited by myocardial stiffness caused by ischemia Much of the improvement will be from a benefit on sudden cardiac death, or could it be that the benefit is on recurrent infarction, which these patients obviously cannot tolerate

10. In a meta-analysis of 24 studies involving a total of 3088 patients with ischemic cardiomyopathy, revascularization decreased the risk of death by 79.6% in patients with evidence of viable myocardial tissue, yielding an annual mortality of 3.2% compared with 16.0% for patients who did not undergo revascularization

11. Several clinical factors play a major role in the decision-making process including:  The presence of angina, severity of heart failure symptoms, LV dimensions, degree of hemodynamic compromise, and comorbidities

12. Other major technical issues to be considered are:  the adequacy of target vessels for revascularization and an adequate conduit strategy.

13.  The most important determinant, however, is the extent of jeopardized but still viable myocardium Current studies have suggested that for a significant improvement in heart failure symptoms and LV function as well as for improvement in survival to occur after coronary revascularization, at least 25% of the myocardium should be viable

14. Benefits of Coronary Artery Bypass Grafting  Improved blood flow to hypoperfused but viable myocardium, with a subsequent improvement in LV function and clinical outcomes.  Alleviation of ischemia may also lessen the tendency toward proarrhythmias, thereby reducing the incidence of sudden cardiac death.  Coronary artery revascularization has the potential to improve symptoms of heart failure, LV function, and survival.

15. Improvement in Left Ventricular Function  A review of pooled viability data demonstrated that significant viability (25% to 30%) predicted an improvement in LVEF.  Nuclear studies, PET, and dobutamine echocardiography predict improvement of LV function of approximately 8% to 10% when viability of the myocardium is present

16. Symptomatic Improvement Several studies have reported marked improvement in heart failure symptoms after revascularization. Freedom from heart failure was 78% and 47% at 1 and 5 years. Only 54% of patients were symptom free of both angina and heart failure at follow-up

17. How much is the risk? The mortality and morbidity! How much is the risk? The mortality and morbidity!

18.  The perioperative risks in patients with severe LV dysfunction range from 2% to nearly 10%, depending on: the availability of targets and their viability, RV dysfunction, Advanced heart failure symptoms (New York Heart Association [NYHA] Class IV), Increased LV end-diastolic pressure, Comorbidities of advanced age, Peripheral vascular disease, chronic obstructive pulmonary disease

19. Studies have indicated that for patients with clinical heart failure, perioperative mortality rates will range from approximately 2.6% to 8.7%, Depending on age and presence of one or more comorbid conditions.

20.  Several studies have shown that overall survival and cardiac events (including cardiac death, infarction, and hospitalization for heart failure) are directly related to the presence of myocardial viability in heart failure patients.

21. In the CABG Patch trial, patients without angina or heart failure had a perioperative mortality of 1.3%. The mortality increased to 4.8% for patients with no angina and mild heart failure, NYHA Class I or II, and 7.4% with no angina and NYHA Class III or IV heart failure.  Importantly, viability imaging was not used to stratify these outcomes.

22. o For cardiogenic shock after myocardial infarction, the results of emergent CABG are poor but still better than medical therapy. o The SHOCK Trial gave 1-year mortality after CABG of 42% and 56% for patients in cardiogenic shock. o This is compared with 56% and 75% with medical therapy alone

23. Stabilization of the patients with the use of an intra-aortic balloon pump decreased in-hospital mortality but had no effect on 1-year survival.  More recently, smaller experiences with percutaneous partial pumps, such as the Impella and TandemHeart devices, suggest that perioperative mortality can be improved after revascularization, but these results have not yet been confirmed with a larger experience.

24. Does the EF will be changed post operatively?

25.  The presence of hibernating or viable myocardium is essential for improvement in LVEF after surgical revascularization.  Recovery of LV function after revascularization is related to the degree of reversible myocardial ischemia, severity of the LV dysfunction, LV chamber dimensions, and LV geometry.  There may be continuing improvements in LVEF as late as 6 to 12 months after surgery

26. A number of surgical approaches have emerged as potentially beneficial in patients with ischemic HF. The goals of such procedures generally include: revascularization, reduction in “geometric” or functional mitral regurgitation, restoration of a more normal LV geometry and function.  Surgical ventricular restoration(SVR) procedure is one of the most extensively studied and applied techniques

27. 2800 patients randomized from 100 centers. Patients with LV dysfunction and coronary artery disease amenable to CABG were randomized to a combination of three different treatment strategies:  CABG, CABG plus surgical ventricular reconstruction (SVR), or intense medical therapy. STICH, a prospective, randomized study

28.  In STICH CABG was associated with an early risk of death as a result of the surgical intervention itself, but this disadvantage for surgery disappeared after two years post procedure.  Over a median follow-up of 56 months, 41% of the medical- therapy group and 36% of the CABG group died,the difference was statistically significant following adjustment for baseline characteristics (p=0.039).  In the medical-therapy group, 68% of the patients died from any cause or were hospitalized for cardiovascular causes, compared with 58% of the CABG group (p<0.0001).

29. STICH trial  The STICH trial was designed to compare coronary bypass (CABG) alone vs. CABG plus surgical ventricular reconstruction (SVR) in patients with left ventricular (LV) dysfunction  It reported that adding SVR to coronary bypass CABG was not associated with a greater improvement in symptoms, exercise tolerance, or reduced intermediate mortality.

30. Surgical ventricular reconstruction is an effective operation when performed by properly trained surgeons in correctly selected patients

33. A randomized comparison of coronary artery bypass graft (CABG) surgery and medical therapy alone in 1212 patients with coronary artery disease amenable to CABG with a left ventricular ejection fraction under 35%.

34. Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction The New England Journal of Medicine april 28, 2011

35. Is there any other options? Can I do PCI? Isn it better? Is there any other options? Can I do PCI? Isn it better?

36. PCI in Heart Failure:  Early surgical or percutaneous intervention, as compared with continued medical therapy, significantly improves the survival of patients with systolic heart failure, according to a retrospective analysis

37.  CABG would still remain the standard treatment option in patients with triple vessel disease, particularly when their SYNTAX scores are high CREDO-Kyoto PCI/CABG registry Cohort-2 :

38.  Findings from study show that PCI was associated with a higher 3-year risk for this primary endpoint (adjusted hazard ratio (HR) 1.47 [95% CI 1.13-1.92, P=0.004]) and for MI (HR 2.39 [95% CI 1.31-4.36, P=0.004]), as compared with CABG.  The risk for cardiac death was not significantly different (HR 1.30 [95% CI 0.81-2.07, P=0.28]), but the risk for all-cause death was significantly higher after PCI (HR 1.62 [95% CI 1.16-2.27, P=0.005]).

39.  Results also showed that the cumulative incidence of the primary endpoint was comparable between the PCI and CABG groups in patients with low (<23) and intermediate (23-32) SYNTAX scores  in patients with high SYNTAX scores (≥33) was markedly higher after PCI than after CABG (15.8% and 12.5%, P=0.25, 18.8% and 16.7%, P=0.24, and 27.0% and 16.4%, P=0.004, respectively).

40. The study population consisted of 2981 patients with triple vessel disease (PCI 1825 patients, and CABG 1156 patients Anatomic complexities of coronary artery disease were assessed by using the SYNTAX score to ensure comparability between the PCI and CABG groups (in an observational study) A composite of all-cause death, myocardial infarction (MI) and stroke was primarily studied.

41. o The SYNTAX score is the sum of the points assigned to each individual lesion identified in the coronary tree with >50% diameter narrowing in vessels >1.5mm diameter. o The coronary tree is divided into 16 segments according to the AHA classification

42. An as-treated analysis of 592 patients treated with medical therapy for the first year after randomization and 620 patients who had CABG within the first year showed a mortality benefit for CABG (hazard ratio 0.70, p<0.001). Also, a per- protocol comparison of the 537 patients randomly assigned to medical therapy who never crossed over and the 555 patients in the CABG group who actually had surgery also showed a mortality benefit for CABG (HR 0.76, p=0.005).

43. Di Carli and colleagues have studied 36 patients with LVEF of 28% by PET imaging. [9] They found a significant correlation between the total extent of a PET mismatch and percentage improvement in functional class after CABG. A blood flow–metabolism mismatch of more than 18% was associated with a sensitivity of 76% and a specificity of 78% for predicting a change in functional status after revascularization. [9]

44. . A substantial objective improvement in physical activity was noted in patients with presurgical mismatches that occupied at least 20% of the ventricular myocardium. Thus, patients with large perfusion-metabolism mismatch exhibited the greatest clinical benefit after revascularization. Another study has shown a similar significant improvement in functional capacity after revascularization, as reflected by a 34% increase in exercise capacity from 5.6 to 7.5 METs (metabolic equivalents) in the group of patients with revascularization PET mismatch.

45. There is also accumulating evidence in patients with ischemic mitral insufficiency that the combination of surgical revascularization and mitral valve repair will improve quality of life significantly. [24-26] In multiple retrospective series, NYHA class improved from greater than NYHA Class III to less than Class II with up to 4 years of follow-up [24-26]

46. In summary, the current literature suggests that functional mitral insufficiency in patients with advanced heart failure and LV dysfunction can be corrected with a low operative mortality in either ischemic or nonischemic cardiomyopathies. There are multiple prospective but nonrandomized series that suggest a symptomatic benefit as well as a remodeling benefit in patients who undergo mitral valve repair in idiopathic dilated cardiomyopathies and coronary revascularization with mitral valve repair in ischemic cardiomyopathies. There is currently no evidence that elimination of mitral insufficiency in heart failure patients conveys a survival benefit

47. Of 765 consecutive HF patients with an LVEF <35% who underwent myocardial viability testing with PET-fluorodeoxyglucose imaging at one center, 230 underwent coronary artery bypass grafting or other open-heart surgical procedures and 42 had percutaneous coronary interventions within six months of the scan. The remaining 535 instead were treated medically. Mortality over a median of three years reached 20% for those managed with surgery or PCI and 34% for the others.

48. Two matched cohorts were created from 153 patients in the surgery-PCI and medical- management groups based on a range of demographic, clinical, and PET-based characteristics. Their three-year mortalities were 15% and 35% respectively, which corresponded to a 48% decrease in the "propensity-adjusted" mortality hazard ratio (p=0.0004) in favor of surgery or PCI.

49. There was no apparent interaction between survival benefit associated with early cardiac intervention and the amount of viable tissue... identified by PET," according to the authors. Viable myocardium was defined as muscle that was either hibernating (noncontractile but metabolically active) or contractile but ischemic. The findings suggest that "early intervention was associated with lower risk of death across the range of ischemia and hibernation," they write.

50. The "PET hypothesis," according to Lauer, holds that patients who display large expanses of viable myocardium are the ones most likely to benefit from revascularization. But their analysis disagrees, he said. "Our data seem to suggest that among any patient who has any degree of viability, there is a benefit.... I'm not so sure that the original PET hypothesis is correct." Their data, observes Lauer in a Clinical Perspective accompanying the report, suggest that "revascularization in the setting of left ventricular dysfunction confers its benefit by means other than relieving ischemia; perhaps it 'works' by stabilizing the arrhythmic substrate." Or, he added when interviewed, "maybe it's PET that is the problem." That is, he said, perhaps the hypothesis would have been supported in a study using other viability imaging techniques, such as magnetic resonance imaging or dobutamine echocardiography.

51. However, the adjusted risk of PCI relative to CABG for the primary endpoint was HR 1.66 (95% CI 1.04-2.65, P=0.03) in the low-score category, HR 1.24 (95% CI 0.83-1.85, P=0.29) in the intermediate-score category, and HR 1.59 (95% CI 0.998-2.54, P=0.051) in the high- score category.

52. Table 3. The SYNTAX score algorithm 1. Dominance 2. Number of lesions 3. Segments involved per lesion Lesion Characteristics 4. Total occlusion i. Number of segments involved ii. Age of the total occlusion (>3 months) iii. Blunt Stump iv. Bridging collaterals v. First segment beyond the occlusion visible by antegrade or retrograde filling vi. Side branch involvement 5. Trifurcation i. Number of segments diseased 6. Bifurcation i. Type ii. Angulation between the distal main vessel and the side branch <70° 7. Aorto-ostial lesion 8. Severe tortuosity 9. Length >20mm 10. Heavy calcification 11. Thrombus 12. Diffuse disease/small vessels i. Number of segments with diffuse disease/small vessels

53. . Each segment is given a score of 1 or 2 based on the presence of disease and this score is then weighted based on a chart, with values ranging from 3.5 for the proximal left anterior descending artery (LAD) to 5.0 for left main, and 0.5 for smaller branches. The branches <1.5 mm in diameter, despite having severe lesions, are not included in the SYNTAX score

54. The percent diameter stenosis is not a consideration in the SYNTAX score, only the presence of a stenosis from 50–99% diameter, <50% diameter narrowing or the total occlusion. A multiplication factor of 2 is used for non-occlusive lesions and 5 is used for occlusive lesions, reflecting the difficulty of PCI.

55.  Recommend Surgery as : Class I indication for those patients with left main or equivalent disease, Class IIa for patients with viable noncontracting muscle Class III for those without evidence of ischemia or viability (ACC/AHA) guidelines for CABG in patients with poor LV function

56. "The take-home message is that: I. the STICH trial supports bypass surgery on top of best medical therapy vs medical therapy alone to reduce cardiovascular morbidity and mortality II.many patients who are now treated for heart failure should be evaluated for CAD, because [coronary disease] does not present the same way in every patient "Heart failure without angina shouldn't exclude patients from an angiographic evaluation."