Introduction • Ischemic left ventricular dysfunction continues to represent a major health care problem because it affects approximately two thirds of the patients referred with congestive heart failure
Introduction • Limitations in organ procurement severely restrict the use of heart transplantation, make listing criteria increasingly selective, and strongly support the development of alternative surgical approaches
Background • IHD may result in left ventricular systolic dysfunction due to myocardial stunning, hibernation or infarction. • Stunning and hibernation there is viable myocardium in contrast to LV systolic dysfunction after myocardial infarction which may not improve with revascularization.
LV dilatation in ischemic Cardiomyopathy falls into three categories • Dyskinetic aneurysms from extensive scar in the absence of reperfusion - The commonest acute LAD occlusion • Akinetic extensively scarred regions following early reperfusion with epicardial salvage
Would You Revascularize It ?
LV dilatation in ischemic Cardiomyopathy falls into three categories • Akinetic areas occurring late due to remote muscle dilation after early aneurysm formation - These patients have significantly dilated poorly contracting left ventricles but without massive scars.
STICH Trial • RCT of 1000 patients with EF < 35% and coronary artery disease CABG or CABG SVR • 499 CABG and 501 CABG SVR • Did not report screening to enrollment ratio
STICH Originally â&#x20AC;˘ Designed to compare CABG alone to CABG SVR in patients with LV dysfunction and Akentic or dyskinetic anterior wall due to MI
â&#x20AC;˘ Eligibility for STICH required evidence of non viable anterior wall , LVESVI>60ml/m2 and akinesia in >35% of anterior wall
STICH Originally • Center selection was based on presence of CMRI to measure the LV volume • Patient had to have HF symptom
STICH Trial • 49% of patient NYHA III/VI ( 66% in RESTOR) • STICH changed the entry criteria during the trial Heart failure symptums where not required any more . • They did not report it during the trial
STICH Trial • The 50 original STICH centers expanded to 127 in 26 country • 501 SVR CABG performed this mean 4 cases per center ( 1 per c per year )
Hazard Plots of Selected Baseline Characteristics cont Subgroup Mitral regurgitation None or trace Mild (â&#x2030;¤ 2+) Mod. or severe Stratum B C Region Poland USA Canada West Europe Other
N
HR (95% CI)
363 449 178
0.89 (0.68, 1.17) 1.12 (0.88, 1.43) 0.94 (0.65, 1.36)
P Value 0.44
0.44 141 859
1.15 (0.76, 1.76) 0.96 (0.81, 1.15)
0.41 288 200 154 164 194
1.02 (0.76, 1.37) 1.10 (0.79, 1.54) 0.77 (0.50, 1.18) 0.80 (0.53, 1.22) 1.24 (0.81, 1.91)
0.5
1.0
CABG+SVG Better CABG+SVR Better
2.0 CABG Better CABG Better
NOTE • The number of randomized patients was LESS than 20% OF ELIGIBLE PATIENTS • 80% OF ELEGIBLE PATIENTS WERE TREATED WITH SVR BECAUSE THE CLINICAL EVIDENCE OF THE SUPERIORITY OF THIS PROCEDURE
STITCH Trial
The right question was asked at the beginning but the right patients werenâ&#x20AC;&#x2122;t enrolled.
STICH Trial â&#x20AC;˘ The two questions are different because we have patients with viable anterior wall and patients with died scared anterior wall
â&#x20AC;˘ We have patients with dilated LV and others with normal LV volume
(EF <35%) Different shape, different size, different dysfunction
EDVI (ml/m2) ESVI (ml/m2) EF (ml/2) SVI(ml/m2)
485 435 10 50
132 95 29 37
228 204 11 24
STICH Trial • Half of the patients reported to have akinesia or dyskinesia due to MI • 13% did not have history of MI • SVR was never been recommended for regional wall dysfunction and absent scar
STICH Trial • The STICH Surgical therapy committee defined SVR as low operative mortality , average increase in EF 10% and LVESVI reduction >30% • STICH Trial mesured post op LVESVI in 43% of the CABG alone by MRI and in 30% of the SVR using ECHO • STICH had an SVR average LVESVI 19%
0
-10
-20
-30
-40
-50
-60 en ic
(2 20 4)
ul ea s (2 00 4)
IC
ST
H
(2 00 9
an t i( 20 Ag 07 ui ) ar R ib er Ya io m (2 ag 00 uc 6) hi O (2 `N 00 ei 6) ll ( 20 06 Co ) nt e (2 00 4)
M
Ci r il lo
At ha na s
Average % ESV reduction following CABG plus SVR
Site Reported Left Ventricular Function for 1,000 Hypothesis 2 Patients by Treatment LV Function
CABG N = 499
CABG + SVR N = 501
Echocardiogram (%)
66%
63%
Contrast ventriculogram
13%
18%
CMR
11%
9%
Gated SPECT
10%
10%
LVEF, median (25th, 75th)
.28 (.23, .31)
.28 (.24, .31)
ESVI, median (25th, 75th), mL/m2
82 (65, 102)
82 (66, 105)
% anterior wall with akinesia/ dyskinesia, median (25th, 75th)
56 (40, 60)
50 (40, 60)
Site Qualifying Study
STICH Trial â&#x20AC;˘ Concluded adding surgical ventricular reconstruction to CABG reduce the LVV as compared with CABG alone â&#x20AC;˘ However this did not show great improvement in symptoms or exercise tolerance or in death rate
Conclusion • STICH Trial did not select the patient properly • STICH Trial is misleading because SVR was not uniformly or effectively performed and poor experienced surgeon in SVR
• STICH Trial failed to meet the goals expected to evidence base study
Conclusion â&#x20AC;˘ The large registry of SVR performed by expert surgeon and good long term results can not be ignored â&#x20AC;˘ SVR registry show improvement of the NYHA class and improvement of the neurohormonal activation which help remodling
Our Experience In KFAFH • • • •
We have done 120 Patients till now We did a pilot study on the first 60 patient It was safe and effective to perform SVR We are now Prospectively fallowing our patients to see 5 years benefit
Inclusion Criteria: • Ant - Sept MI > 2 month with Symptoms of angina or heart failure • EF < 35 % • Inducible symptoms • LVESVI > 60 mls/m2 • Favorable anatomy as per ECHO , dobutamine ECHO , contrast Echo and Cardiac MRI • Suitable anatomy of coronary arteries for revascularization.!!!!
Exclusion criteria • • • • • •
Failure to Get informed Consent & full study Recent acute MI < 4 - 6 Weeks or No AMI RV Failure.: CMR › ECHO History of prior coronary artery surgery. Severe Pulmonary Hypertension(> 60mmHg) Non cardiac illness imposing substantial operative mortality
PATIENT
AMI CARDIAC CATH.
NO AKINESIA AW
ECHO
• AKINESIA AW / DYSKINASIA • FUNCTIONING BASAL SEGMENTS
CONTRAST ECHO
VIABLE MYOCORDIUM
NO VIABLE MYOCORDIUM
CARDIAC MR CABG SVR + REVASULOIZATION
Dobutamin Echo
Transmurality of Scar
A
B
Wall Thick
Scar Thick Transmurality (%): Scar
Thick
/ Wall
Thick
x 100 or A/B x 100
e.g. 9mm/11mm x 100 = 81.81%
Chase Medical (Richardson, Texas)
Optimizing the Shape of the Ventricle and the Size
Severity of MR MITRAL Regration cevirity
Number Of Patient (%)
Trace
25 (41.6 %)
Mild
10 (16.6 %)
Modrate
15 ( 25%)
Severe
10 (16%)
LVESI changes
EF changes
NYHA :PRE AND POSTOP. 4
NYHA CLASS
3.5
3.3
3 2.5 2 1.3 1.5 1 0.5 0 Pre-Op
Post-Op
BMJ 2003;327:1459–61
37
Please Do Not Deny Your Patients The Chance of Surgical Management of Heart Failure Thanks Wabukhudair@hotmail.com