Prognostic Value of Myocardial Viability by Delayed-Enhanced Magnetic Resonance in Patients With Coronary Artery Disease and Low Ejection Fraction Impact of Revascularization Therapy
Prognostic Value of Myocardial Viability by Delayed-Enhanced Magnetic Resonance in Patients With Coronary Artery Disease and Low Ejection Fraction Impact of Revascularization Therapy
复制标题
DOI：
10.1016/j.jacc.2011.09.073
复制
发表时间：
2012-02-28
影响因子：
24
通讯作者：
Vanoverschelde, Jean-Louis J.
中科院分区：
文献类型：
--
作者：
Gerber, Bernhard L.;Rousseau, Michel F.;Vanoverschelde, Jean-Louis J.
目的探讨延迟增强心脏磁共振(DE-CMR)和血管重建术对冠心病(CAD)和低射血分数(EF)患者存活率的影响。既往研究表明，DE-CMR可预测冠状动脉重建后左心功能不全的恢复。86例患者接受了功能障碍心肌的完全血运重建(79例冠状动脉搭桥术，7例经皮冠状动脉介入治疗)，58例患者仍在接受内科治疗。结果中位3年随访期间，49例患者死亡。接受药物治疗的存活功能障碍患者的三年存活率明显低于无存活心肌的患者(48%比77%，p=0.02)。相比之下，在血运重建的患者中，无论心肌存活与否，存活率都是相似的(分别为88%和71%，p=NS)。存活心肌继续接受药物治疗与完全血运重建相比死亡风险为4.56(95%可信区间[CI]：1.93至10.8)。COX多变量分析显示，血运重建和生存能力的交互作用为基线生存预测因素(纽约心脏协会功能分级、室壁运动评分和外周动脉疾病)提供了显著的附加值(卡方检验=13.1p=0.004)。更重要的是，在43对倾向评分匹配的患者中，接受药物治疗的患者的死亡风险(风险比：2.5[95%CI：1.1至6.1]，p=0.02)仍然显著高于那些完全血运重建的存活心肌患者。结论在没有血管重建的情况下，DE-CMR存在功能障碍的存活心肌是缺血性左心功能不全患者死亡的独立预测因素。这一观察结果可能有助于术前选择患者进行血运重建。(J Am Coll心脏ol 2012；59：825-35)(C)2012，美国心脏病学会基金会
Objectives The purpose of this study was to evaluate the impact of myocardial viability assessment by delayed-enhanced cardiac magnetic resonance (DE-CMR) and of revascularization therapy on survival in patients with coronary artery disease (CAD) and low ejection fraction (EF).Background Prior studies have shown that DE-CMR predicts recovery of left ventricular (LV) dysfunction after revascularization.Methods The authors prospectively evaluated survival of 144 consecutive patients (130 males, age 65 +/- 11 years) with CAD and LV dysfunction (EF: 24 +/- 7%) undergoing DE-CMR. Eighty-six patients underwent complete revascularization of dysfunctional myocardium (79 coronary artery bypass grafting, 7 percutaneous coronary intervention), whereas 58 patients remained under medical treatment.Results Over the 3-year median follow-up, 49 patients died. Three-year survival was significantly worse in medically treated patients with dysfunctional viable than with nonviable myocardium (48% vs. 77% survival, p = 0.02). By contrast, in revascularized patients, survival was similar whether myocardium was viable or not (88% and 71% survival, respectively, p = NS). Hazard of death of viable myocardium remaining under medical treatment versus complete revascularization was 4.56 (95% confidence interval [CI]: 1.93 to 10.8). Cox multivariate analysis indicated that interaction of revascularization and viability provided significant additional value (chi-square test = 13.1, p = 0.004) to baseline predictors of survival (New York Heart Association functional class, wall motion score, and peripheral artery disease). More importantly, in 43 pairs of propensity score-matched patients, hazard of death (hazard ratio: 2.5 [95% CI: 1.1 to 6.1], p = 0.02) remained significantly higher for medically treated patients rather than for those with fully revascularized viable myocardium.Conclusions Without revascularization, presence of dysfunctional viable myocardium by DE-CMR is an independent predictor of mortality in patients with ischemic LV dysfunction. This observation may be useful for pre-operative selection of patients for revascularization. (J Am Coll Cardiol 2012; 59: 825-35) (C) 2012 by the American College of Cardiology Foundation