(Circulation. 1999;100:141-148.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Prognostic Value of Myocardial Ischemia and Viability in Patients With Chronic Left Ventricular Ischemic Dysfunction
From the Divisions of Cardiology and Nuclear Medicine, University of Louvain Medical School, Brussels, Belgium.
Correspondence to Jean-Louis J. Vanoverschelde, MD, PhD, Division of Cardiology, Cliniques Universitaires St Luc, Avenue Hippocrate, 10-2881, B-1200, Brussels, Belgium. E-mail Vanoverschelde{at}card.ucl.ac.be
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Background—Previous studies showed that thallium scintigraphy and dobutamine echocardiography were accurate, noninvasive ways of predicting contractile recovery after revascularization in patients with left ventricular (LV) dysfunction. However, the prognostic impact of such methods remains uncertain.
Methods and Results—We prospectively studied 137 consecutive patients with coronary disease and LV dysfunction who underwent exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography to identify myocardial ischemia and viability. A total of 94 patients subsequently underwent revascularization, and 43 underwent medical treatment. The primary endpoint was cardiac mortality, and mean follow-up was 33±10 months. Twenty-four patients died of cardiac causes. By Cox's regression analysis, long-term survival was related to the extent of coronary disease, the presence of diabetes, type of treatment, the presence of ischemic myocardium as determined by thallium scintigraphy, and the presence of viable myocardium as determined by both tests. Three-year survival was greater in patients with ischemic myocardium (as determined by thallium scintigraphy) or viable myocardium (as determined by both tests) who underwent revascularization than in the other groups (P=0.018 with thallium; P<0.001 with dobutamine). Subgroup analyses indicated that among patients with 1- or 2-vessel disease, only those with ischemic or viable myocardium improved survival after revascularization, whereas in patients with 3-vessel or left main diseases, revascularization always improved survival, albeit more in the presence of ischemic or viable myocardium.
Conclusions—Among the parameters commonly available in patients with LV ischemic dysfunction, the presence of ischemic myocardium (as determined by thallium scintigraphy) and that of viable myocardium (as determined by dobutamine echocardiography) are independent predictors of subsequent mortality. These observations may be useful in the preoperative selection of patients for revascularization.
Key Words: myocardial stunning • coronary artery bypass • angioplasty • myocardial infarction
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Over the past 50 years, ischemic heart diseases have become a widespread cause of morbidity and the leading cause of mortality in the economically developed countries of the Western world. Although the relative importance of coronary deaths has declined gradually during the last decade, coronary heart disease still accounts for approximately 25% of all deaths in the United States and Europe. Mortality rates are even higher in patients with severely depressed left ventricular (LV) function.1 Several studies showed that surgical revascularization can improve the survival and symptoms of heart failure in some patients.2 3 The potential benefits of revascularization should be balanced, however, with the higher surgical mortality of patients with LV dysfunction.4
Presumably, the beneficial effects of revascularization result from restoring blood supply to dysfunctional but viable myocardial regions, with subsequent improvement in regional and global LV function. During the past decade, delineation of viable from nonviable myocardium has become the focus of considerable attention and has fostered the development of several new modalities aimed at predicting the return of LV function after revascularization. Among these modalities, exercise-redistribution-reinjection thallium scintigraphy5 6 7 8 and low-dose dobutamine echocardiography7 8 9 10 11 have recently emerged as safe, noninvasive, and accurate means of identifying viable myocardium. Although existing data suggest that both imaging modalities are useful for predicting the return of contractile function after revascularization, few data are currently available on their potential value for predicting long-term survival. Accordingly, the aims of the present study were (1) to evaluate the potential prognostic value of exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography in patients with LV ischemic dysfunction and (2) to determine whether assessing myocardial viability by either means adds independent prognostic information to that provided by baseline clinical, hemodynamic, and angiographic data and by the assessment of myocardial ischemia alone.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Study Population
Between October of 1991 and November of 1994, we prospectively studied 141 consecutive patients with coronary disease and LV dysfunction who had been referred to our institution for diagnostic cardiac catheterization. Four patients who subsequently underwent heart transplantation were excluded from the study. Among the 137 remaining patients, 117 had sustained at least 1 previous myocardial infarction, the most recent occurring 33 days before inclusion into the study. Patients were eligible for inclusion (1) if they had severe regional dysfunction in the anatomic distribution of a significantly narrowed or occluded epicardial artery as determined by contrast left ventriculography and (2) if the coronary arteries supplying the area of dysfunction were suitable for coronary bypass grafting (CABG) or percutaneous coronary angioplasty (PTCA). All patients underwent exercise-redistribution-reinjection thallium scintigraphy and low-dose dobutamine echocardiography during their hospital stay for cardiac catheterization. Subsequently, 94 patients underwent revascularization (72 by CABG and 22 by PTCA), and 43 patients were treated medically. No patient received an automatic implantable cardiac defibrillator. The decision concerning the choice of treatment was left to the referring cardiologist and was not based on the results of the viability studies. The study protocol was approved by the Ethical Committee of the University of Louvain Medical School.
Cardiac Catheterization
Selective coronary arteriography and contrast left
ventriculography were performed from the femoral approach and before
the scintigraphic and echocardiographic studies.
Significant coronary disease was defined as >70% luminal
diameter stenosis in any major coronary branch. A total
of 105 patients had 
1 major epicardial coronary segment(s)
occluded; of these 105 patients, 64 also had occlusion of the left
anterior descending coronary artery, 29 had occlusion of the
proximal circumflex artery, and 66 had occlusion of the right
coronary artery. The remaining 32 patients had severe proximal
stenoses on at least 1 major epicardial segment.
Exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography were performed and analyzed as previously described.8,11 Delineation of inducible ischemia with the 2 methods was performed using previously validated criteria.11 12 13 Patients were considered to have inducible ischemia by thallium scintigraphy if their defect extent score decreased by >3 grades between exercise and redistribution.11 12 Similarly, patients were considered to have inducible ischemia by dobutamine echocardiography in the presence of a new or the worsening of a preexisting wall motion abnormality in at least 1 myocardial segment.13 Delineation of reversible dysfunction with the 2 methods was also performed using previously validated criteria.12,13 Patients were considered to have viable myocardium by thallium scintigraphy if >50% of the dysfunctional segments exhibited a thallium uptake >50% at reinjection.12 Similarly, patients were considered to have viable myocardium on the basis of dobutamine echocardiography if wall motion score improved by at least 1 full grade in 2 adjacent akinetic segments from the same vascular territory during low-dose dobutamine treatment.13
Follow-Up Data
Patients were followed-up for 33±10 months (range, 13 to 48
months). Survival status was obtained by telephone contact with the
patients, their relatives, or the referring physician and from review
of visit or hospital records. The cause of death was categorized as
cardiac or noncardiac. Cardiac death was defined as death attributable
to congestive heart failure, myocardial infarction, cardiac arrest, or
sudden death (death within the first hour after the onset of
symptoms).
Statistical Analysis
Data were analyzed with BMDP New System Professional
Edition statistical software.14 Data are reported as
mean±SD and follow-up times as median and range. Groups were compared
with 
2 tests for discrete variables and
with a 2-way ANOVA with a Scheffé criterion for continuous
variables. Survival curves were computed with the Kaplan-Meier
method and compared using the log-rank 2 test.
A Cox's model was used to adjust for the effects of baseline
characteristics on survival. For this purpose, a preliminary model was
built from which the results of the tests were excluded.15
The ability of myocardial ischemia or viability (with and
without their interaction with treatment) to improve the prediction of
death by the preliminary model was tested by the maximum partial
likelihood ratio 2 statistic. The assumption
of proportional hazards was checked by complementary log plots.
Relative hazard ratios for each specific covariate of the final models
were computed as the exponential of the regression
coefficient.16 The total hazard ratio in a particular
patient was calculated as the product of all relative hazard
ratios. As the models only included binary covariates, the baseline
death rate corresponded to the death rate of patients with all
covariates=0. A total hazard ratio >1/1 indicates an increase in death
rate compared with baseline. Conversely, a hazard ratio <1/1 indicates
a decrease in death rate compared with baseline.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The baseline characteristics of the study population are shown in Table 1
. During follow-up, 24
patients died of cardiac causes: 5 immediately postoperatively (in the
intensive care unit), 6 of congestive heart failure, 2 of acute
myocardial infarction, and 11 of sudden death. Among the patients who
died during follow-up, 13 had undergone
revascularization, and 11 others had received
medical treatment. Figure 1 shows the
Kaplan-Meier survival curves in these 2 groups, together with that
expected in the age- and sex-adjusted Belgian population.
|
|
Relation Between Myocardial Ischemia and Myocardial
Viability
The proportion of patients exhibiting myocardial ischemia
or viability by either thallium scintigraphy or
dobutamine echocardiography is
illustrated in Figure 2. The concordance
between thallium scintigraphy and dobutamine
echocardiography for identifying myocardial
ischemia and viability is shown in Figure 3. Overall, the degree of agreement
between the 2 methods was only modest (57% for myocardial
ischemia, 63% for myocardial viability).
|
|
Relation of Myocardial Ischemia and Treatment Strategy to
Cardiac Mortality
To assess the potential prognostic value of ischemic
myocardium on long-term survival, the study population was
subdivided twice (once for thallium scintigraphy and once
for dobutamine echocardiography) into 4
subgroups composed of patients with or without myocardial
ischemia who did or did not undergo
revascularization. The different subgroups were
similar with respect to demographic variables, risk factors, extent
of coronary disease, history of previous myocardial infarction,
and indices of global LV function.
As shown in Figure 4, 3
-year survival was
higher in patients with ischemic myocardium
determined by thallium scintigraphy who underwent
revascularization (91±4%) than in the 3 other
subgroups (range, 73% to 75%; pooled value, 74±5% [logrank
P=0.015]). By contrast, 3-year survival was lower in
patients with ischemic myocardium determined by
dobutamine echocardiography who
underwent medical treatment (66±9%) than in the 3 other subgroups
(range, 84% to 90%; pooled value, 85±4% [logrank
P=0.006]).
|
Relation of Myocardial Viability and Treatment Strategy to
Cardiac Mortality
To evaluate the potential impact of myocardial viability and
treatment strategy on long-term survival, an analysis similar
to that used for ischemia was performed. The study population
was again subdivided twice (once for thallium scintigraphy
and once for dobutamine
echocardiography) into 4 subgroups composed of
patients with or without myocardial viability who did or did not
undergo revascularization. These different
subgroups were also similar with respect to most variables, except
for LV end-diastolic volume, which was larger in patients
treated medically who lacked evidence of myocardial viability by
dobutamine echocardiography.
As illustrated in Figure 5, 3-year
survival was higher in patients with viable myocardium who
underwent revascularization (91±4% with thallium
scintigraphy; 95±3% with dobutamine
echocardiography) than in any other patient
subgroups (range, 71% to 78%; pooled value, 74±5% for thallium
scintigraphy [logrank P=0.018] and 71±5% for
dobutamine echocardiography [logrank
P=0.0009]).
|
Cox's Proportional Hazards Survival Analysis
To assess the potential additive prognostic value of myocardial
ischemia and viability, a preliminary Cox's survival model was
built, on which the results of the stress tests were not included. This
model used treatment as a fixed covariate. Among the demographic,
clinical, hemodynamic, and angiographic variables
(and their interaction with treatment) included, 5 covariates were
independently associated with the time to death (Table 2). The ability of the stress tests to
improve the prediction of death by this preliminary model was tested in
4 different models, 2 for thallium scintigraphy and 2 for
dobutamine echocardiography, in which
the 5 preliminary covariates were used as fixed covariates. As shown in
Table 2, the presence of ischemic myocardium
(determined by thallium scintigraphy) and the presence of
viable myocardium (by both methods) added significant
prognostic information to that provided by the 5 initial covariates.
After multivariate analysis, however, only the
presence of myocardial ischemia determined by thallium
scintigraphy and the presence of myocardial viability
determined by dobutamine
echocardiography were independently related to
long-term prognosis. Table 3 shows the
variables retained in the final multivariate models
together with all partial hazard ratios. With the 3 models, diabetes
and extensive coronary disease (3-vessel disease, left main
stenosis, or both) were associated with an increased risk of
death. This risk was reduced in patients undergoing
revascularization. Evidence of ischemic
myocardium by thallium scintigraphy or viable
myocardium by either method in a patient undergoing
revascularization was also associated with a
reduced risk of death.
|
|
Table 3 and Figure 6 illustrate
the potential clinical impact on individual patients of a strategy in
which the variables retained in the dobutamine
echocardiography model are considered. For
instance, nondiabetic patients with moderate coronary disease
who undergo revascularization have a 2.4-fold
increase in mortality in the absence of viable myocardium
(hazard ratio [HR]=2.4), but a 2.6-fold decrease in mortality
in the presence of viable myocardium (HR=0.38). Similarly,
the baseline risk of death in diabetic patients with moderate
coronary disease treated medically is 8.9-fold higher than that
of nondiabetic patients. If these patients undergo
revascularization in the absence of viable
myocardium, their risk of death decreases only marginally
(HR=7.2). It decreases much more, however, in the presence of viable
myocardium (HR=1.2). In all instances, except with
nondiabetic patients with moderate coronary disease and
nonviable myocardium, revascularization
improved survival. The gain was significantly greater, however, in the
presence of viable myocardium. Similar results were
obtained when using thallium scintigraphy for assessing
myocardial ischemia or viability.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The long-term outcome of patients with LV ischemic dysfunction is poor, particularly when they are treated medically.1 2 3 A major goal in the management of these patients is, thus, to identify those at risk for future adverse cardiac events so that active treatment can be initiated and these events can be prevented. Risk stratification in patients with LV ischemic dysfunction typically includes a combination of clinical, hemodynamic, and angiographic parameters.17 Recent studies using myocardial metabolic imaging with positron emission tomography (PET) have indicated that assessing myocardial viability also provides useful prognostic information in these patients,17 18 19 20 21 with an effect additive to that of the usual clinical assessment.21 Whereas PET is expensive and not widely available, exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography are less expensive and potentially more widely available methods that can also distinguish viable from nonviable myocardium. Until now, studies addressing the contribution of these techniques to the detection and treatment of viable myocardium have mainly concentrated on their ability to predict the return of contractile function after revascularization.5 6 7 8 The purpose of the present study was to establish the potential prognostic implications of identifying viable and/or ischemic myocardium by either of these 2 methods in patients with LV ischemic dysfunction. The results can be summarized as follows:
- Long-term survival in patients with LV ischemic
dysfunction was related to the extent of the underlying
coronary disease, the presence of diabetes, and treatment
strategy.
- After adjusting for these clinical variables, the 3-year
survival of patients undergoing revascularization
was significantly better in the presence of myocardial ischemia
or viability. In contrast, in patients receiving medical treatment,
long-term survival was not influenced by the presence or absence of
myocardial ischemia or viability.
- In patients with viable or ischemic
myocardium, 3-year survival was significantly better in
patients undergoing revascularization as opposed to
medical treatment. In patients with nonviable myocardium,
outcome was not significantly influenced by treatment strategy.
Prognostic Implications of Myocardial Ischemia and
Viability in Patients With Chronic LV Ischemic Dysfunction
The salient findings of our study relate to the impact of viable
myocardium on the long-term outcome of patients with LV
ischemic dysfunction. The presence of viable
myocardium was evaluated in our study by
exercise-redistribution-reinjection thallium scintigraphy
and by low-dose dobutamine
echocardiography. We and others5 6 7 8 9 10 11
previously showed that both methods accurately predict the return of
regional and global LV function after
revascularization. The present study
demonstrates that, in addition, these 2 methods also provide valuable
prognostic information, with significant therapeutic implications.
Specifically, we showed that the presence of viable
myocardium by either method and the presence of
ischemic myocardium by thallium
scintigraphy help identify patients who can benefit from
revascularization. Indeed, in our study, the 3-year
survival of patients with viable or ischemic
myocardium who underwent
revascularization was 91% to 95% (depending on
the parameter used), a value that is remarkably similar to
that expected in the age- and sex-adjusted Belgian population (93%).
In contrast, in similar patients treated medically, 3-year survival was
only 71% to 75%, thus demonstrating the need to proceed to
revascularization in such patients. It is probable
that the prognostic benefits of revascularization
in patients with viable myocardium extend well beyond the
simple prevention of recurrent ischemia and involve a direct
effect on global LV function. In a subgroup of 43 patients with viable
myocardium included in this study, we had previously shown
that revascularization improved global LV ejection
fraction by an average of 13%, a change that is likely to impact
survival.8 In contrast, in 30 patients with nonviable
myocardium, revascularization did not
result in any significant changes in global LV function and barely
prevented LV dilatation.8 Likewise, in the present
study, revascularization had no major influence on
long-term outcome in the absence of viable myocardium. This
was particularly true for nondiabetic patients with moderately severe
coronary disease and nonviable myocardium; in these
patients, surgical revascularization tended to
increase the risk of death 2.4-fold (Table 3).
Recent studies have started to address the prognostic significance of viable myocardium in patients who do and do not undergo revascularization. Eitzman et al18 used PET to study the role of viable myocardium in the occurrence of adverse cardiac events in 80 coronary patients, 40 of whom underwent revascularization. Patients with viable myocardium who were not revascularized had significantly more events and were more likely to die than those undergoing revascularization. Similarly, in 79 patients with severe LV dysfunction undergoing metabolic imaging with PET, Di Carli et al20 showed that unrevascularized patients with viable myocardium had a greater likelihood of sudden cardiac death than patients undergoing revascularization. Similar findings were recently reported by Lee et al.21 Thus, with respect to the outcome of patients with viable myocardium, our results agree with those from these earlier reports. They differ, however, with respect to the outcome of patients with nonviable myocardium. Whereas in the studies of Eitzman et al,18 Di Carli et al,20 and Lee et al,21 patients with nonviable myocardium had an excellent prognosis (3-year survival, 82% to 100%), these patients definitely had a poorer outcome in our study. Our results are nonetheless in agreement with those of Yoshida and Gould,22 who used 82Rb and PET to identify myocardial viability, and with the more recent reports of Pagley et al23 and Petretta et al,24 who used thallium scintigraphy as a means of identifying viable myocardium. They also concur with those of Williams et al,25 who studied 136 medically treated patients with LV ischemic dysfunction with low-dose dobutamine echocardiography. Interestingly, in this latter study, the authors divided their population of patients with nonviable myocardium into 2 groups according to the presence of inducible ischemia at higher doses of dobutamine. Whereas the outcome of patients with nonviable myocardium but inducible ischemia was extremely poor, that of patients without inducible ischemia was good. We made very similar observations in our study. Indeed, the 3-year survival of our medically treated patients with nonviable myocardium was poor (43%) when ischemia was inducible at high doses of dobutamine, whereas it was much better in the absence of inducible ischemia (7 of 7 patients were alive after 3 years). Altogether, these data suggest that myocardial ischemia and viability probably need to be assessed in combination to fully appreciate the long-term prognosis of patients with chronic LV ischemic dysfunction. In daily clinical practice, this can be probably achieved by either of 3 methods: exercise-redistribution-reinjection thallium scintigraphy single photon emission computed tomography (SPECT), low- and high-dose dobutamine echocardiography, and rest fluorodeoxyglucose-PET imaging (because it can readily identify both viable and ischemically compromised myocardium).
Risk Stratification in Patients With LV Ischemic
Dysfunction
This study categorized patients into subgroups with varying risks
of death and used this information clinically. By combining the
clinical variables retained in the initial Cox's model with the
information on myocardial ischemia and viability, it became
possible to evaluate the risk of death in an individual patient and to
determine whether he or she was likely to benefit from an intervention
in terms of long-term outcome. For instance, the data indicate that
patients with 1- or 2-vessel disease and LV dysfunction (55% of our
study population) are unlikely to benefit from
revascularization in the absence of viable or
ischemic myocardium. In patients with more severe
coronary disease, the data show that
revascularization will always improve survival. The
survival benefit is 3 to 4 times greater, however, in the presence of
viable or ischemic myocardium.
Study Limitations
Although the present study had a prospective design, for
obvious ethical reasons, we did not randomly allocate patients to
either medical treatment or revascularization. This
decision was based on the fact that many of our patients had extensive
coronary disease and a low ejection fraction. Therefore, we
felt it was unethical to randomize treatment. Thus, we always proposed
a revascularization procedure to the referring
cardiologist and the patients. For various reasons, a significant
number of patients did not undergo the proposed
revascularization procedure, giving us the
opportunity to examine the impact of ischemia and viability on
the prognosis of medically treated patients as well. It should be
stressed that the decision to treat medically was never based on the
fact that the coronary vessels were inadequate for a
revascularization procedure. Instead, we only
selected patients whose coronary vessels were angiographically
suitable for either PTCA or CABG and in whom the likelihood of complete
revascularization was high. In addition, none of
the patients suffered from potentially lethal noncardiac diseases that
could have compromised their long-term prognosis. As a consequence of
this selection procedure and despite the absence of randomization, most
of the variables that were considered in the survival
analysis were well balanced between the different patient
subgroups. However, we cannot completely exclude the possibility that
some unaccounted factors influencing selection for either treatment
option nonetheless contributed to our results.
|
Conclusions |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The present study indicates that, among the parameters commonly available in the preoperative assessment of patients with chronic LV ischemic dysfunction, the presence of diabetes, the extent of the underlying coronary artery disease, the treatment options, the presence of inducible ischemia (determined by thallium scintigraphy but not by dobutamine echocardiography), and the presence of viable myocardium (determined by both thallium scintigraphy and dobutamine echocardiography) are independently associated with subsequent mortality. These observations may be useful in determining which patients with impaired LV function are most likely to benefit from revascularization.
|
Acknowledgments |
|---|
This work was supported in part by grant Action de recherche concertée n°96/01-199 and Fonds de recherche scientifique et médicale n°3.4540.95.
Received August 7, 1998; revision received April 21, 1999; accepted April 22, 1999.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
1. Emond M, Mock MB, Davis KB, Fisher LD, Holmes DR, Chaitman BR, Kaiser GC, Alderman E, Killip T. Long-term survival of medically-treated patients in the Coronary Artery Surgery Study (CASS) registry. Circulation. 1994;90:2645–2657.
2.
Alderman EL, Fisher LD, Litwin P, Kaiser GC, Myers WO,
Maynard C, Levine F, Schloss M. Results of coronary artery
surgery in patients with poor left ventricular function
(CASS). Circulation. 1983;68:785–795.
3. European Coronary Surgery Study Group. Long term results of prospective randomized study of coronary artery bypass surgery in stable angina pectoris. Lancet. 1982;2:1173–1180.[Medline] [Order article via Infotrieve]
4. Kirklin JW, Naftel DC, Blackstone EH, Prohost GM. Summary of a consensus concerning death and ischemic events after coronary artery bypass surgery. Circulation. 1989;79(suppl I):81–91.
5. Dilsizian V, Rocco TP, Freedman-NM, Leon MB, Bonow RO. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress redistribution imaging. N Engl J Med. 1990;323:141–146.[Abstract]
6.
Bonow RO, Dilsizian V, Cuocolo-A, Bacharach SL.
Identification of viable myocardium in patients with
chronic coronary artery disease and left
ventricular dysfunction. Comparison of thallium
scintigraphy with reinjection and PET imaging with F-18
deoxyglucose. Circulation. 1991;83:26–37.
7.
Arnese M, Cornel JH, Salustri A, Maat APWM, Elhendy A,
Ambroos EMR, TenCate FJ, Keane D, Balk AHMM, Roelandt JRTC, Fioretti
PM. Prediction of improvement of regional left ventricular
function after surgical revascularization: a
comparison of low-dose dobutamine
echocardiography with 201Tl
single photon emission computed tomography. Circulation. 1995;91:2748–2752.
8. Vanoverschelde J-L, d'Hondt A-M, Marwick T, Gerber BL, De Kock M, Dion R, Wijns W, Melin JA. Head-to-head comparison of exercise-redistribution-reinjection thallium SPECT and low-dose dobutamine echocardiography for prediction of the reversibility of chronic left ventricular ischemic dysfunction. J Am Coll Cardiol. 1996;28:432–442.[Abstract]
9.
Cigarroa CG, deFilippi CR, Brickner E, Alvarez LG,
Wait MA, Grayburn PA. Dobutamine stress
echocardiography identifies hibernating
myocardium and predicts recovery of left
ventricular function after coronary
revascularization. Circulation. 1993;88:430–436.
10. La Canna G, Alfieri O, Giubbini R, Gargano M, Ferrari R, Visioli O. Echocardiography during infusion of dobutamine for identification of reversible dysfunction in patients with coronary artery disease. J Am Coll Cardiol. 1994;23:617–626.[Abstract]
11. Vanoverschelde J-L, Gerber BL, D'Hondt A-M, De Kock M, Dion R, Wijns W, Melin JA. Preoperative selection of patients with severely impaired left ventricular function for coronary revascularization: role of low-dose dobutamine echocardiography and exercise-redistribution-reinjection thallium SPECT. Circulation. 1995;92:II-37–II44.
12. Iskandrian AS, Chae SC, Heo J, Stanberry CD, Wasserleben V, Cave V. Independent and incremental prognostic value of exercise single photon emission computed (SPECT) thallium imaging in coronary artery disease. J Am Coll Cardiol. 1993;22:665–667.[Abstract]
13. Afridi I, Main ML, Grayburn PA. Accuracy of dobutamine echocardiography for detection of myocardial viability in patients with an occluded left anterior descending coronary artery. J Am Coll Cardiol. 1996;25:455–459.
14. Statistical Solutions Inc. BMDP New System Professional Edition. Berkeley, Calif: University of California Press; 1995.
15. Harrel FE, Kerry LL, Mark DB. Multivariate prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15:361–387.[Medline] [Order article via Infotrieve]
16. Parmar MKB, Machin D. Survival Analysis: A Practical Approach. New York: John Wiley; 1995.
17.
Hamer AW, Takayama M, Abraham KA, Roche AHG, Kerr
AR, Williams BF, Ramage C, White HD. End-systolic volume and
long-term survival after coronary artery bypass graft surgery
in patients with impaired left ventricular function.
Circulation. 1994;90:2899–2904.
18. Eitzman D, Al-Aouar Z, Kanter HL, vom Dahl J, Kirsh M, Deeb GM, Schwaiger M. Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography. J Am Coll Cardiol. 1992;20:559–565.[Abstract]
19. Tamaki N, Kawamoto M, Takahashi N, Yonekura Y, Magata Y, Nohara R, Kambara H, Sasayama S, Hirata K, Ban T, Konishi J. Prognostic value of an increase in fluorine-18-deoxyglucose uptake in patients with myocardial infarction: comparison with stress-thallium imaging. J Am Coll Cardiol. 1993;22:1621–1627.[Abstract]
20. Di Carli MF, Davidson M, Little R, Khanna S, Mody FV, Brunken RC, Czernin J, Rokhsar S, Stevenson LW, Laks H, Schelbert HR. Value of metabolic imaging with positron emission tomography for evaluating prognosis in patients with coronary artery disease and left ventricular dysfunction. Am J Cardiol. 1994;73:527–533.[Medline] [Order article via Infotrieve]
21.
Lee KS, Marwick TH, Cook SA, Go RT, Fix JS, James KB,
Sapp SK, MacIntyre WJ, Thomas JD. Prognosis of patients with left
ventricular dysfunction, with and without viable
myocardium after myocardial infarction: relative efficacy
of medical therapy and revascularization.
Circulation. 1994;90:2687–2694.
22. Yoshida K, Gould KL. Quantitative relation of infarct size and myocardial viability by positron emission tomography to left ventricular ejection fraction and 3-year mortality with and without revascularization. J Am Coll Cardiol. 1993;22:984–997.[Abstract]
23.
Pagley PR, Beller GA, Watson DD, Gimple LW, Ragosta M.
Improved outcome after coronary bypass surgery in patients with
ischemic cardiomyopathy and residual
myocardial viability. Circulation. 1997;96:793–800.
24.
Petretta M, Cuocolo A, Bonaduce D, Nicolai E, Cardei S,
Berardino S, Ianniciello A, Apicella C, Bianchi V, Salvatore M.
Incremental prognostic value of thallium reinjection after
stress-redistribution imaging in patients with previous myocardial
infarction and left ventricular dysfunction. J
Nucl Med. 1997;38:195–200.
25. Williams MJ, Odabashian J, Lauer MS, Thomas JD, Marwick TH. Prognostic value of dobutamine echocardiography in patients with left ventricular dysfunction. J Am Coll Cardiol. 1996;27:132–139. We investigated the prognostic value of myocardial viability and ischemia by exercise-redistribution-reinjection thallium scintigraphy and dobutamine echocardiography in 137 consecutive patients with coronary disease and LV dysfunction. Three-year mortality was lower in patients undergoing revascularization who exhibited ischemic myocardium by thallium scintigraphy or viable myocardium by dobutamine echocardiography.[Abstract]
This article has been cited by other articles:
 |
|
 |
|
  R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC) Eur J Echocardiogr, July 1, 2008; 9(4): 415 - 437. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. G. Camici, S. K. Prasad, and O. E. Rimoldi Stunning, Hibernation, and Assessment of Myocardial Viability Circulation, January 1, 2008; 117(1): 103 - 114. [Full Text] [PDF]
|
|
|
|
 |
|
 L. Cortigiani, R. Sicari, A. Desideri, R. Bigi, F. Bovenzi, E. Picano, and on behalf of the VIDA (Viability Identification wi Dobutamine stress echocardiography and the effect of revascularization on outcome in diabetic and non-diabetic patients with chronic ischaemic left ventricular dysfunction Eur J Heart Fail, October 1, 2007; 9(10): 1038 - 1043. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Pocar, A. Moneta, A. Grossi, and F. Donatelli Coronary Artery Bypass for Heart Failure in Ischemic Cardiomyopathy: 17-Year Follow-Up Ann. Thorac. Surg., February 1, 2007; 83(2): 468 - 474. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. Rizzello, D. Poldermans, E. Biagini, A. F.L. Schinkel, E. Boersma, A. Elhendy, F. B. Sozzi, A. Maat, J. R.T.C. Roelandt, and J. J. Bax Benefits of coronary revascularisation in diabetic and non-diabetic patients with ischaemic cardiomyopathy: Role of myocardial viability Eur J Heart Fail, May 1, 2006; 8(3): 314 - 320. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V Rizzello, D Poldermans, A F L Schinkel, E Biagini, E Boersma, A Elhendy, F B Sozzi, A Maat, F Crea, J R T C Roelandt, et al. Long term prognostic value of myocardial viability and ischaemia during dobutamine stress echocardiography in patients with ischaemic cardiomyopathy undergoing coronary revascularisation Heart, February 1, 2006; 92(2): 239 - 244. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Chareonthaitawee, B. J. Gersh, P. A. Araoz, and R. J. Gibbons Revascularization in Severe Left Ventricular Dysfunction: The Role of Viability Testing J. Am. Coll. Cardiol., August 16, 2005; 46(4): 567 - 574. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T Zaglavara, T Pillay, H Karvounis, R Haaverstad, G Parharidis, G Louridas, and A Kenny Detection of myocardial viability by dobutamine stress echocardiography: incremental value of diastolic wall thickness measurement Heart, May 1, 2005; 91(5): 613 - 617. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S.R. Underwood, J. J Bax, J. v. Dahl, M. Y Henein, A. C van Rossum, E. R Schwarz, J.-L. Vanoverschelde, E. E.v. d. Wall, and W. Wijns Imaging techniques for the assessment of myocardial hibernation: Report of a Study Group of the European Society of Cardiology Eur. Heart J., May 2, 2004; 25(10): 815 - 836. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Nelson, J. McCrohon, F. Khafagi, S. Rose, R. Leano, and T. H. Marwick Impact of scar thickness on the assessment of viability using dobutamine echocardiography and thallium single-photon emission computed tomography: A comparison with contrast-enhanced magnetic resonance imaging J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1248 - 1256. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J H McGowan Hibernating myocardium: high or low risk? Heart, March 1, 2004; 90(3): 237 - 238. [Full Text] [PDF]
|
|
|
|
|
|
H. Yang, M. Pu, D. Rodriguez, D. Underwood, B. P. Griffin, V. Kalahasti, J. D. Thomas, and R. C. Brunken Ischemic and viable myocardium in patients with Non-Q-Wave or Q-Wave myocardial infarction and left ventricular dysfunction: A clinical study using positron emission tomography, echocardiography, and electrocardiography J. Am. Coll. Cardiol., February 18, 2004; 43(4): 592 - 598. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Sawada, A. Bapat, D. Vaz, J. Weksler, N. Fineberg, A. Greene, I. Gradus-Pizlo, and H. Feigenbaum Incremental value of myocardial viability for prediction of Long-Term prognosis in surgically revascularized patients with left ventricular dysfunction J. Am. Coll. Cardiol., December 17, 2003; 42(12): 2099 - 2105. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. R. Knuesel, D. Nanz, C. Wyss, M. Buechi, P. A. Kaufmann, G. K. von Schulthess, T. F. Luscher, and J. Schwitter Characterization of Dysfunctional Myocardium by Positron Emission Tomography and Magnetic Resonance: Relation to Functional Outcome After Revascularization Circulation, September 2, 2003; 108(9): 1095 - 1100. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.G.F. Cleland, N. Freemantle, S.G. Ball, R.S. Bonser, P. Camici, S. Chattopadhyay, D. Dutka, J. Eastaugh, J. Hampton, S. Large, et al. The heart failure revascularisation trial (HEART): rationale, design and methodology Eur J Heart Fail, June 1, 2003; 5(3): 295 - 303. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Meluzin, J. Cerny, L. Spinarova, J. Toman, L. Groch, F. Stetka, M. Frelich, P. Hude, J. Krejci, L. Rambouskova, et al. Prognosis of patients with chronic coronary artery disease and severe left ventricular dysfunction. The importance of myocardial viability Eur J Heart Fail, January 1, 2003; 5(1): 85 - 93. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F.-J. Neumann and N. Jander How to best counteract the enemies? By ensuring adequate oxygen delivery Eur. Heart J. Suppl., November 1, 2002; 4(suppl_G): G35 - G42. [Abstract] [PDF]
|
|
|
|
|
|
K. C. Allman, L. J. Shaw, R. Hachamovitch, and J. E. Udelson Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis J. Am. Coll. Cardiol., April 3, 2002; 39(7): 1151 - 1158. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. O. Bonow Myocardial viability and prognosis in patients with ischemic left ventricular dysfunction J. Am. Coll. Cardiol., April 3, 2002; 39(7): 1159 - 1162. [Full Text] [PDF]
|
|
|
|
 |
|
 K. F. Kofoed, R. Bangsgaard, S. Carstensen, J. H. Svendsen, P. R. Hansen, H. Arendrup, B. Hesse, and H. Kelbaek Prolonged ischemic heart disease and coronary artery bypass -- relation to contractile reserve Eur. J. Cardiothorac. Surg., March 1, 2002; 21(3): 417 - 423. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B.L Gerber, F.F Ordoubadi, W Wijns, J.-L.J Vanoverschelde, M.J Knuuti, M Janier, P Melon, P.K Blanksma, A Bol, J.J Bax, et al. Positron emission tomography using18F-fluoro-deoxyglucose and euglycaemic hyperinsulinaemic glucose clamp: optimal criteria for the prediction of recovery of post-ischaemic left ventricular dysfunction. Results from the European Community Concerted Action Multicenter study on use of18F-fluoro-deoxyglucose Positron Emission Tomography for the Detection of Myocardial Viability Eur. Heart J., September 2, 2001; 22(18): 1691 - 1701. [Abstract] [PDF]
|
|
|
|
|
|
Task Force for the Diagnosis and Treatment of Chro, W. J. Remme, and K. Swedberg Guidelines for the diagnosis and treatment of chronic heart failure Eur. Heart J., September 1, 2001; 22(17): 1527 - 1560. [PDF]
|
|
|
|
|
|
J.J. Bax, A. Elhendy, E. Boersma, and D. Poldermans Evaluation of patients with chronic ischaemic left ventricular dysfunction - assessment of tissue viability Eur. Heart J. Suppl., September 1, 2001; 3(suppl_F): F11 - F14. [Abstract] [PDF]
|
|
|
|
|
|
J. Shirani, J. Lee, R. Quigg, R. Pick, S. L. Bacharach, and V. Dilsizian Relation of thallium uptake to morphologic features of chronic ischemic heart disease: evidence for myocardial remodeling in noninfarcted myocardium J. Am. Coll. Cardiol., July 1, 2001; 38(1): 84 - 90. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R Schulz and G Heusch Hibernating myocardium Heart, December 1, 2000; 84(6): 587 - 594. [Full Text]
|
|
|
|
|
|
G. A. Beller and B. L. Zaret Contributions of Nuclear Cardiology to Diagnosis and Prognosis of Patients With Coronary Artery Disease Circulation, March 28, 2000; 101(12): 1465 - 1478. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||