Effect of Myocardial Viability, Functional Recovery and PCI on Clinical Outcomes in the - PowerPoint Presentation

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Effect of Myocardial Viability, Functional Recovery and PCI on Clinical Outcomes in the - PPT Presentation

Prof Divaka Perera MD FRCP Kings College London UK On behalf of the REVIVED Investigators divakaperera REVIVEDBCIS2 Allman Shaw Hachamovitch Udelson JACC 2002 Binary Viability Classification ID: 1048533

characterization viability viable recovery viability characterization recovery viable adjusted cmr outcome ventricular primary death revived scar predicts segments lge

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1. Effect of Myocardial Viability, Functional Recovery and PCI on Clinical Outcomes in the REVIVED-BCIS2 Trial Prof Divaka Perera MD FRCPKing’s College London, UKOn behalf of the REVIVED Investigators@divaka_perera | @REVIVED_BCIS2

2. Allman, Shaw, Hachamovitch, Udelson. JACC 2002Binary Viability ClassificationSPECT/PET/DSEObservationalMeta-analysis

3. STICH(ES) Viability StudyBonow et al NEJM 2011; Panza et al NEJM 2019Binary Viability ClassificationSPECT/DSEDiscretionary Testing

5. H1Hypothesis 1Viability characterization predicts event-free survival

6. H1H2Hypothesis 2Viability characterization predicts left ventricular recovery

7. H1H3H2Hypothesis 3Viability characterization predicts response toPCI vs OMT

8. H1H4H3H2Hypothesis 4Left ventricular recovery predicts event-free survival

9. ScarPotential for recoveryViability characterized by continuous variables

10. Primary OutcomeAll-cause death or hospitalisation for heart failureMajor Secondary OutcomeLeft ventricular ejection fraction at 6- and 12-monthsPerera et al, NEJM 2022: 1351-1360

11. Viability CharacterizationBlinded CMR Core LaboratoryDirector: Prof Amedeo ChiribiriBlinded Stress Echo Core LaboratoryDirector: Prof Roxy Senior

12. All segments DysfunctionalNormokineticWall motionPotential for recoveryDysfunctional-ViableDSE (CR)CMR LGE ≤25%Non-Viable DSE (no CR)CMR LGE >25%610 patientsDysfunctional yet viable myocardium (% of LV)Viability Characterization: Potential for Recovery

13. All segments DysfunctionalNormokineticWall motionPotential for recoveryDysfunctional-ViableDSE (CR)CMR LGE ≤25%Non-Viable DSE (no CR)CMR LGE >25%Viability Characterization: Potential for Recovery Dysfunctional-ViableNormalAll Viable Myocardium+(% of LV)

14. 141 - 2526 - 5051 - 75Scar Burden(% of LV)Wall motionSegmental scarAll segments 478patients76 - 100Viability Characterization: Scar Burden0

15. Outcome measures All-cause death or hospitalization for heart failureChange in LV EF at 6 months Binary (≥ median change)Cox Proportional Hazardsadjusted for agesexdiabetesprevious HFHchronic renal failureextent of CAD (BCIS-JS)modality of viability testingbaseline LV ejection fractionStatistical considerations

16. 700 underwent randomisation347 assigned to PCI + OMT353 assigned to OMT only Primary outcome in 99.2%Primary outcome in 98.7%Primary outcome in 100%Primary outcome in 100%Follow up6 unavailable4 insufficient qualityCMRn = 236DSEn = 594 insufficient quality16 unavailable3 had CMR2 insufficient qualityDSEn = 72CMRn = 24324 unavailable4 had CMR4 insufficient qualityCore labsDSEn = 93 DSEn = 91CMRn = 246CMRn = 247Othern = 14Othern = 17Viability testingRandomisation

17. 17PCIn=295OMTn=315Alln=610Age (yrs)69.8 (9.1)68.8 (8.9)69.3 (9.0)Female sex37 (12.5)38 (12.1)75 (12.3)Diabetes116 (39.3)134 (42.5)250 (41.0)BCIS jeopardy score 10 [8, 12]10 [8, 12]10 [8, 12]Left ventricular ejection fraction (%)32.0 (9.9)32.0 (9.7)32.0 (9.8)Viability test CMR DSE236 (80.0)59 (20.0)243 (77.1)72 (22.9)479 (78.5)131 (21.5)Normal segments6 [4, 9]6 [4, 9]6 [4, 9]Dysfunctional-Viable segments5 [3, 9]5 [2, 8]5 [2, 8]Non-viable segments5 [2, 7]5 [2, 7]5 [2, 7]Baseline characteristics

18. Dysfunctional-Viable MyocardiumHR 0.98 (CI 0.93 to 1.04)*p=0.56 (adjusted) All-Viable MyocardiumHR 0.93 (CI 0.87 to 1.00)*p=0.048 (adjusted) Death or HHF by viability characterization*per 10% increase in volume

19. Scar burdenHR 1.18 (CI 1.04 to 1.33)p=0.009 (adjusted)per 10% increase in scar volume Death or HHF by scar burden

20. Treatment effect by viability characterization

21. Adjusted hazard ratio 0.98 (0.61 to 1.59)Adjusted hazard ratio 0.83 (0.54 to 1.28)Adjusted hazard ratio 1.28 (0.79 to 2.10)p for interaction = 0.43Treatment effect by viability characterization

22. Left ventricular recovery by viability characterizationBinary LV recovery: ≥ median change (4.7% EF)

23. Treatment effect by viability characterization

24. Death or HHF by LV recoveryGraph only includes patients with paired baseline and 6-month corelab-analyzed echocardiograms(without imputation)HR 0.62 (0.41 to 0.95)p=0.029 (adjusted)

25. ConclusionsThe abundance of dysfunctional-yet-viable segments was not associated with prognosis or likelihood of LV recovery✅Scar burden predicts prognosis and likelihood of LV recovery in ischemic cardiomyopathyindependent of baseline LVEF or extent of CAD✅✅PCI does not improve prognosis or LV recovery in ischemic cardiomyopathy, compared to OMT alone, regardless of viability characteristics at baseline❌❌@divaka_perera | @REVIVED_BCIS2

26. THANK YOU@divaka_perera | @REVIVED_BCIS2CORE LABSCMRDSEEcho