Clinical Outcomes and Prognosis

1342643 - Left anterior descending artery viability by cardiac magnetic resonance imaging in Heart Team patients with complex coronary artery disease including severe left anterior descending stenosis

Thursday, January 26, 2023

1:00 PM – 2:00 PM

Location: Pacific Jewel

Presenting Author(s)

CM

Christopher Madison, MD

Advanced Imaging Fellow
Spectrum Health
Grand Rapids, Michigan, United States

Primary Author(s)

DM

David A. McNamara, MD

Attending Physician
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, United States

Co-Author(s)

MA

Mohammad Ahmed, MD

Resident Physician
Spectrum Health/Michigan State University College of Human Medicine, United States
CK

Connor Kerndt, DO

Resident Physican
Michigan State University/Spectrum Health Internal Medicine Residency
Grand rapids, Michigan, United States
MA

Mahrukh F. Akram, MD

Fellow Physician
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
JP

Jessica L. Parker, MSc

Manager, Scholarly Activity and Scientific Support
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
SV

Stacie M. VanOosterhout

Clinical Research Coordinator/ M Ed
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
AB

Andrea Burgess, RN

Clinical Research Coordinator
Spectrum Health/Michigan State University College of Human Medicine, United States
RM

Richard F. McNamara, MD

Attending Physician
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
RM

Ryan D. Madder, MD

Attending Physician
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
DW

David H. Wohns, MD

Attending Physician
Spectrum Health/Michigan State University College of Human Medicine
Grand Rapids, Michigan, United States
Jose Mariano T. Tan, II, MD, MBA

Attending Physician
Spectrum Health
Grand Rapids, Michigan, United States
LF

Laura M. Franey, MD

Attending Physician
Spectrum Health
Grand Rapids, Michigan, United States
WA

Wissam M. Abdallah, MD

Attending Physician
Spectrum Health
Grand Rapids, Michigan, United States

Background: Cardiac MRI (CMR) is a well-established and increasingly used method of assessing myocardial viability in ischemic cardiomyopathies. However, the associations of viability in the left anterior descending (LAD) territory with treatment allocations, mortality, and change in left ventricular ejection fraction (LVEF) in those undergoing revascularization compared to those undergoing optimal medical therapy presented at a quaternary Heart Team (HT) have not been previously described.

Methods: Data were analyzed retrospectively from patients ≥18 years old presented to a HT from January 2015 to March 2021 for complex CAD. Patients with severe LAD disease, defined as stenoses ≥70% or 50-70% with fractional flow reserve < 0.80 on invasive coronary angiogram, with a CMR in the preceding 6 months were included; patients with severe valve disease/concomitant valve surgery were excluded. Data extracted included baseline comorbidities, labs, CMR findings, treatment allocation (medical therapy, percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG]), and mortality rates from the Michigan Death Index. The LAD territory was defined as the following 7 of 17 myocardial segments: basal to apical anterior, basal to mid anteroseptal, apical septal, and apical cap segments. Each segment was determined to be viable if having < 50% subendocardial fibrosis, otherwise it was deemed nonviable. The LAD territory was considered viable if at least 4 of its 7 segments were viable. LVEF change was calculated by subtracting the difference between baseline LVEF by CMR and LVEF by repeat echocardiogram.

Results: A total of 198 HT patients (75% male, mean age 65 ± 10 years) with severe LAD stenosis had a high clinical complexity and high rates of cardiovascular comorbidities (Table 1). Of these, 156 (79%) had viability in the LAD territory by CMR criteria. Baseline LV systolic function by CMR was moderate to severely reduced with an LVEF of 30%. HT treatment recommendations were as follows: 84 patients (42%) optimal medical therapy; 77 patients (39%) CABG; and, 37 patients (19%) PCI with a trend towards a higher proportion of CABG recommendations among patients with a viable compared to non-viable LAD territory (42% vs 29%, p = 0.10). No significant difference in LVEF change was observed between medical therapy and revascularization (6% vs 8%, p=0.37, Table 2) with a mean time to repeat echocardiogram of 9 months. Two-year mortality between non-viable LAD territory and viable territory was 10% vs 16% (p = 0.29) (Table 3).

Conclusion: In a large quaternary care center HT of patients referred for management of severe LAD stenosis, there was a trend toward higher CABG rates with LAD viability compared to non-viability, suggesting viability testing may play a role in HT recommendations. No differences in mortality were observed at 2 years when stratified by viability. Revascularization was not associated with differences in LVEF when compared to medical therapy alone.