美国西切斯特医学中心Jolio A. Panza小组分析了缺血性心肌病的心肌存活和远期预后。相关论文于2019年8月22日发表在国际学术期刊《新英格兰医学杂志》上。

在601例接受冠状动脉旁路移植术（CABG，即心脏搭桥术）且左心室射血分数低于35%的冠状动脉疾病患者中，研究团队采用单光子发射计算机断层扫描或多巴酚丁胺超声心动图对心肌存活进行了前瞻性评估。患者被随机分配至CABG联合药物治疗组或单独药物治疗组，平均随访时间为10.4年。

CABG联合药物治疗组298例患者中有182例死亡，总死亡率显著低于单独药物治疗组（303例患者中有209例死亡），调整后的风险比为0.73。然而，两组之间的临床疗效与是否有心肌存活无显著交互作用。仅在心肌存活的患者中观察到左心室射血分数增加，与治疗方案无关。左心室射血分数的变化与后续死亡也无关。

综上，该课题组的研究结果不支持心肌存活会使缺血性心肌病患者CABG术后长期获益。存活心肌的存在可改善左心室收缩功能，但与治疗方案无关，亦不会改善长期生存。

研究人员表示，心肌存活评估在确定缺血性心肌病患者可能受益于手术血运重建仍存在争议。此外，尽管改善左心室功能是血运重建的目标之一，但其预后尚不明确。

附：英文原文

Title: Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy

Author: Julio A. Panza, M.D., Alicia M. Ellis, Ph.D., Hussein R. Al-Khalidi, Ph.D., Thomas A. Holly, M.D., Daniel S. Berman, M.D., Jae K. Oh, M.D., Gerald M. Pohost, M.D., George Sopko, M.D., Lukasz Chrzanowski, M.D., Daniel B. Mark, M.D., Tomasz Kukulski, M.D., Liliana E. Favaloro, M.D., Gerald Maurer, M.D., Pedro S. Farsky, M.D., Ru-San Tan, M.D., Federico M. Asch, M.D., Eric J. Velazquez, M.D., Jean L. Rouleau, M.D., Kerry L. Lee, Ph.D., and Robert O. Bonow, M.D.

Issue&Volume: Vol 381 No 7, 22 August 2019

Abstract:

The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear.

Methods

Among 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years.

Results

CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P=0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death.

Conclusions

The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival.

DOI: 10.1056/NEJMoa1807365

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1807365