Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction
Authors: Perera Divaka , Ryan Matthew , Morgan Holly P. , Greenwood John P. , Petrie Mark C. , Dodd Matthew , Weerackody Roshan , O’Kane Peter D. , Masci Pier Giorgio , Nazir Muhummad Sohaib , Papachristidis Alexandros , Chahal Navtej , Khattar Rajdeep , Ezad Saad M. , Kapetanakis Stam , Dixon Lana J. , De Silva Kalpa , McDiarmid Adam K. , Marber Michael S. , McDonagh Theresa , McCann Gerry P. , Clayton Tim C. , Senior Roxy , Chiribiri Amedeo ,   REVIVED-BCIS2 Investigators, Carr-White Gerry , Pavlidis Antonis , Redwood Simon , Clapp Brian , Rinaldi Aldo , Rahman Haseeb , Briceno Natalia , Arnold Sophie , Raynsford Amy , McEntegart Margaret , Watkins Stuart , Shaukat Aadil , Rocchiccioli Paul , Cowan Louise , Davies Ceri , Smith Elliott , Modi Bhavik , Din Jehangir , Hinton Jonathon , Blaxill Jonathan , Mozid Abdul , Anderson Michelle , Walsh Simon , Spence Mark , Glover Patricia , Edwards Richard , Egred Mohaned , Stevenson Hannah , Amin-Youssef George , Shah Ajay , Byrne Jonathan , Pareek Nilesh , Breeze Jonathan , Gershlick Anthony , Ladwiniec Andrew , Squire Iain , Alexander Donna , Strange Julian , Johnson Tom , Nightingale Angus , Gallego Laura , Spratt James , Cosgrove Claudia , Williams Rupert , Firoozi Sam , Lim Pitt , Conway Dwayne , Swoboda Peter , Brooksby Paul , Cotton James , Horton Richard , Metherell Stella , Hogrefe Kai , Cheng Adrian , Sidgwick Sian , Lockie Tim , Patel Niket , Rakhit Roby , Ahmed Fozia , Hendry Cara , Fath-Ordoubadi Farzin , Frazer Douglas , Mamas Mamas , Behan Miles , Japp Alan , Jenkins Nicholas , McClure Sam , Martin Karen , Abdelaal Eltigani , Sarma Jaydeep , Sastry Sanjay , Riley Jo , Magapu Pradeep , Stables Rod , Wright David , Mahmoudi Michael , Flett Andrew , Curzen Nick , Gough Sam , Nicholas Zoe , Ludman Andrew , Kurdi Hibba , Keenan Sam , Thorpe Kevin , Banerjee Prithwish , Tapp Luke , Panicker Abeesh , De Belder Mark , Thambyrajah Jeet , Swanson Neil , Kukreja Neville , Lynch Mary , Viswanathan Girish , Jones Elaine , Norman Sarah , Routledge Helen , Trevelyan Jasper , Pegge Nick , Dhamrajit Sukhbir , Wells Tim , Sinha Manas , Galasko Gavin , Cassidy Christopher , Edwards Tim , Iqbal Javed , Witherow Fraser , Lee Kaeng , Beattie James , Pitt Mike , Gunn Julian , Al-Mohammad Abdallah , Denney Helen , Griffiths Huw , Kalra Paul , Gray Tim , Sobolewska Jolanta , Ramcharitar Steve , McCafferty Laura , Martin Thomas , Irving John , Iskandar Zaid , Glover Jason , Beynon James , Pye Maurice , Megarry Simon , Das Paul , Bellamy Chris 
Published: October 2023

Importance

In the Revascularization for Ischemic Ventricular Dysfunction (REVIVED-BCIS2) trial, percutaneous coronary intervention (PCI) did not improve outcomes for patients with ischemic left ventricular dysfunction. Whether myocardial viability testing had prognostic utility for these patients or identified a subpopulation who may benefit from PCI remained unclear.

Objective

To determine the effect of the extent of viable and nonviable myocardium on the effectiveness of PCI, prognosis, and improvement in left ventricular function.

Design, Setting, and Participants

Prospective open-label randomized clinical trial recruiting between August 28, 2013, and March 19, 2020, with a median follow-up of 3.4 years (IQR, 2.3-5.0 years). A total of 40 secondary and tertiary care centers in the United Kingdom were included. Of 700 randomly assigned patients, 610 with left ventricular ejection fraction less than or equal to 35%, extensive coronary artery disease, and evidence of viability in at least 4 myocardial segments that were dysfunctional at rest and who underwent blinded core laboratory viability characterization were included. Data analysis was conducted from March 31, 2022, to May 1, 2023.

Intervention

Percutaneous coronary intervention in addition to optimal medical therapy.

Main Outcomes and Measures

Blinded core laboratory analysis was performed of cardiac magnetic resonance imaging scans and dobutamine stress echocardiograms to quantify the extent of viable and nonviable myocardium, expressed as an absolute percentage of left ventricular mass. The primary outcome of this subgroup analysis was the composite of all-cause death or hospitalization for heart failure. Secondary outcomes were all-cause death, cardiovascular death, hospitalization for heart failure, and improved left ventricular function at 6 months.

Results

The mean (SD) age of the participants was 69.3 (9.0) years. In the PCI group, 258 (87%) were male, and in the optimal medical therapy group, 277 (88%) were male. The primary outcome occurred in 107 of 295 participants assigned to PCI and 114 of 315 participants assigned to optimal medical therapy alone. There was no interaction between the extent of viable or nonviable myocardium and the effect of PCI on the primary or any secondary outcome. Across the study population, the extent of viable myocardium was not associated with the primary outcome (hazard ratio per 10% increase, 0.98; 95% CI, 0.93-1.04) or any secondary outcome. The extent of nonviable myocardium was associated with the primary outcome (hazard ratio, 1.07; 95% CI, 1.00-1.15), all-cause death, cardiovascular death, and improvement in left ventricular function.

Conclusions and Relevance

This study found that viability testing does not identify patients with ischemic cardiomyopathy who benefit from PCI. The extent of nonviable myocardium, but not the extent of viable myocardium, is associated with event-free survival and likelihood of improvement of left ventricular function.

Trial Registration

ClinicalTrials.gov Identifier:NCT01920048