Effect of Myocardial Viability, Percutaneous Coronary Intervention and Functional Recovery on Clinical Outcomes in the REVIVED-BCIS2 Randomized Trial

Presented at the ACC.23 by: Prof. Divaka Perera, MD - London, UK

Introduction and methods

Data on the role of myocardial viability testing to select patients who will benefit from revascularization are contradictory. Previously, the REVIVED-BCIS2

(Revascularization for Ischemic Ventricular Dysfunction) trial showed that revascularization with PCI plus optimal medical therapy (OMT) did not reduce the incidence of all-cause mortality or HF hospitalization compared with OMT alone in a total of 700 patients with LVEF ≤35% and extensive coronary artery disease (CAD). It also did not improve the LVEF. To identify patients eligible for this RCT, myocardial viability was assessed in ≥4 dysfunctional myocardial segments, mostly using late gadolinium-enhanced cardiac magnetic resonance imaging (CMR) or dobutamine stress echocardiography.

The aims of the current REVIVED viability analysis were to assess whether (1) the extent of viability characterized by CMR determined the impact of PCI on clinical outcomes and (2) reverse LV remodeling affected clinical outcomes. Independent core laboratories blinded to treatment assignment and clinical details analyzed the baseline CMR scans and serial echocardiograms. Myocardial viability was characterized by the potential for recovery (based on wall motion; n=610) and scar burden (based on each segment; n=478).

Outcome measures were identical to those in the REVIVED-BCIS2 trial: The primary endpoint was a composite outcome of all-cause mortality or HF hospitalization, and a major secondary endpoint was change in LVEF from baseline to 6 months.

Main results

• In the overall population, patients with a higher LVEF had a lower risk of all-cause mortality or HF hospitalization (adjusted HR per 10% increase in viable myocardial volume: 0.93; 95%CI: 0.87–1.00; P=0.048). However, in patients with a dysfunctional-yet-viable myocardium at baseline, the adjusted HR per 10% increase in volume was 0.98 (95%CI: 0.93–1.04; P=0.56).
• In patients with scar burden, the adjusted HR per 10% increase in scar volume was 1.18 (95%CI: 1.04–1.33; P=0.009).
• There was no impact of the viability assessment (i.e., abundance of dysfunctional-yet-viable segments or scar burden) on the treatment effect of PCI versus OMT for both the primary and secondary endpoints (all P=nonsignificant).
• Reverse LV remodeling (≥4.7%) lowered the incidence of all-cause death or HF hospitalization compared with no remodeling (<4.7% change) (HR 0.62, 95%CI:0.41-0.95, P=0.029).

Conclusion

The REVIVED-BCIS2 trial and the current REVIVED viability analysis showed that PCI did not improve prognosis or LV recovery in patients with extensive CAD compared with OMT alone, regardless of viability characteristics at baseline. Scar burden, but not the abundance of dysfunctional-yet-viable segments predicted prognosis and likelihood of LV recovery independent of baseline LVEF or extent of CAD.

- Our reporting is based on the information provided at the ACC.23 -