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J Thorac Cardiovasc Surg 2009;138:1060-1064
© 2009 The American Association for Thoracic Surgery

Expert Commentary

The STICH trial: Misguided conclusions

^a University of California Los Angeles, Los Angeles, Calif
^b University of Alabama, Birmingham, Ala

Received for publication May 28, 2009; revisions received June 12, 2009; accepted for publication July 7, 2009.

^_* Address for reprints: Gerald D. Buckberg, MD, David Geffen School of Medicine at UCLA, Division of Cardiothoracic Surgery 62-258 CHS, 10833 Le Conte Ave, Los Angeles, CA 90095. (Email: gbuckberg@mednet.ucla.edu).

The first 300 words of the full text of this article appear below.

	Introduction

 
This editorial summarizes a counterpoint American Association for Thoracic Surgery debate opinion after the recent Surgical Treatment for Ischemic Heart Failure (STICH) trial published in The New England Journal of Medicine (NEJM). ¹ That article may potentially alter treatment of congestive heart failure (CHF) after ischemic dilated cardiomyopathy following myocardial infarction because the authors conclude that adding surgical ventricular reconstruction to reduce ventricular volume to coronary artery bypass grafting (CABG) does not improve symptoms or exercise tolerance and fails to lower death rate or cardiac rehospitalization.

The original study examined the role of surgical ventricular reconstruction or "surgical ventricular restoration" (SVR) in the dilated ventricles of patients with CHF with regional scar after anterior myocardial infarction ( Figure 1 ). The adverse effects of dilatation are codified by White and associates² (Figure 2 , A), who showed that increased ventricular volume rather than altered ejection fraction became the principal surrogate for mortality.

View larger version (74K):   Figure 1. Changes in LV size and shape after SVR. The elliptical normal form (A) becomes spherical after anterior septal infarction (B). Size and shape are returned toward a more normal elliptical configuration by placing a patch to exclude the scar and returning nonscarred remote muscle back to its conical form (C). Reprinted with permission from Buckberg G. Ventricular Structure and surgical history. Heart Failure Rev. 2005;9:255-68.

View larger version (24K):   Figure 2. A, Relationship between LV end-systolic volume and mortality. Note (1) that volume is in milliliters, not milliliters per square meter, so that the LV end-systolic volume index would be twice this number if patient size were 2m2 and (2) that volume increase is a surrogate for increased mortality.2 B, Comparison of prognosis in survivors and nonsurvivors in relationship to ejection fraction (solid line is at 35%) and LV end-systolic volume in milliliters. Note that lower LV end-systolic volume at 35% ejection fraction is associated . . . [Full Text of this Article]