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J Thorac Cardiovasc Surg 2005;130:245-249
© 2005 The American Association for Thoracic Surgery

Editorial

Questions and answers about the STICH trial: A different perspective

Department of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles, Calif

Received for publication February 24, 2005; accepted for publication March 1, 2005.

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

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

A recent editorial, the first on this subject, appeared in the Journal ¹ : "To STICH or not to STICH: We know the answer, but do we understand the question?" Although the article indicates the answer is "to STICH," this report asks whether the STICH investigators’ response understood the question.

Patient Selection and Inclusion Criteria

The underlying principle of the STICH (Surgical Treatment for IschemiC Heart failure) trial involves recognition of the potentially lethal complications of enlarging ventricular volume, and its questions are closely linked to volume measurements, the first entry criteria for inclusion in the trial. This fundamental concept stems from the seminal work of White and colleagues, ² showing how increased left ventricular end-systolic volume affects mortality. For example, Figure 1A shows that doubling of mortality follows doubling of volume and defines how death rate worsens after the progressive end-systolic volume expansion. Measuring ventricular volume is a central ingredient of the STICH trial and is expressed as left ventricular end-systolic volume index (LVESVI) in the database. The congestive heart failure (CHF) community must recognize that this vital measurement reflects a major departure from conventional analysis because ejection fraction is now the traditional marker. White and colleagues ² have shown, in Figure 1B, the survival discrepancy between conventional ejection fraction and LVESVI measurement. Unfortunately, this central issue is never raised in the invited editorial that just appeared in the Journal.

View larger version (44K): [in this window] [in a new window]   Figure 1. A, Relationship between LV end-systolic volume and mortality. Note that (1) volume is in milliliters, not milliliters per square meter, so that the LVESVI would be twice this number if patient size is 2 m and (2) that volume increase is a surrogate for increased mortality. (Reprinted with permission from White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left Ventricular End-Systolic Volume as the Major Determinant of Survival After Recovery . . . [Full Text of this Article]

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