Decision-making in end-stage coronary artery disease: Revascularization or heart transplantation?
ABSTRACT Left ventricular function is the most important predictor of survival in patients with coronary artery disease. It is also an important indicator for hospital and late mortality after operation for endstage coronary artery disease.
Between April 1986 and December 1994, 514 patients with end-stage coronary artery disease and left ventricular ejection fraction between 0.10 and 0.30 underwent coronary artery bypass grafting at the German Heart Institute Berlin. Two hundred twenty-five of these patients had been referred as possible candidates for heart transplantation. The prime criterion for bypass grafting was ischemia diagnosed by myocardial scintigraphy and echocardiography ("hibernating myocardium").
Operative mortality for the group was 7.1%. The actuarial survival rate was 90.8% after 2 years, 87.6% after 4, and 78.9% after 6. Left heart catheterizations performed 1 year after the operation showed that left ventricular ejection fraction had increased from a mean of 0.24 +/- 0.03 preoperatively to 0.39 +/- 0.06 postoperatively (p < 0.0001). Preoperatively 91.6% of the patients were in New York Heart Association (NYHA) class III or IV; 6 months postoperatively 90.2% of the surviving patients were in NYHA class I or II. Two hundred thirty-one patients with end-stage coronary artery disease and predominant heart failure underwent heart transplantation. Their actuarial survival rate was 74.9% after 2 years, 73.2% after 4, and 68.9% after 6. All of the patients could be recategorized into NYHA class I or II after the operation.
We conclude that coronary artery bypass grafting and heart transplantation can be used successfully to improve the life expectancy of patients with end-stage coronary artery disease. Coronary artery bypass grafting leads to an excellent prognosis for these high-risk patients when the myocardium is preoperatively identified as being viable.
- SourceAvailable from: Francesco Nicolini
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- "A recent study published by Kleisli et al. has confirmed that complete revascularization improves long-term cardiac survival : in consideration of these findings it appears mandatory to perform a rigorous selection of potential candidates for this technique, particularly in the setting of ischemic cardiomyopathy. Hausmann et al. studied patients with end-stage ischemic cardiomyopathy and severely depressed left ventricular function in order to identify differential indications for CABG versus cardiac transplantation . The study group consisted of 225 patients, potential candidates to cardiac transplantation, who underwent high-risk CABG because of viable myocardium detected preoperatively with myocardial thallium scintigraphy and echocardiography. "
ABSTRACT: Despite considerable improvements in the medical treatment of heart failure (HF), the gold standard for the treatment of these patients remains heart transplantation. Nevertheless, in consideration of the shortage of organ donors, this procedure can be offered only to a small percentage of patients who could benefit from a new heart. A number of innovative approaches are being investigated in terms of improved survival and quality of life in patients refractory to medical therapy and excluded from cardiac transplantation lists. These procedures include the optimization of medical therapy, coronary artery bypass surgery and valve surgery in high-risk patients, ventricular restoration techniques, and the implantation of ventricular assist devices as destination therapy. Future therapies for HF could include stem cell therapy, associated with standard revascularization techniques or with other procedures such as ventricular assist devices implantation or ventricular restoration techniques, allowing the potential differentiation of implanted stem cells in a resting and unloaded heart. The modern approach to surgical treatment of HF is multidisciplinary, given that the number of alternative available options to heart transplantation requires a close collaboration between both cardiologists and cardiac surgeons in treating patients with end-stage HF who are not candidates for transplant.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2009; 35(2):214-28. DOI:10.1016/j.ejcts.2008.11.003 · 2.81 Impact Factor
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- "Prior to embarking on high-risk reoperative coronary and mitral operation, this subset of patients would stand to benefit most from having additional viability studies such as PET scanning  or cardiac MRI imaging technique . Hausmann and coauthors  had described several useful clinical variables that might aid in making the correct decisions in ischemic cardiomyopathy patients. Prior open-heart surgery was one variable to consider when deciding between revascularization versus transplantation. "
ABSTRACT: To determine the impact of mitral insufficiency on survival after reoperative coronary artery bypass grafting (CABG) in ischemic cardiomyopathy patients. We retrospectively studied 891 (Initial 708, Redo 183) consecutive CABG patients (1993-2002) with ejection fraction (EF) 35% or less. Patient characteristics: mean age=67.0+/-10.5 yrs, men=77.1%, EF=26.4+/-7.4%, mean CCS=3.47+/-0.73, mean NYHA=3.50+/-0.68. There were 180 (Initial 141, Redo 39) patients with 3/4+mitral regurgitation (MR). Late survival statistics of cohorts were compiled using National Death Index. At a mean follow-up period of 3 years, reoperative CABG with MR (Redo/MR+) survival was 41.7+/-9.2% (n=39), which was worse than reoperative CABG without MR (Redo/MR-) survival of 71.8+/-4.1% (n=144, P=0.0003), initial CABG with MR (Initial/MR+) survival of 68.5+/-4.2% (n=141, P=0.014) and initial CABG without MR (Initial/MR-) survival of 76.2+/-2.0% (n=567, P<0.0001). By multivariate analysis, congestive heart failure (P=0.029), 3/4+MR (P=0.044) were independent predictors of Redo late mortality. In contrast, renal failure on dialysis, stroke, no angina, age >65 yrs, absence of hypercholesterolemia, EF<26% but not 3/4+MR were independent predictors of Initial late mortality. In subset analysis, adverse impact of 3/4+MR on late survival was greatest in Redo with EF<26%. The 3- and 5-yr late survival were only 44.4 and 26.8% (P=0.041). Concomitant mitral valve repair (MVrep) was performed in 100 (Initial 75, Redo 25) patients. MVrep in Initial/MR+patients achieved similar late survival as Initial/MR- patients. MVrep did not produce the same late survival benefit in Redo/MR+ patients. (1) Mitral insufficiency has a greater survival impact on redo than initial CABG patients with ischemic cardiomyopathy. (2) Mitral insufficiency and congestive heart failure are the primary independent predictors of late survival following redo CABG. (3) Mitral repair has less neutralizing effect on late survival in redo than initial CABG patients.European Journal of Cardio-Thoracic Surgery 01/2005; 26(6):1118-28. DOI:10.1016/j.ejcts.2004.07.046 · 2.81 Impact Factor