Decision-Making in End-Stage Coronary Artery Disease: Revascularization or Heart Transplantation?
Department of Thoracic and Cardiovascular Surgery, German Heart Institute Berlin, Germany. The Annals of Thoracic Surgery
(Impact Factor: 3.85).
12/1997; 64(5):1296-301; discussion 1302. DOI: 10.1016/S0003-4975(97)00805-9
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.
Available from: PubMed Central
- "The authors concluded that both 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 grafting leads to an excellent prognosis of these high-risk patients where the myocardium is preoperatively identified as being viable . "
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ABSTRACT: Patients with heart failure symptoms due to ischemic cardiomyopathy face a poor prognosis without adequate treatment. In these patients with viable ischemic myocardium, revascularization surgery is not a new but an established treatment concept. the CASS study, published in 1983, was already able to document the superiority of coronary artery revascularization in patients with poor left ventricular function. It is of utmost importance to predict regional functional recovery in order to assess viability and, thus, the indication for revascularization. Late gadoliniium enhancement cardiovascular magnetic resonance is the new gold standard. By applying this technique, it can be demonstrated that the transmural extent of a scar predicts segmental functional recovery. Numerous studies describe the predictors of survival of surgical revascularization, the indication and impact of medical antiarrhythmic treatment or choice of graft. In addition to conventional surgery, off-pump procedures, minimal extracorporeal circulation and hybrid revascularization have a special role in the treatment of patients with ischemic cardiomyopathy. Surgical techniques and medical therapies continue to improve. The future revascularization in these patients will focus on improving results and making coronary artery bypass grafting for elective revascularization less invasive and safer. Technical evolution, including the use of robotics and anastomotic connectors, intraoperative imaging and protein enzyme therapies, have to be defined concerning their special impact in these patients.
Available from: Andre M De Wolf
- "Other authors  have reported that an age of > 70 years was the only independent predictor of in-hospital mortality in patients with an EF of ≤ 30% who underwent CABG. Hausmann and colleagues  noted that increased left ventricular end diastolic pressures, decreased cardiac index, and New York Heart Association class were univariate predictors of operative mortality in patients with an EF of < 30%. Argenziano and colleagues  found that reoperation and congestive heart failure were predictors of perioperative mortality in patients with an EF of ≤ 35%. "
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ABSTRACT: Preoperative left ventricular dysfunction is an established risk factor for early and late mortality after revascularization. This retrospective analysis demonstrates the effects of preoperative ejection fraction on the short-term and long-term survival of patients after coronary artery bypass grafting.
Early and late mortality were determined retrospectively in 10 626 consecutive patients who underwent isolated coronary bypass between January 1998 and December 2007. The subjects were divided into 3 groups according to their preoperative ejection fraction. Expected survival was estimated by comparison with a general Dutch population group described in the database of the Dutch Central Bureau for Statistics. For each of our groups with a known preoperative ejection fraction, a general Dutch population group was matched for age, sex, and year of operation.
One hundred twenty-two patients were lost to follow-up. In 219 patients, the preoperative ejection fraction could not be retrieved. In the remaining patients (n = 10 285), the results of multivariate logistic regression and Cox regression analysis identified the ejection fraction as a predictor of early and late mortality. When we compared long-term survival and expected survival, we found a relatively poorer outcome in all subjects with an ejection fraction of < 50%. In subjects with a preoperative ejection fraction of > 50%, long-term survival exceeded expected survival.
The severity of left ventricular dysfunction was associated with poor survival. Compared with the survival of the matched general population, our coronary bypass patients had a worse outcome only if their preoperative ejection fraction was < 50%.
Available from: stemcellmedicine.cn
- "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. "
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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.
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