The bad ventricle--revascularization versus transplantation.

Area of Science:

• Cardiology
• Cardiac Surgery
• Cardiovascular Research

Background:

• Increasing proportion of patients with left-ventricular dysfunction (LVD) undergoing high-risk revascularization.
• Elevated perioperative risk in LVD patients due to pre-existing pathophysiology.
• Mandatory detailed evaluation and interdisciplinary therapeutic considerations, including cardiac transplantation alternatives.

Purpose of the Study:

• To compare the outcomes of coronary artery bypass grafting (CABG) in patients with severe left-ventricular dysfunction (ejection fraction <20%) against those listed for cardiac transplantation due to ischemic cardiomyopathy.
• To evaluate the safety and efficacy of revascularization in high-risk cardiac patients.

Main Methods:

• Retrospective analysis of 7275 patients undergoing CABG (1990-1998).
• Comparison of 51 patients with ejection fraction <20% (group CABG) against 163 patients listed for cardiac transplantation (group HTX).
• Survival analysis based on the intention-to-treat principle.

Main Results:

• Similar 1-year survival between CABG (71.9%) and HTX (66.3%) groups.
• CABG patients were older and had a higher percentage of women.
• Perioperative (30-day) survival in the CABG group was 88.2%.
• Elevated preoperative creatinine and non-usage of internal thoracic artery predicted adverse outcomes.
• Significant improvement in NYHA functional class from III to I postoperatively in the CABG group.

Conclusions:

• Coronary artery bypass grafting is a viable option for patients with ischemic cardiomyopathy, viable myocardium, and graftable vessels, offering acceptable risk.
• Anticipation of perioperative mechanical circulatory support is essential for these patients.
• Establishment of dedicated infrastructure for mechanical circulatory support within cardiac centers is recommended.