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[Refractory heart failure. Myocardial revascularization as alternative to heart transplantation]
Ottavio Alfieri1, Rolando Mangia
1Dipartimento di Cardiochirurgia, Ospedale San Raffaele, Milano.
Insights
Coronary artery disease often causes heart failure. Myocardial revascularization can be a viable treatment for select patients with severe left ventricular dysfunction, improving cardiac function.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Research
Context:
- Coronary artery disease (CAD) is the leading cause of heart failure in Western countries.
- Heart transplantation is limited by donor availability, making alternative treatments crucial.
- Surgical revascularization offers a potential solution for selected heart failure patients.
Purpose:
- To identify key variables for selecting patients with severe left ventricular dysfunction who may benefit from myocardial revascularization.
- To outline criteria for successful outcomes in myocardial revascularization for heart failure patients.
Summary:
- Successful recovery of cardiac function after revascularization depends on the presence of hibernating myocardium and documented contractile reserve.
- Favorable coronary artery anatomy for bypass grafting and good run-off are essential.
- Contraindications include excessively dilated hearts, right heart failure symptoms, and significant pulmonary hypertension.
Impact:
- This research aids in optimizing patient selection for myocardial revascularization, thereby improving treatment efficacy.
- It provides a framework for surgical strategies, including ventricular volume reduction and mitral insufficiency correction, to enhance outcomes in CAD patients with heart failure.
Abstract:
Coronary artery disease is the most common cause of heart failure in the western world. Due to shortage of donors, heart transplantation is not a realistic treatment for the great majority of patients with heart failure, while surgical revascularization is a valuable alternative in selected patients. Several variables have to be taken into account in order to appropriately identify patients with severe left ventricular dysfunction who are likely to benefit from myocardial revascularization. The recovery of cardiac function can be expected only in patients with sufficiently large areas of hibernating myocardium, particularly when the contractile reserve is documented. The anatomy of the coronary arteries should be suitable for coronary bypass grafting and provide a good run-off. Patients with an excessively dilated heart, with signs and symptoms of right heart failure and significant pulmonary hypertension are not candidates for myocardial revascularization. An appropriate surgical strategy, also including the reduction of the left ventricular volume and/or the correction of mitral insufficiency if needed, is the key factor for a successful revascularization procedure in patients with coronary artery disease and heart failure as the predominant symptom.