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Ischemic cardiomyopathy. Criteria for coronary revascularization and cardiac transplantation
H W Louie1, H Laks, E Milgalter
1Department of Surgery, UCLA School of Medicine 90024-1741.
Insights
Coronary revascularization can be a viable option for patients with ischemic cardiomyopathy awaiting heart transplantation, improving survival rates. Identifying suitable candidates through imaging is key to successful outcomes.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Transplantation Medicine
Background:
- Donor heart shortage leads to high mortality in ischemic cardiomyopathy patients awaiting transplantation.
- Effective coronary revascularization strategies are crucial for managing patients with ischemic cardiomyopathy.
- Identifying patients who benefit from revascularization is essential for improving outcomes.
Purpose of the Study:
- To determine factors predicting successful coronary revascularization in ischemic cardiomyopathy patients.
- To identify patients who may benefit from revascularization as an alternative to heart transplantation.
- To evaluate the survival rates and clinical outcomes of revascularized patients compared to transplanted patients.
Main Methods:
- Retrospective analysis of 207 ischemic cardiomyopathy patients evaluated for heart transplantation between 1984 and 1990.
- Comparison of outcomes between revascularized (n=22), transplanted (n=83), and non-accepted (n=54) patient groups.
- Preoperative assessment including ejection fraction, left ventricular end-diastolic dimension, New York Heart Association functional class, and positron emission tomography (PET) imaging for myocardial blood flow and metabolism.
Main Results:
- Overall mortality in the revascularized group was 27%, with 72% 3-year survival.
- Successful revascularization was associated with improved preoperative ejection fraction and New York Heart Association functional class.
- Patients with preoperative PET scans indicating reversible ischemia had successful revascularization, while those with negative scans failed.
Conclusions:
- Coronary revascularization offers a survival benefit for selected ischemic cardiomyopathy patients.
- Preoperative assessment of left ventricular function and myocardial viability is critical for patient selection.
- Positron emission tomography imaging can predict successful revascularization outcomes in this patient population.
Abstract:
Because of the shortage of donor hearts, 16 (33%) of 48 patients with ischemic cardiomyopathy died awaiting transplantation. Determining factors that predict effective coronary revascularization and identifying patients who may benefit from revascularization is crucial. From 1984 to 1990, 207 ischemic cardiomyopathy patients were evaluated for heart transplantation; 131 were accepted (83 transplanted), 54 were not accepted, and 22 were revascularized (19 underwent bypass graft surgery and three underwent percutaneous transluminal coronary angioplasty). Four bypass patients failed early (less than or equal to 30 days, three deaths and one urgent heart transplant) and two late deaths (greater than or equal to 1 year) occurred. Overall mortality was 27%. Three-year survival of revascularized and transplanted patients was 72 +/- 10% and 73 +/- 6%, respectively. Successfully revascularized patients had preoperative ejection fraction, left ventricular end-diastolic dimension, and New York Heart Association functional class of 26 +/- 9%, 68 +/- 3 mm, and 3.9 +/- 0.4, respectively, compared with 36 +/- 9% (p less than 0.05), 64 +/- 6 mm (p = NS), and 1.2 +/- 0.4 (p less than 0.05) after revascularization. Preoperative ejection fraction of patients failing revascularization was 15 +/- 4% (p = NS compared with successful revascularization), and left ventricular end-diastolic dimension was 81 +/- 4 mm (p less than 0.05). Preoperative positron emission tomography imaging myocardial blood flow and glucose metabolism was performed in 12 patients: 10 patients with scans predicting reversible ischemia were successfully revascularized, and two patients with negative scans had failed revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)