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Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy
I L Kron1, T L Flanagan, L H Blackbourne
1Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908.
Insights
Myocardial revascularization is a viable option for patients with severe ischemic cardiomyopathy and low ejection fraction. This approach offers a 3-year survival rate of 83%, preserving ventricular function when transplants are unavailable.
Area of Science:
- Cardiology
- Cardiac Surgery
Background:
- Ischemic cardiomyopathy with ejection fraction <20% presents a poor prognosis with medical management.
- Cardiac transplantation is often indicated but donor availability is limited.
Purpose of the Study:
- To evaluate the efficacy and safety of myocardial revascularization in patients with chronic ischemic cardiomyopathy and severely depressed ventricular function.
Main Methods:
- Retrospective analysis of 39 patients with ejection fraction <20% undergoing coronary artery bypass grafting.
- Exclusion criteria included significant valvular disease, left ventricular aneurysm resection, or emergency operations.
- Mean follow-up was 21 months.
Main Results:
- One operative death (2.6%) and a total mortality rate of 21% over mean follow-up.
- Late deaths were predominantly due to arrhythmias (7 of 8).
- Life table analysis showed a 3-year survival rate of 83%.
Conclusions:
- Myocardial revascularization is a reasonably effective treatment for chronic ischemic cardiomyopathy with poor ventricular function.
- It serves as a valuable option for preserving cardiac function, especially given the shortage of cardiac transplant donors.
Abstract:
Patients with very poor ventricular function have been thought to be highly vulnerable to elective myocardial revascularization. Ischemic cardiomyopathy is now the major indication for cardiac transplantation. The 2-year survival of medically treated patients with ejection fractions less than 20%, but who are not sufficiently symptomatic for cardiac transplantation, is less than 25%. At our institution we have taken an aggressive approach by using myocardial revascularization for chronic ischemic cardiomyopathy. Between 1983 and 1988, 39 patients with preoperative ejection fractions less than 20% underwent coronary artery bypass. Patients were excluded if they had valvular heart disease other than mild to moderate mitral regurgitation, required resection of a left ventricular aneurysm, or required emergency operation for acute coronary occlusion. Mean age was 63.3 years (range, 43 to 80 years) and 31 were men. Mean preoperative ejection fraction was 18.3% (range, 10% to 20%) and the mean preoperative left ventricular end diastolic pressure was 22 mm Hg (range, 8 mm Hg to 38 mm Hg). There was one operative death (2.6%). Mean follow-up was 21 months (range, 3 to 60 months) with eight late deaths (a total mortality rate of 21%). Seven deaths were due to arrhythmias. Three patients continued to have severe heart failure, one of whom underwent successful cardiac transplantation. By life table analysis, there was a 3-year survival rate of 83%. With the present shortage of cardiac transplant donors, myocardial revascularization for ischemic cardiomyopathy is a reasonably effective means for preserving residual ventricular function.