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Ischemic cardiomyopathy--revascularization vs. transplantation
G Kleikamp1, H Posival, K Minami
1Klinik für Thorax- und Kardiovaskularchirurgie Herzzentrum Nordrhein-Westfalen Universtatsklinik der Ruhr-Universitat, Bochum, Germany.
Insights
Surgical revascularization can improve survival and reduce symptoms in advanced coronary artery disease (CAD) patients with heart failure. Identifying hibernating myocardium offers a potentially reversible treatment, avoiding heart transplantation.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Advanced coronary artery disease (CAD) and ischemic cardiomyopathy with elevated pulmonary artery pressures signify severe illness.
- Historically, studies focused on angina pectoris, excluding patients with predominant congestive heart failure.
- The concept of hibernating myocardium has shifted focus to potentially reversible left ventricular dysfunction.
Purpose of the Study:
- To evaluate the role of myocardial revascularization in patients with advanced CAD and heart failure.
- To highlight the significance of diagnosing hibernating myocardium for treatment selection.
- To present the institutional policy of prioritizing revascularization over transplantation when feasible.
Main Methods:
- Review of patients undergoing evaluation for cardiac transplantation or other treatments.
- Identification of patients with hibernating myocardium.
- Surgical revascularization (coronary bypass surgery) as a primary treatment strategy.
Main Results:
- Myocardial revascularization improves survival, reduces morbidity, and alleviates angina in selected CAD patients.
- Successful revascularization can restore function in hibernating myocardium, improving left ventricular dysfunction.
- This approach offers an alternative to cardiac transplantation for patients with potentially reversible heart failure.
Conclusions:
- Hibernating myocardium is a crucial diagnosis, identifying patients who can benefit from revascularization instead of transplantation.
- Surgical revascularization is a viable and often preferred treatment for selected patients with advanced CAD and heart failure.
- Given donor organ shortages, revascularization offers a critical therapeutic option, improving outcomes and potentially extending patient lives.
Abstract:
Advanced coronary artery disease (CAD) and ischemic cardiomyopathy with elevated pulmonary artery pressures are criteria of a severe illness. In selected cases surgical revascularization has proved beneficial in terms of survival, reduction of morbidity and lowering the frequency of angina pectoris [6] in numerous studies over the past 25 years. But most of the earlier publications concentrated on patients with angina pectoris (AP) as a dominant symptom. Patients without AP but with predominant signs of congestive heart failure were largely excluded. This has changed recently [1-3,7,8,10,12,16,18] with the advent of the concept of hibernating myocardium. This term is defined as the presence of persistent myocardial and left ventricular dysfunction at rest due to reduced regional coronary blood flow that can be partially or completely restored to normal by myocardial revascularization [5,19]. Salvage of viable myocardium by successful revascularization improves left ventricular dysfunction. Diagnosis of hibernating myocardium is crucial because it does not leave the patient with chronic heart failure a candidate only for cardiac transplantation. Instead, these patients' left ventricular dysfunction is potentially reversible following revascularization by coronary bypass surgery. Furthermore we face a critical shortage of donor organs and extending waiting lists for possible transplant candidates. Following the start of the heart transplantation (HTX) program at our institution more than 690 operations were performed until September 1995. We screened more than 1600 patients for their eligibility as cardiac transplant recipients or for other forms of treatment. In this group of patients it has always been our policy to revascularize rather than transplant whenever possible.