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Decision-making in end-stage coronary artery disease: revascularization or heart transplantation?
H Hausmann1, H Topp, H Siniawski
1Department of Thoracic and Cardiovascular Surgery, German Heart Institute Berlin, Germany.
Insights
Coronary artery bypass grafting (CABG) significantly improves survival and left ventricular function in patients with end-stage coronary artery disease and viable myocardium. This procedure offers an excellent prognosis for high-risk individuals.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Left ventricular function is a critical predictor of survival in coronary artery disease (CAD).
- It also indicates hospital and long-term mortality risk after surgery for end-stage CAD.
Purpose of the Study:
- To evaluate the effectiveness of coronary artery bypass grafting (CABG) in patients with end-stage CAD and severely reduced left ventricular ejection fraction (LVEF).
- To compare outcomes with heart transplantation in similar patient cohorts.
Main Methods:
- 514 patients with end-stage CAD and LVEF 0.10-0.30 underwent CABG (April 1986-December 1994).
- Myocardial viability was assessed using scintigraphy and echocardiography to identify "hibernating myocardium."
- Outcomes were compared with 231 heart transplant recipients with similar conditions.
Main Results:
- CABG group: 7.1% operative mortality; 6-year survival 78.9%.
- Post-CABG LVEF improved from 0.24 to 0.39 (p < 0.0001); NYHA class improved from III/IV to I/II in 90.2% of survivors.
- Heart transplant group: 6-year survival 68.9%; all patients improved to NYHA class I/II.
Conclusions:
- CABG and heart transplantation successfully improve life expectancy in end-stage CAD patients.
- CABG offers an excellent prognosis for high-risk patients when viable myocardium is identified preoperatively.
Background:
Left ventricular function is the most important predictor of survival in patients with coronary artery disease. It is also an important indicator for hospital and late mortality after operation for endstage coronary artery disease.
Methods:
Between April 1986 and December 1994, 514 patients with end-stage coronary artery disease and left ventricular ejection fraction between 0.10 and 0.30 underwent coronary artery bypass grafting at the German Heart Institute Berlin. Two hundred twenty-five of these patients had been referred as possible candidates for heart transplantation. The prime criterion for bypass grafting was ischemia diagnosed by myocardial scintigraphy and echocardiography ("hibernating myocardium").
Results:
Operative mortality for the group was 7.1%. The actuarial survival rate was 90.8% after 2 years, 87.6% after 4, and 78.9% after 6. Left heart catheterizations performed 1 year after the operation showed that left ventricular ejection fraction had increased from a mean of 0.24 +/- 0.03 preoperatively to 0.39 +/- 0.06 postoperatively (p < 0.0001). Preoperatively 91.6% of the patients were in New York Heart Association (NYHA) class III or IV; 6 months postoperatively 90.2% of the surviving patients were in NYHA class I or II. Two hundred thirty-one patients with end-stage coronary artery disease and predominant heart failure underwent heart transplantation. Their actuarial survival rate was 74.9% after 2 years, 73.2% after 4, and 68.9% after 6. All of the patients could be recategorized into NYHA class I or II after the operation.
Conclusions:
We conclude that coronary artery bypass grafting and heart transplantation can be used successfully to improve the life expectancy of patients with end-stage coronary artery disease. Coronary artery bypass grafting leads to an excellent prognosis for these high-risk patients when the myocardium is preoperatively identified as being viable.