Elsevier

The Annals of Thoracic Surgery

Volume 64, Issue 5, November 1997, Pages 1296-1302
The Annals of Thoracic Surgery

Decision-Making in End-Stage Coronary Artery Disease: Revascularization or Heart Transplantation?

https://doi.org/10.1016/S0003-4975(97)00805-9Get rights and content

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.

Section snippets

Material and Methods

In a prospective study from April 1986 until December 1994, 514 patients with CAD and LVEF between 0.10 and 0.30 were examined and prepared for CABG. Patients with an aneurysm of the left ventricle, valvular heart disease, ventricular septal defect after myocardial infarction, or cardiomyopathy were not included in this group. Two hundred twenty-five of the patients were referred to the German Heart Institute Berlin as possible HTx candidates. The most important criteria for bypass grafting

Results

Operative mortality was 7.1% (16 of 225) in the CABG group. One patient died of septicemia and multiple organ failure. Fifteen patients died of early postoperative low cardiac output syndrome. Intraaortic balloon pumps were implanted in 46 of 225 patients (20.4%) to aid weaning from heart-lung bypass; 29 (63.0%) of these 46 were successfully explanted preoperatively. In 2 patients the intraaortic balloon pump had to be implanted through the ascending aorta because of peripheral

Comment

Clinical characteristics and angiographic features associated with increased OPM after CABG on patients with normal or mildly reduced ventricular function were first described in the medical literature more than a decade ago [12, 13]. At that time LVEF was considered the most important predictor of survival after CABG. In recent years parallel improvements in surgical procedures and medical management in intensive and outpatient care have lead to increased success in performing CABG on patients

References (28)

  • N. Friedel et al.

    Recovery of end-organ failure during mechanical circulatory support

    Eur J Cardiothorac Surg

    (1993)
  • SAS users guide: statistics and basics. Version 5 ed. Cary NC: SAS Institute Inc.,...
  • M. Hummel et al.

    Therapie der terminalen Herzinsuffizienz durch Herztransplantation

    Klin Wochenschr

    (1991)
  • D.L. Shearn et al.

    Coronary artery bypass surgery in patients with left ventricular dysfunction

    Am J Med

    (1985)
  • Cited by (98)

    • Surgical Treatment of Heart Failure

      2017, Surgical Clinics of North America
    • Is detection of hibernating myocardium necessary in deciding revascularization in systolic heart failure?

      2010, American Journal of Cardiology
      Citation Excerpt :

      These results indicate that revascularization of hibernating myocardium can improve prognosis along with relief of symptoms in patients with severe SHF. An earlier uncontrolled single-center study compared the long-term survival of patients who underwent CABG to that of patients who underwent cardiac transplantation.69 Operative mortality for CABG was 7.2% and for cardiac transplantation was 18.2%.

    • Alternatives to transplantation in the surgical therapy for heart failure

      2009, European Journal of Cardio-thoracic Surgery
    View all citing articles on Scopus
    View full text