Coronary Revascularization Rather than Cardiac Transplantation for Chronic Ischemic Cardiomyopathy

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.

18F-FDG PET Imaging of Myocardial Viability in an Experienced Center with Access to 18F-FDG and Integration with Clinical Management Teams: The Ottawa-FIVE Substudy of the PARR 2 Trial

“…Coronary revascularization may be beneficial for patients with ischemic cardiomyopathy; however, there are significant perioperative risks (1)(2)(3). 18 F-FDG PET has been shown to be the most sensitive noninvasive means for the prediction of left ventricular functional recovery after coronary revascularization (4).…”

Ventricular Reconstruction Results in Improved Left Ventricular Function and Amelioration of Mitral Insufficiency

“…We have shown in the past that patients with ischemic cardiomyopathy can undergo coronary artery bypass or mitral valve replacement safely. 2,3 Heart transplantation has evolved as the treatment for ischemic cardiomyopathy refractory to the above surgical strategy 4 but donor shortage and cost are the major issues. Several new ventricular remodeling procedures have been proposed for the treatment of the dilated ventricle secondary to ischemia.…”

Additive value of low‐dose dobutamine to technetium‐99m sestamibi‐gated single‐photon emission computed tomography for prediction of wall motion improvement in patients undergoing coronary artery bypass graft

“…[3][4][5][6][7][8][9] Limitations of the Study Data acquisition during dobutamine was performed with one dose of 10 µkg/kg/min. It was impossible to increase the dobutamine dose gradually on-line for wall motion assessment with each dose, as for echocardiography.…”

“…[1][2][3] A pooled analysis of 37 studies by Bax et al 4 showed that perfusion imaging (by thallium and sestamibi), 18 F-fluorodeoxyglucose ( 18 FDG) metabolic imaging with positron emission tomography (PET), and dobutamine echocardiography are useful techniques for assessing myocardial viability, with a high sensitivity in predicting wall motion improvement, in patients after revascularization. [4][5][6][7][8][9][10][11][12][13] However, the specificity of the perfusion agents, especially thallium, is low.…”