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Trang 2Revascularization in Heart Failure: Coronary Bypass
or Percutaneous Coronary Intervention?
Emory University School of Medicine, Atlanta, GA, USA
Coronary artery disease (CAD) is currently the
single most common cause of heart failure in
adults [1] The prognosis of patients who have
severe CAD and left ventricular (LV) dysfunction
remains poor despite new medical management
algorithms [2–6] Patients who have heart failure
symptoms and a large area of ischemic
myocar-dium treated medically may have a 5-year
mortal-ity as high as 60% [7] Such patients often show
marked improvement in symptoms and
ventricu-lar function following revascuventricu-larization.
Baseline left ventricular ejection fraction
(LVEF) is the single most powerful variable
pre-dictive of mortality after revascularization for
acute myocardial infarction [8] Its usefulness in
se-lecting patients who have chronic disease for
revascularization may not be as great, however.
As an indicator of depressed LV function, ejection
fraction alone does not distinguish between
myo-cardium that is depressed because of reversible
ischemia (ie, hibernating myocardium) and that
which is replaced by fibrosis and scarring after
pre-vious myocardial infarction There is increasing
evidence that chronic LV dysfunction resulting
from hibernating myocardium in patients who
have severe multivessel disease is not uncommon
[9] Furthermore, even if some studies suggest that
revascularization, particularly early
revasculari-zation (less than 6 months after testing), could
help all patients who have decreased LVEF and
coronary artery disease regardless of myocardial vi-ability [10] , observational evidence suggests that myocardial revascularization results in stabiliza-tion or even improvement in ventricular funcstabiliza-tion most commonly in patients who have viable, hiber-nating myocardium [11,12]
This article focuses primarily on the use of coronary artery bypass grafting (CABG) in CAD patients who have low LVEF (with or without congestive symptoms) and compares it with per-cutaneous coronary interventions (PCI) in this setting Alternative modalities for the surgical treatment of ischemic heart failure, such as heart transplantation, surgical ventricular restoration, the Dor procedure, cardiomyoplasty, and the use
of mechanical assist device for destination ther-apy, are not addressed in this article.
Results of coronary artery bypass grafting
in patients who have low left ventricular ejection fraction
Many retrospective studies [13–17] and a large meta-analysis [18] have investigated the use of CABG in patients who have low LVEF Several more recent studies are summarized in Table 1 [19–25] Most of these document an operative mortality between 5% and 12% and a 5-year survival ranging from 60% to 80%.
One of the largest retrospective studies of CABG in patients who had advanced left ventric-ular dysfunction came from Emory University
[26] The study investigated short- and long-term survival and relief of angina among all patients who underwent cardiac catheterization followed
by primary CABG at Emory University Hospitals from January 1981 to December 1995 A total of 11,830 patients were identified and stratified in
* Corresponding author Emory Heart Center,
Divi-sion of Cardiothoracic Surgery, Emory University
School of Medicine, Emory Crawford Long Hospital,
6th Floor Medical Office Tower, 550 Peachtree Street
NE, Atlanta, GA 30308
E-mail address: john.puskas@emoryhealthcare.org
(J.D Puskas)
1551-7136/07/$ - see front matterÓ 2007 Elsevier Inc All rights reserved
Heart Failure Clin 3 (2007) 211–228