THE ROLE OF SURGERY IN HEART FAILURE - part 8 pdf

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210
COMAS et al
Revascularization in Heart Failure: Coronary Bypass
or Percutaneous Coronary Intervention?
Sorin V. Pusca, MD, John D. Puskas, MD
*
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 revascularization.
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 function
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:
(J.D. Puskas).
1551-7136/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.hfc.2007.05.002 heartfailure.theclinics.com
Heart Failure Clin 3 (2007) 211–228