Results of revascularization in patients with severe left ventricular dysfunction

The effectiveness of a motivational text-messaging program for smoking cessation after coronary angioplasty: a quasi-experimental study

OBJECTIVE

Smoking is an important risk factor of coronary artery stenosis after angioplasty. Therefore, this investigation aimed to determine the effectiveness of a motivational text-messaging program for smoking cessation after coronary angioplasty. This quasi-experimental study was conducted on 100 patients after angioplasty. The patients were divided randomly into two intervention and control groups. The intervention group received 32 text messages about smoking cessation for 2 months. The control group received only routine training. The primary and secondary outcomes were success and self-efficacy in quitting smoking cigarettes, respectively. Both groups filled out the related questionnaires before and after the intervention. The data were analyzed using SPSS software version 22 and Chi-square tests, independent t-test, and paired t-test. P < 0.05 was considered significant.

RESULTS

Success in quitting cigarette smoking was significantly higher in the intervention group (n = 29, 61.7%) compared to the control group (n = 2, 4.3%) (p < 0.001). Moreover, after the intervention, the mean score of self-efficacy in the intervention group (11.01 ± 44.75) was significantly higher than the control group (6.51 ± 3.11) and also higher than before the intervention (5.51 ± 2.44) (P˂0.001). The motivational text-messaging program can improve self-efficacy and success in smoking cessation in patients after coronary angioplasty.

Outcomes of Coronary Artery Bypass Grafting in Patients With Poor Myocardial Viability: A Systematic Review and Meta-Analysis of the Last Decade

OBJECTIVES

Our objective is to assess whether the presence of myocardial viability is a predictor of mortality among patients undergoing coronary artery bypasss grafting (CABG) through a systematic review meta-analysis.

METHODS

Comprehensive review of EMBASE and PubMed in accordance with PRISMA guidelines, including studies of patients undergoing CABG with assessment of myocardial viability and recorded long-term mortality, age and sex. Studies were restricted to the last decade, and data were stratified by imaging modality (magnetic resonance imaging [MRI] or nuclear medicine). Random-effects model for assessing pooled effect, heterogeneity assessment using Chi-square and I² statistics, publication bias assessed by funnel plots and Egger's test.

RESULTS

Meta-analysis of contemporary data (January 2010 to October 2020) yielded 3,621 manuscripts of which 92 were relevant, and 6 appropriate for inclusion with 993 patients. Pooled analysis showed that patients with non-viable myocardium undergoing CABG are at 1.34 times the risk of mortality compared to those with viable myocardium (95% CI 1.01-1.79, p=0.05). Subgroup analysis of the MRI or nuclear medicine modalities was not statistically significant and there was no confounding by age or sex in meta-regression. There was significant heterogeneity in imaging modality and diagnostic criteria, but heterogeneity between study findings was low with an I² statistic of 29%. The risk of publication bias was moderate on the Newcastle-Ottawa Scale), but not statistically significant (Egger's Test coefficient=1.3, 95%CI -0.35-2.61, p=0.10).

CONCLUSIONS

There is a multitude of methods for assessing cardiac viability for coronary revascularisation surgery, making meta-analyses fraught with limitations. Our meta-analysis demonstrates that the finding of non-viable myocardium can not be used draw conclusions for risk assessment in coronary surgery.

A comparison of drug-eluting stent and coronary artery bypass grafting in mildly to moderately ischemic heart failure

Aims

The best revascularization strategy for patients with ischaemic heart failure (IHF) remains unclear. Current evidence and guidelines mainly focus on patients with severe ischaemic heart failure (ejection fraction [EF] < 35%). There are limited data comparing clinical outcomes of coronary artery bypass grafting (CABG) with implantation of drug‐eluting stents (DESs) in patients with mild to moderate ischaemic heart failure (EF 35–50%). It is therefore unknown whether percutaneous coronary intervention (PCI) with DES implantation can provide comparable outcomes to CABG in these patients.

Methods and results

From January 2016 to December 2017, we enrolled patients with mildly to moderately reduced EF (35–50%) who had undergone PCI with DESs or CABG. Patients with a history of CABG, presented with acute ST‐elevation myocardial infarction (MI) or acute heart failure, and patients who had undergone CABG concomitant valvular or aortic surgery were excluded. Propensity score‐matching analysis was performed between the two groups. Kaplan–Meier analysis and multivariate Cox proportional hazard regression were applied to assess all‐cause mortality and individual end points. A total of 2050 patients (1330 PCIs and 720 CABGs) were included, and median follow‐up was 45 months (interquartile range 40 to 54). There were significant differences in all‐cause death between the two groups: 77 patients in the PCI group and 27 in the CABG group (DES vs. CABG: 5.8% vs. 3.8%, P = 0.045). After propensity score matching for the entire population, 601 matched pairs were obtained. The long‐term cumulative rate of all‐cause death was significantly different between the two groups (DES vs. CABG: 5.8% vs. 2.7%, P = 0.006). No differences were found in the rates of cardiac death (DES vs. CABG: 4.8% vs. 3.0%, P = 0.096), recurrent MI (DES vs. CABG: 4.0% vs. 2.8%, P = 0.234), and stroke (DES vs. CABG: 6.8% vs. 5.2%, P = 0.163). The rate of repeat coronary revascularization was significantly higher in the PCI group than in the CABG group (12.1% vs. 6.0%, P = 0.000).

Conclusions

Considering the higher long‐term survival rate and lower repeat‐revascularization rate, CABG may be superior to DES implantation in patients with mildly to moderately reduced EF (35–50%) and significant CAD.

Cardiac surgery improves survival in advanced left ventricular dysfunction: multivariate analysis of a consecutive series of 4491 patients over an 18-year period

OBJECTIVES

Risks of cardiac surgery in patients with poor [ejection fraction (EF) ≤ 30%] and very poor left ventricular (LV) function (EF ≤ 20%) may be considered high due to increased mortality. We examine our results in this cohort of patients.

METHODS

Data were prospectively collected and retrospectively analysed from 4491 consecutive patients referred for cardiac surgery over 18 years (July 1993-June 2012). Univariate predictors of in-hospital postoperative mortality were analysed by the appropriate tests. Variables with P < 0.1 were entered into multivariable logistic-regression model to identify predictors of in-hospital postoperative mortality, with data presented as odds ratios; P < 0.05 was statistically significant. Data on long-term survival and cardiac-specific mortality were obtained from the UK Office for National Statistics; the date of last follow-up was 13 October 2013 for the alive patients. Univariate predictors influencing cardiac death were determined by log-rank method. Variables with P < 0.1 were entered into multivariable Cox regression model to determine independent predictors of long-term survival, with data presented as hazard ratios; P < 0.05 was statistically significant.

RESULTS

Cardiac surgery was performed on 3890 consecutive patients (74.7% male, age 68.7 ± 8.1 years); 601 patients did not undergo surgery. Postoperative hospital mortality was 2.9% (n = 112/3890). Predictors of postoperative hospital mortality included age ≥ 70 years, female sex, hypertension, LVEF < 50%, neurological dysfunction, previous cardiac surgery, early time period 1993-1997, emergency procedures and triple procedures. All patients were followed until the date of last follow-up or date of death, with a median follow-up of 8.1 ± 7.6 years and a total follow-up of 33 208 years. There were 533 (13.7%) postoperative early and late deaths from cardiac causes. Predictors of long-term survival free from cardiac death included LVEF > 50%. Predictors of postoperative cardiac deaths in the long-term follow-up included older age, diabetes, neurological dysfunction, LVEF < 50%, non-coronary artery bypass surgery, early time period of surgery (1993-1997) and redo-cardiac surgery.

CONCLUSIONS

Cardiac surgery provides long-term survival benefit in all subsets of LV function, including advanced LV dysfunction.

Long-term outcomes of drug-eluting stent implantation versus coronary artery bypass grafting for patients with coronary artery disease and chronic left ventricular systolic dysfunction

Limited data are available on comparing the clinical outcomes of coronary artery bypass grafting (CABG) and drug-eluting stent (DES) implantation in patients with reduced left ventricular systolic function in the DES era. From January 2003 to December 2010, 953 patients with reduced left ventricular systolic function, defined as a left ventricular ejection fraction <50%, who had undergone percutaneous coronary intervention with DESs (n = 402) or CABG (n = 551) were enrolled in a retrospective, observational registry. Patients with acute myocardial infarction were excluded. Propensity score-matching analysis was also performed in 141 patient pairs. The primary outcome was all-cause death. The median follow-up duration was 32 months (interquartile range 15 to 61). All-cause death occurred in 81 patients (20.1%) in the DES group and 98 patient (17.8%) in the CABG group (p = 0.524). After propensity score matching, the long-term cumulative rate of death was not significantly different between the 2 groups (DES vs CABG 21.3% vs 19.1%; adjusted hazard ratio 1.23, 95% confidence interval 0.57 to 2.66, p = 0.603). However, the rate of major adverse cardiac and cerebrovascular events (35.5% vs 24.1%, adjusted hazard ratio 1.69, 95% confidence interval 1.04 to 2.77, p = 0.036) was higher in the DES group than the CABG group. This was driven by the higher incidence of repeat revascularization in the DES group (11.3% vs 4.3%, adjusted hazard ratio 3.65, 95% confidence interval 1.01 to 10.37, p = 0.018). In conclusion, DES implantation provides comparable long-term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.

Decision making and results of coronary artery bypass grafting for patients with poor left ventricular function

BACKGROUND

The aim of this study is to determine the results of coronary artery bypass surgery in patients with a low ejection fraction. Between January 2007 and January 2011, 3556 consecutive patients who underwent coronary artery bypass grafting at the Cardiovascular Surgery Clinic at Sifa University Hospital, Izmir, Turkey, were analyzed retrospectively.

METHODS

The patients were divided into 2 groups. Patients undergoing isolated first-time elective coronary bypass surgery were classified according to their preoperative ejection fraction; Patients in Group I had an ejection fraction between 20% and 35% with poor left ventricular function (n = 1246; 695 men and 551 women; mean age, 62.25 ± 5.72 years, range, 47-78 years). Control patients in Group II underwent elective coronary artery bypass grafting at the same time and had left ventricular ejection fraction between 36% and 49% (n = 2310; 1211 men and 1099 women; mean age, 61.83 ± 8.12 years, range, 41-81 years). The mean follow-up time for all patients was 24 ± 9.4 months (range, 12-48 months). Patients were followed postoperatively at the end of the first month and every 6 months. The left ventricular ejection fraction was assessed by transthoracic echocardiography.

RESULTS

The mean number of distal anastomoses, myocardial infarction, and mean age was not significantly different between the 2 groups; however, cross-clamp time was longer in Group I. Patient recovery time was significantly longer in Group I. Morbidity (14.5% in Group I versus 7.4% in Group II, P < .005) and mortality (1.76% versus 0.30%, P < .005) were higher in Group I. During late follow-up, the 2-year survival rate (85.1% versus 94.5%) and 2-year event-free rate (77.6% versus 86.9%) were significantly lower in Group I when compared to Group II. Postoperative left ventricular ejection fraction values were significantly superior in Group I compared to Group II.

CONCLUSION

Coronary artery bypass grafting can be safely performed in patients with low ejection fraction with minimal postoperative morbidity and mortality. The viable myocardium could be reliably determined by positron emission tomography. Low ejection fraction patients could greatly benefit from coronary bypass surgery regarding postoperative ejection fraction, increased long-term survival, improvement in New York Heart Association classification, and higher quality of life.

Noise spatial nonuniformity and the impact of statistical image reconstruction in CT myocardial perfusion imaging

PURPOSE

To achieve high temporal resolution in CT myocardial perfusion imaging (MPI), images are often reconstructed using filtered backprojection (FBP) algorithms from data acquired within a short-scan angular range. However, the variation in the central angle from one time frame to the next in gated short scans has been shown to create detrimental partial scan artifacts when performing quantitative MPI measurements. This study has two main purposes. (1) To demonstrate the existence of a distinct detrimental effect in short-scan FBP, i.e., the introduction of a nonuniform spatial image noise distribution; this nonuniformity can lead to unexpectedly high image noise and streaking artifacts, which may affect CT MPI quantification. (2) To demonstrate that statistical image reconstruction (SIR) algorithms can be a potential solution to address the nonuniform spatial noise distribution problem and can also lead to radiation dose reduction in the context of CT MPI.

METHODS

Projection datasets from a numerically simulated perfusion phantom and an in vivo animal myocardial perfusion CT scan were used in this study. In the numerical phantom, multiple realizations of Poisson noise were added to projection data at each time frame to investigate the spatial distribution of noise. Images from all datasets were reconstructed using both FBP and SIR reconstruction algorithms. To quantify the spatial distribution of noise, the mean and standard deviation were measured in several regions of interest (ROIs) and analyzed across time frames. In the in vivo study, two low-dose scans at tube currents of 25 and 50 mA were reconstructed using FBP and SIR. Quantitative perfusion metrics, namely, the normalized upslope (NUS), myocardial blood volume (MBV), and first moment transit time (FMT), were measured for two ROIs and compared to reference values obtained from a high-dose scan performed at 500 mA.

RESULTS

Images reconstructed using FBP showed a highly nonuniform spatial distribution of noise. This spatial nonuniformity led to large fluctuations in the temporal direction. In the numerical phantom study, the level of noise was shown to vary by as much as 87% within a given image, and as much as 110% between different time frames for a ROI far from isocenter. The spatially nonuniform noise pattern was shown to correlate with the source trajectory and the object structure. In contrast, images reconstructed using SIR showed a highly uniform spatial distribution of noise, leading to smaller unexpected noise fluctuations in the temporal direction when a short scan angular range was used. In the numerical phantom study, the noise varied by less than 37% within a given image, and by less than 20% between different time frames. Also, the noise standard deviation in SIR images was on average half of that of FBP images. In the in vivo studies, the deviation observed between quantitative perfusion metrics measured from low-dose scans and high-dose scans was mitigated when SIR was used instead of FBP to reconstruct images.

CONCLUSIONS

(1) Images reconstructed using FBP suffered from nonuniform spatial noise levels. This nonuniformity is another manifestation of the detrimental effects caused by short-scan reconstruction in CT MPI. (2) Images reconstructed using SIR had a much lower and more uniform noise level and thus can be used as a potential solution to address the FBP nonuniformity. (3) Given the improvement in the accuracy of the perfusion metrics when using SIR, it may be desirable to use a statistical reconstruction framework to perform low-dose dynamic CT MPI.

Persistent ventricular asynchrony after coronary artery bypass surgery predicts cardiac events

AIM

The aim of this study was to identify echocardiographic LV systolic and diastolic measurements that predict clinical events post-coronary artery bypass graft (CABG) surgery.

METHODS

We collected data from 27 patients (age 70 +/- 7 years) who underwent elective CABG, before and within 6 weeks after surgery. LV systolic function was assessed by conventional echocardiographic parameters. A number of LV filling measurements were also made, which included total isovolumic time (t-IVT), Tei index, and restrictive filling pattern. Postoperative cardiac events were death or hospitalization for chest pain, breathlessness, or arrhythmia.

RESULTS

Patient's follow-up period was 17 +/- 10 months. Of the 27 patients (age 70 +/- 7 years, 22 male), 10 had postoperative cardiac events. LV ejection fraction (EF) and fractional shortening (FS) were lower (P = 0.01, and P = 0.007, respectively), t-IVT longer (P < 0.001), and Tei index was higher (P < 0.001) preoperatively in patients with events compared to those without. The same differences between groups remained after surgery; EF (P = 0.002), FS (P = 0.002), t-IVT (P < 0.001), and Tei index (P < 0.001). T-IVT was the only preoperative predictor of events (P = 0.038) but its postoperative value as well as that of FS predicted events (P = 0.034, and P = 0.042, respectively). T-IVT of 12.2 s/min and FS of 26% were 80% sensitive and 88% specific for predicting postoperative events.

CONCLUSION

Despite successful surgical revascularization residual impairment of LV systolic function and persistent asynchrony in the form of prolonged t-IVT are associated with postoperative events. Since these abnormalities remained despite full medical therapy, they may thus suggest a need for electrical resynchronization therapy.

Surgical myocardial revascularization of patients with ischemic cardiomyopathy and severe left ventricular disfunction

OBJECTIVE

To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction.

METHODS

Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis.

RESULTS

Mean left ventricular ejection fraction was 29+/-4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32+/-5% to 39+/-5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27+/-8%/23+/-7% to 37+/-5%/31+/-6%, p <0.001.

CONCLUSIONS

In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.

Relationship between myocardial viability and coronary run-off in jeopardized myocardium

OBJECTIVE

The aim of this study was to evaluate the relationship between coronary run-off and myocardial viability in jeopardized regions.

METHOD

We studied 50 patients (40 male, mean age: 55.63 +/- 10.54 years) with coronary artery stenosis >70% and ejection fraction <40% referred for viability study via dobutamine stress echocardiography. The relationship between coronary run-off and viability was evaluated. Good run-off demonstrates good or moderate and no run-off means poor or no run-off.

RESULTS

In the apical region, 33% of the segments with good antegrade run-off were viable and 67% nonviable. Also, 72% of the segments with no run-off were nonviable and 28% viable. In the midportion region, 70% of the segments with good antegrade run-off were viable and 30% nonviable; 50% of the segments with no run-off were nonviable and 50% viable. In the basal region, 85% of the segments with good antegrade run-off were viable and 15% nonviable; 19% of the segments with no run-off were nonviable and 81% viable. The proportion of the nonviable segments increased significantly from the basal to apical regions either with good (p < 0.001) or no run-off (p = 0.004). From 239 viable segments, 58.6% had antegrade, 15.4% retrograde, and 25.5% no run-off. Of 181 nonviable segments, 44% had antegrade, 34% retrograde, and 34.8% no run-off.

CONCLUSION

There was more susceptibility to nonviability in the apical regions despite good run-off, while the basal segments showed more viability in spite of having no run-off. The findings may be helpful for selecting patients with coronary artery disease and left ventricular systolic dysfunction that benefit from revascularization.

Prolonged total isovolumic time predicts cardiac events following coronary artery bypass surgery

AIMS

Left ventricular (LV) systolic dysfunction may be associated with compromised stroke volume, which may be caused by asynchrony, reflected on the prolongation of isovolumic time (t-IVT). To assess the prognostic role of Doppler echocardiographic measurements in predicting cardiac events after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

The study included 74 patients undergoing routine CABG. A pre-CABG Doppler echocardiographic assessment of LV dimensions, filling and ejection was performed and t-IVT was determined as [60 - (total ejection time + total filling time)]. Follow-up period was 18 +/- 12 months. Of the 74 patients (age 65 +/- 16 years, 59 males), 29 underwent hospital admission for a cardiac event or died. There were no differences in age, gender, incidence of previous infarct or mitral regurgitation, LV-EDD (left ventricular end-diastolic dimension), left atrial or right ventricular size in patients with cardiac events compared with those without events. Left ventricular end-systolic dimension (LV-ESD) was greater (4.5 +/- 0.9 vs. 3.9 +/- 0.9 cm, P = 0.003), fractional shortening (FS) was lower (21 +/- 4 vs. 32 +/- 8%), E:A ratio and Tei index were higher (2.1 +/- 0.8 vs. 1.0 +/- 0.6 and 0.9 +/- 0.3 vs. 0.6 +/- 0.3, all P < 0.001), and t-IVT was longer (16 +/- 5 vs.10 +/- 4 s/min, P < 0.001) in patients with events. Multivariate predictors of post-CABG events (odds ratio 95% confidence interval) were low FS [0.66 (0.50-0.87), P < 0.001], high E:A ratio [l4.13 (1.17-14.60), P = 0.028], large LV-ESD [0.19 (0.05-0.84), P = 0.029], and long t-IVT [1.37 (1.02-1.84), P = 0.035].

CONCLUSION

Despite satisfactory surgical revascularization, long t-IVT and systolic dysfunction suggest persistent ventricular dyssynchrony that contributes to post-CABG cardiac events. Early assessment of such patients for potential benefit from electrical resynchronization may optimize their cardiac performance and hence clinical outcome.

Surgical coronary revascularization in severe left ventricular dysfunction

Surgical revascularization in patients with coronary artery disease and severe left ventricular dysfunction is a common practice and poses a surgical challenge. From September 2002 to May 2004, 50 patients (47 men and 3 women; mean age, 59 +/- 9 years) with a mean preoperative ejection fraction of 19.7% +/- 3.2% underwent surgical revascularization. The mean EuroSCORE was 7.2 +/- 3.4. Indications for surgery were congestive heart failure in 8 patients (16%), angina in 20 (40%), ventricular arrhythmias in 4 (8%), and critical left main stem disease in 12 (24%). Twenty-two patients (44%) had emergency surgery for critical anatomy and unstable symptoms. The number of grafts per patient was 3.7 +/- 0.8. Seventeen patients (34%) required intra-aortic balloon pump support, 16 (32%) needed pacing, and 48 (96%) had inotropic support postoperatively. Morbidity included re-operation for bleeding (2%), acute renal failure (10%), hemodialysis (4%), and fatal multiorgan failure (4%). Postoperative (4.9 +/- 3.7 months) 2-dimentional echocardiography was available in 18 patients of whom 11 (61%) showed improved left ventricular function (range, 5% to 45%). Thirty-day hospital mortality was 8%. These data indicate that surgical revascularization can be performed safely with acceptable hospital mortality in high-risk patients with severe left ventricular dysfunction.

Cardiovascular Molecular Imaging

The goal of this review is to highlight how molecular imaging will impact the management and improved understanding of the major cardiovascular diseases that have substantial clinical impact and research interest. These topics include atherosclerosis, myocardial ischemia, myocardial viability, heart failure, gene therapy, and stem cell transplantation. Traditional methods of evaluation for these diseases will be presented first, followed by methods that incorporate conventional and molecular imaging approaches.

Cardiac Transplantation: Any Role Left?

The authors analyze the question of whether heart transplantation still has a role in the current era of complex technologies. To achieve this objective, the authors first discuss the known benefits of different therapeutic modalities currently available for patients who have end-stage heart failure, including pharmacologic management, electrophysiologic therapies, high-risk surgical strategies, implantation of mechanical circulatory support device therapy, and heart transplantation. The authors then evaluate the current developments and future perspectives in the field that may influence the likelihood of heart transplantation to remain the therapeutic modality of choice for end-stage heart failure.

Implantable cardioverter-defibrillators improve survival after coronary artery bypass grafting in patients with severely impaired left ventricular function

Objective

Patients with severe left ventricular (LV) dysfunction have a poor long term survival despite complete surgical revascularization. Recent data suggests that the use of Implantable Cardioverter-Defibrillator (ICD) improves survival in patients with severe LV dysfunction. We compared the survival impact of ICD implantation in patients with severe LV dysfunction who underwent CABG.

Methods

Between January 1996 and August 2004, 305 patients with LV ejection fraction (EF) ≤25% had CABG surgery at our institution. Demographics of patients who had received an ICD (ICD+) in the post -operative period was compared to those without ICD (ICD-). Survival was evaluated by the Kaplan-Meier method.

Results

Of the entire group, 35 (11.5%) patients received an ICD with a median of 2 (+/-2) years after CABG. Indication for ICD implantation was clinical evidence of non sustained ventricular tachycardia (NSVT). There were no differences between the 2 groups with respect to age, gender, NYHA classification, number of bypasses, or other co-morbidities. Survival at 1, 3 and 5 years was 88%, 79%, and 67% for the ICD- group compared to 94%, 89% and 83% for the ICD+ group, respectively (figure, p < 0.05).

Conclusion

Implantation of ICD after CABG confers improved short and long term survival benefit to patients with severe LV dysfunction. Prophylactic ICD implantation in the setting of severe LV dysfunction and CABG surgery should be considered.

Outcome of Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting: Renal Function and Mortality After 3.8 Years

BACKGROUND

There are few data regarding medium-term outcome of coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction, particularly in the modern era, and even less assessing preoperative factors that might identify patients at highest risk.

METHODS AND RESULTS

Three hundred seventy-nine consecutive patients with LV ejection fraction < or = 35%, who underwent isolated first CABG between 1995 and 1999 were studied. Potential preoperative and perioperative predictors of outcome were recorded and patients followed-up for a median of 3.8 years. The primary study end-point was all-cause mortality. The 30-day, 1-year, and 3-year survival rates were 94.5%, 88%, and 81%, respectively. The independent predictors of mortality were preoperative estimated glomerular filtration rate (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.97 to 0.99 per mL/min/1.73 m2; P<0.001) and age (HR, 1.03; 95% CI, 1.01 to 1.06 per year; P=0.005).

CONCLUSIONS

Patients with significant LV systolic dysfunction undergoing isolated CABG using contemporary techniques have a good medium-term survival. Renal dysfunction is the strongest independent predictor of mortality.

Coronary artery bypass grafting in patients with left ventricular dysfunction

BACKGROUND

Coronary artery bypass grafting surgery (CABG) remains a challenge for patients with coronary artery disease and left ventricular (LV) dysfunction. The aim of this study was to evaluate the result of CABG in patients with LV dysfunction.

METHODS

Medical records of 1,847 patients who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 2002, were reviewed. The mortality rate associated with clinical and operative variables was compared between patients with LV ejection fraction (LVEF) > or = 35% and patients with LVEF < 35%.

RESULTS

Patients with LVEF < 35% had more episodes of myocardial infarction (57.5% vs 28.9%, p < 0.001) and history of congestive heart failure (18.1% vs 3.2%, p < 0.001), higher New York Heart Association (NYHA) class, and higher angina class. Longer cardiopulmonary bypass time (147 +/- 44 minutes vs 137 +/- 40 minutes, p < 0.001) but fewer left internal mammary artery (LIMA) grafts (46.8% vs 65.7%, p < 0.001) were used in patients with LVEF < 35%. Patients with LVEF < 35% had significantly higher hospital mortality (6.6% vs 2.2%, p < 0.001), higher major morbidity (23.3% vs 16.1%, p < 0.01), and longer hospital stay (25 +/- 23 days vs 21 +/- 16 days, p < 0.01).

CONCLUSION

Although patients with LV dysfunction had higher mortality and morbidity, CABG could be done in these high-risk patients with acceptable results.

What is the evidence for percutaneous coronary intervention or coronary artery bypass graft in ischemic cardiomyopathy?

Coronary artery disease has supplanted hypertension as the leading cause of congestive heart failure in the United States. The recognition that contraction abnormalities could accrue from gradual stunning, or longer-term 'hibernation,' raised the possibility that revascularization of viable but hypocontractile elements could improve myocardial performance. This review focuses on the data from randomized trials and registries regarding the potential benefits and risks of either coronary artery bypass grafting (CABG) or percutaneous coronary intervention for patients with severe left ventricular dysfunction secondary to coronary artery disease. For patients with medically refractory angina and ischemic cardiomyopathy, revascularization with CABG or percutaneous coronary intervention is recommended. The ongoing National Institutes of Health-sponsored Surgical Treatment for Ischemic Heart Failure (STICH) trial, a multicenter, prospective, randomized trial comparing contemporary medical therapy with CABG for patients with ischemic cardiomyopathy, should provide important information regarding patients who do not have angina. The conclusion of this review is that a trial of medical therapy vs. percutaneous coronary intervention could be of additional value, especially for patients at particularly high risk, when undergoing CABG.

On-Pump/Beating-Heart Myocardial Protection for Isolated or Combined Coronary Artery Bypass Grafting in Patients with Severe Left Ventricle Dysfunction: Assessment of Myocardial Function and Clinical Outcome

BACKGROUND

Myocardial protection in coronary artery bypass grafting (CABG) with severe left ventricular (LV) dysfunction is still a surgical dilemma. Preoperative myocardial infarction (MI) and postoperative low output syndrome are serious complications in cases of inadequate protection of the heart, which has limited myocardial reserve. The aim of this study was to evaluate myocardial function and clinical outcome after on-pump/beating-heart CABG in patients with severe LV dysfunction.

METHODS

Between March 2001 and March 2004, clinical, operative, and postoperative data were prospectively collected from patients with LV ejection fraction (EF) < 30% who underwent on-pump/beating-heart CABG and associated procedures.

RESULTS

There were 46 patients and the mean patient age was 58.38 +/- 9.23. The mean EF was 25.6 +/- 2.8%. Operating time was 275 +/- 63 minutes. The frequency of distal anastomosis was 3.06 +/- 1.04. Twenty-four patients required aneurysmectomy in addition to CABG, and 2 of the 24 required mitral repairs. Inotropic support was required in 14 patients (30%) and 5 of them (10.9%) also required IABP. The LV EF improved significantly after the operation when compared to preoperative measurements (25.6 +/- 2.8 versus 33.64 +/- 4.69, P < .05). Hospital mortality rate was 4.3% (2 of the 46 patients). No mortality was observed at a mean followup of 16 months after discharge from the hospital.

CONCLUSIONS

On-pump/beating-heart CABG technique is effective in protecting myocardial functions in patients with severe LV dysfunction. The main advantage of the on-pump/beating-heart technique is the ability it provides one to perform complete revascularization, and intracavitary procedures with low morbidity and mortality even in impaired LV function.

Surgical therapies for heart failure

A variety of invasive procedures have been utilized to reduce the burden on the left ventricle in order to slow or reverse the progressive changes of structural remodeling. These include mitral valve repair, left ventricular assist devices, left ventricular chamber reduction surgery, endovascular patchplasty, dynamic cardiomyoplasty, and a variety of prosthetic implants designed to inhibit remodeling either by constraining chamber enlargement or reducing wall stress to inhibit further growth. Resynchronization therapy also may favorably affect remodeling. The potential of these procedures to slow the progression of heart failure needs to be confirmed in prospective studies.

Long-term outcome of isolated coronary artery bypass surgery in patients with severe left ventricular dysfunction

BACKGROUND

Coronary artery bypass grafting (CABG) is indicated in patients with coronary artery disease and impaired ventricular function. However, earlier studies have suggested that prognosis of patients with severe left ventricular dysfunction is extremely poor. We used the APPROACH registry to derive contemporary estimates of prognosis associated with CABG for this high-risk patient population.

METHODS AND RESULTS

The study group consisted of 7841 patients who had isolated CABG in the province of Alberta, Canada between 1996 and 2001. Patients with markedly reduced left ventricular function (ejection fraction [EF] <30%, Lo EF, n =430) were compared with those with moderate reduction in ventricular function (EF 30% to 50%, Med EF, n =2581) and those with normal left ventricular function (EF >50%, normal [Nl] EF, n=4830). The operative mortality was higher in the patient group with Lo EF (4.6%) compared with Med EF and Nl EF groups (3.4% and 1.9%, respectively, P<0.001). At 5 years, survival was 77.7% for Lo EF patients compared with 85.5% and 91.2% for Med EF and Nl EF patients, respectively (P<0.001). After controlling for other independent variables, the adjusted hazard ratio for death was 1.98 (95% CI, 1.49 to 2.62) for Lo EF relative to Nl EF. The mortality rate at 1 year was significantly lower for Lo EF patients who underwent CABG than it was for nonrevascularized Lo EF patients (risk-adjusted odds ratio, 0.36; 95% CI, 0.24 to 0.55).

CONCLUSIONS

In the modern era of cardiac surgery, CABG can be performed in Lo EF cases with an acceptable perioperative mortality risk. Our estimate of 5-year survival in this high-risk group is better than previously reported in the literature from earlier periods.

PET in cardiology

Myocardial perfusion imaging with single-photon emission CT (SPECT) is a key investigation in the work-up of patients with coronary artery disease. PET, however, with inherently better spatial and temporal resolution, offers several advantages over SPECT. The last decade has witnessed extensive application of PET techniques to assess myocardial viability and has provided valuable information important in analyzing the risk: benefit ratio for several therapeutic measures. Recent advances in PET instrumentation and radiopharmaceuticals have generated considerable interest to use PET for evaluating an array of cardiovascular disease.

Coronary artery disease and prevention of heart failure

Coronary artery disease is a major contributor to the progression of left ventricular systolic dysfunction and heart failure (HF). Recognizing that coronary artery disease is a leading cause of HF in the United States is critical to reducing mortality resulting from this condition. Although some patients may be candidates for mechanical revascularization to improve left ventricular function, all patients are candidates for aggressive secondary prevention strategies. This review discusses the prevalence of coronary artery disease, prognostic significance and pathophysiology, risk factor modifications, pharmacologic treatments, and the role of revascularization.

Quantification of myocardial infarct size and transmurality by contrast-enhanced magnetic resonance imaging in men

Contrast-enhanced magnetic resonance (ce-MR) imaging allows precise delineation of infarct transmurality. An issue of debate is whether data analysis should be performed visually or quantitatively. Accordingly, a head-to-head comparison was performed between visual and quantitative analyses of infarct transmurality on ce-MR imaging. In addition, infarct transmurality was related to the severity of wall motion abnormalities at rest. In 27 patients with long-term ischemic left ventricular (LV) dysfunction (LV ejection fraction 33 +/- 8%) and previous infarction, cine MR imaging (to assess regional wall motion) and ce-MR imaging were performed. Using a 17-segment model, each segment was assigned a wall motion score (from normokinesia to dyskinesia), and segmental infarct transmurality was visually assessed on a 5-point scale (0 = no infarction, 1 = transmurality < or =25% of LV wall thickness, 2 = transmurality 26% to 50%, 3 = transmurality 51% to 75%, and 4 = transmurality 76% to 100%). Quantification of transmurality was performed with threshold analysis; myocardium showing signal intensity above the threshold was considered scar tissue, and percent transmurality was calculated automatically. Wall motion was abnormal in 56% of the 459 segments, and 55% of segments showed hyperenhancement (indicating scar tissue). The agreement between visual and quantitative analyses was excellent: 90% of segments (kappa 0.86) were categorized similarly by visual and quantitative analyses. Infarct transmurality paralleled the severity of contractile dysfunction; 96% of normal or mildly hypokinetic segments had infarct transmurality < or =25%, whereas 93% of akinetic and dyskinetic segments had transmurality >50% on visual analysis. In conclusion, visual analysis of ce-MR imaging studies may be sufficient for assessment of transmurality of infarction.

Coronary artery bypass with ventricular restoration is superior to coronary artery bypass alone in patients with ischemic cardiomyopathy

BACKGROUND

Coronary artery bypass is an acceptable therapy in patients with ischemic cardiomyopathy. However, it has been demonstrated that patients with increased left ventricular volume have a worse outcome than patients with normal ventricular volume. Our hypothesis was that ventricular restoration plus coronary artery bypass provides improved outcome compared with coronary artery bypass alone in ischemic cardiomyopathy with ventricular enlargement.

METHODS

A retrospective analysis was performed of patients with ischemic cardiomyopathy (ejection fraction <30%) who underwent operation between 1998 and 2002. Patients with enlarged ventricles (end-diastolic dimension > or =6.0 cm) who underwent either coronary artery bypass alone or coronary artery bypass with ventricular restoration were compared. Preoperative and postoperative ejection fraction, morbidity, mortality, and freedom from heart failure (hospitalization secondary to heart failure) were assessed.

RESULTS

Ninety-five patients were included in the study. Thirty-nine patients had coronary artery bypass alone, whereas 56 patients had ventricular restoration with coronary artery bypass. Both groups demonstrated an improved postoperative ejection fraction; however, the improvement was significantly greater in the ventricular restoration plus coronary artery bypass group (P <.01). There were no hospital deaths in either group; however, late mortality was higher in the coronary artery bypass group. Freedom from heart failure was achieved in all but 2 of the ventricular restoration plus coronary artery bypass patients (2/56, or 3.6%) versus 7 in the coronary artery bypass group (7/39, or 18%). The combined outcomes of freedom from failure and late mortality were significantly improved in the ventricular restoration plus coronary artery bypass group (P <.05).

CONCLUSIONS

Ventricular restoration affords significant improvement in ejection fraction compared with coronary artery bypass alone, without added mortality. Most importantly, left ventricular restoration reduces late morbidity and mortality compared with coronary artery bypass alone in patients with large ventricles.

Prognostic and therapeutic implications of myocardial viability in patients with heart failure

Substantial progress has been made in understanding the pathophysiology of regional and global left ventricular (LV) dysfunction and the states of hibernation and stunning in patients with heart failure. The clinical literature on the use of noninvasive imaging to assess myocardial viability has evolved from predicting improvement in regional LV function to predicting patient-related outcomes, including heart failure symptom improvement and survival after revascularization. A substantial body of observational cohort data demonstrates that mortality risk is high in patients with coronary artery disease and LV dysfunction who have substantial viable myocardium, and that risk is reduced by revascularization. Thus, noninvasive imaging of myocardial ischemia and viability can provide important prognostic information in patients with heart failure and LV dysfunction, and provide a signal of the potential benefit of revascularization.

Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization?

OBJECTIVE

In patients with ischemic cardiomyopathy and a substantial amount of dysfunctional but viable myocardium, myocardial revascularization may improve left ventricular ejection fraction. The aim of this study was to evaluate why not all patients with a substantial amount of viable tissue recover in function after revascularization.

METHODS

A total of 118 consecutive patients with a depressed left ventricular ejection fraction (on average 29% +/- 6%) due to chronic coronary artery disease underwent myocardial revascularization. Before revascularization all patients underwent dobutamine stress echocardiography to assess regional dysfunction, left ventricular volumes, and myocardial viability as well as radionuclide ventriculography to determine the left ventricular ejection fraction. Next, 3 to 6 months after revascularization, the left ventricular ejection fraction and regional contractile function were reassessed. Improvement of left ventricular ejection fraction > or = 5% following revascularization was considered clinically significant.

RESULTS

Dobutamine stress echocardiography revealed that 489 (37%) of the 1329 dysfunctional segments were viable. A total of 61 (52%) patients had a substantial amount of viable myocardium (> or = 4 viable segments). In these 61 patients the global function was expected to recover > or = 5% after revascularization. However, left ventricular ejection fraction did not improve in 20 (33%) of 61 patients despite the presence of substantial viability. Clinical characteristics and echocardiographic data were comparable between patients with and without improvement. However, patients without improvement had considerably larger end systolic volumes (153 +/- 41 mL vs 133 +/- 46 mL, P =.007). The likelihood of recovery of global function decreased proportionally with the increase of end systolic volume (P <.001, R = 0.43, n = 61). Receiver operating characteristic curve analysis demonstrated that an end systolic volume > or = 140 mL had the highest sensitivity/specificity to predict the absence of global recovery.

CONCLUSIONS

In patients with ischemic cardiomyopathy not only the amount of dysfunctional but viable myocardium but also the extent of left ventricular remodeling determines the improvement in function following myocardial revascularization. Patients with a high end systolic volume due to left ventricular remodeling have a decreased likelihood of improvement of global function.

Coronary revascularization in ischemic cardiomyopathy

This article first discusses coronary artery disease, including left-ventricular dysfunction, hibernating myocardium, the relationship between stunning, hibernation, and heart failure, and molecular mechanisms underlying myocardial hibernation. Left ventricular function and the prognosis and pathophysiology of left-ventricular dysfunction are then examined. Selection of patients for revascularization is discussed, to include which coronary patients should be investigated for myocardial viability, and other surgical considerations are outlined. The outcome following revascularization in the heart failure patient, the results of revascularization, and the time course of functional recovery after coronary artery bypass graft are also covered.

Incidence of recovery of contractile function following revascularization in patients with ischemic left ventricular dysfunction

Contractile function in patients with ischemic left ventricular (LV) dysfunction may improve after myocardial revascularization. Currently, the incidence of contractile function recovery after revascularization in these patients is unclear. The aim of this study was to assess the incidence of function improvement after myocardial revascularization in patients with ischemic LV dysfunction. A total of 258 consecutive patients (aged 59 +/- 12 years) with severely depressed LV ejection fractions (EFs) due to chronic coronary artery disease and heart failure symptoms were studied. All patients underwent radionuclide ventriculography and 2-dimensional echocardiography at rest before and 3 to 6 months after revascularization. At baseline, 1,330 segments (32%) were normal and 2,775 segments (68%) were dysfunctional. Improvement after revascularization occurred in 736 of the 2,775 dysfunctional segments (27%). Overall, LVEF improved from 29 +/- 7 to 32 +/- 9 (p <0.0001). A clinically significant improvement of LVEF (>/=5% postrevascularization) was present in 101 patients (39%). Improvement of LVEF after revascularization was frequently observed in patients with a more severely impaired baseline LVEF. At least 3 segments with improvement of function were needed for an improvement of LVEF of >/=5%.

Management issues for patients with coronary artery disease and heart failure

Despite recent favorable trends in survival, heart failure remains a highly fatal disease. Improvements in the prevention of early death from coronary artery disease, along with an aging population, have resulted in an increased prevalence for heart failure in the United States. In the management of patients with heart failure secondary to coronary artery disease, the relative efficacy of invasive therapies such as coronary revascularization, surgical left ventricle remodeling, internal cardiac defibrillator implantation, cardioverter resynchronization therapy, mechanical ventricular assist, and cardiac transplantation need to be considered. Clinical studies examining these important treatment options are reviewed in order to better define the optimal management strategy for this challenging population of patients.

Coronary artery surgery for ischaemic heart failure: the surgeon's view

Recent advances in medical therapy have improved outcomes for patients with severe heart failure. However, overall survival remains poor. Transplantation is an established therapy for these patients but is limited by the large mismatch between demand and donor organ availability. Recently it has been recognised that not all ventricular dysfunction secondary to coronary artery disease is irreversible. Revascularisation in certain patients would appear to improve ventricular function. These patients are said to demonstrate myocardial "hibernation". Revascularisation in these patients may provide a further treatment option in the treatment of heart failure.

Coronary surgery with non-cardioplegic methods in patients with advanced left ventricular dysfunction: immediate and long term results

OBJECTIVE

To evaluate perioperative results and long term survival in patients with severe left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) using non-cardioplegic methods.

METHODS

From April 1990 through December 1999, 4100 consecutive patients underwent isolated CABG using hypothermic ventricular fibrillation. Of these, 141 (3.4%) had severe LV dysfunction (ejection fraction < 30%). Mean age was 58.3 (9.6) years. 64 patients (45.4%) were in Canadian Cardiovascular Society class III or IV and 16 (11.3%) were subjected to urgent or emergent surgery. A previous myocardial infarction was recorded in 127 (90.1%). The majority (89.4%) had triple vessel and 26 (18.4%) had left main disease. The mean number of grafts per patient was 3.1. At least one internal thoracic artery was used in all patients and 21 (14.8%) had bilateral internal thoracic artery grafts (1.2 arterial grafts per patient).

RESULTS

Perioperative mortality was 2.8% (4 patients) and the incidence of acute myocardial infarction 2.8%. 50 (35.5%) patients required inotropes but only 16 (11.3%) required it for longer than 24 hours; 5 patients (3.5%) needed mechanical support. The incidence of renal failure was 3.5%. Mean duration of hospital stay was 9.6 (8.3) days. Follow up was 95% complete and extended for a mean of 57 (30) months. Late mortality was 11.5%. Actuarial survival rates at 1, 3, and 5 years were 96%, 91%, and 86%, respectively.

CONCLUSIONS

Non-cardioplegic techniques are safe and effective in preserving the myocardium during CABG in patients with coronary artery disease and poor LV function, with low operative mortality and morbidity, and encouraging medium to long term survival rates.

Intraoperative and postoperative risk factors for respiratory failure after coronary bypass

BACKGROUND

Unlike preoperative events, the influence of intraoperative or postoperative events on respiratory failure after coronary artery bypass grafting (CABG) remains unclear. The purpose of this study was to identify intraoperative and postoperative risk factors that predispose respiratory impairment after CABG.

METHODS

A single institutional database combined with a mandatory report submitted to the Cardiac Surgery Registry of the New York State Department of Health was used. A total of 8,802 consecutive patients who underwent primary CABG with or without a concomitant cardiac operation from January 1993 through December 2000 were included. Respiratory failure was defined as the need for postoperative mechanical ventilatory support longer than 72 hours. Univariate and multivariate logistic regression model was used in the analysis.

RESULTS

Of 8,802 consecutive patients (6,234 males and 2,568 females) who underwent CABG with or without a concomitant operation, 491 patients (5.6%) suffered from postoperative respiratory failure. Although univariate analysis identified 39 statistically significant preoperative risk factors for post-CABG respiratory failure, only six preoperative risk factors were statistically significant by multivariate analysis (p < 0.001). CPB time (in 30 minutes increments) was the only validated intraoperative variable that increased the risk of postrespiratory failure (odds ratio [OR], 1.2; p less than 0.0001). Postoperative events contributing significantly to an increased risk of post-CABG respiratory failure were (1) sepsis and endocarditis (OR, 90.4; p < 0.0001), (2) gastrointestinal bleeding with or without infarction and perforation (OR, 38.8; p < 0.0001), (3) renal failure (OR, 30.7; p < 0.0001), (4) deep sternal wound infection (OR, 11.3; p < 0.0001), (5) new stroke, intraoperative at 24 hours (OR, 9.3; p < 0.0001), and (6) bleeding that required reoperation (OR, 5.5; p < 0.0001). All perioperative variables together accounted for only 28.6% (R2) of the variation.

CONCLUSIONS

Respiratory function after CABG is readily influenced by postoperative occurrence of extracardiac organ or system complications.

Prognosis of patients with chronic coronary artery disease and severe left ventricular dysfunction. The importance of myocardial viability

BACKGROUND AND AIM

The choice of optimal treatment strategy in patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction is often difficult. The aim of this study was to compare long-term results of patients with chronic CAD, severe heart failure and a defined scope of myocardial viability treated with coronary revascularization, heart transplantation, or kept on medical therapy.

METHODS

From 1993 to 2000, viability evaluation using low-dose dobutamine echocardiography was performed in 124 patients with CAD and LV ejection fraction <or=30%. The dysfunctional myocardial segments were defined as viable if they exhibited improvement in their thickening at any dose of dobutamine or worsening without initial improvement. The patients were divided into five groups and followed up for a mean period of 27+/-23 months. Group A consisted of 39 patients with viability (at least two dysfunctional but viable segments) who were revascularized. Group B consisted of 29 patients with viability treated medically. Groups C (n=23) and D (n=22) comprised patients with non-viable dysfunctional myocardial segments who were revascularized or kept on medical therapy, respectively. Eleven patients referred for heart transplantation after dobutamine echocardiography and 62 patients with ischemic cardiomyopathy transplanted in the same time interval were included in the group of transplanted patients (Group E).

RESULTS

The Kaplan-Meier survival analysis demonstrated a significantly better survival of group A patients as compared with group B patients (P<0.05). The prognostic benefit of revascularization in patients with viability was not manifested until 3 years after the procedure. At 5 years, survival in groups A, B, C, D and E was 89, 60, 67, 50 and 78%, respectively.

CONCLUSION

In patients with CAD, severe LV dysfunction, and the evidence of viability in dysfunctional myocardium, coronary revascularization improves survival. At least 3-years follow-up is necessary to objectively assess the prognostic effect of coronary revascularization.

Coronary artery bypass grafting in patients with poor left ventricular function

Coronary artery bypass grafting (CABG) in patients with poor left ventricular function remains a surgical challenge and is still controversial. The purposes of this study were to evaluate the effectiveness of CABG in such patients when performed without case selection on the basis of preoperative viability tests and to determine the predictors of postperative outcome. The preoperative, perioperative, and postoperative early and mid-term follow-up data of 273 patients with < or = 30% left ventricular ejection fraction (LVEF) who underwent isolated CABG between January 1995 and November 2000 were evaluated. Preoperative echocardiography and cardiac catheterization, and postoperative control echocardiography were performed in all patients. Follow-up was achieved via monthly periodical examinations in the first 6 months, and thereafter by either regular visits or phone contact. Preoperatively, 242 (88.65%) patients were in NYHA class III or IV, and the mean LVEF was 26.51 +/- 3.64%. The overall hospital mortality total was 14 (5.13%) patients. There were 44 (16.12%) late mortalities. Postoperative morbidities were observed in 74 (27.1%) patients. Two-hundred and two (93.95%) of the surviving 215 (78.75%) patients were in NYHA class I or II at 49.55 +/- 14.84 months of follow-up. Postoperative follow-up echocardiographic examinations revealed a mean LVEF of 39.66% +/- 5.43%. The improvements in functional capacity and LVEF were significant. Advanced age, diabetes, hypertension, cross-clamp time >60 min, bypass time>120 min, and severity of functional class (class III-IV of NYHA) were found to be the determinants of mortality. However, multivariate analyses revealed only older age and class III-IV of NYHA and CCS were predictors of mortality. The low mortality and morbidity rates as well as satisfactory postoperative improvements in functional capacity and LVEF measurements support the use of CABG without the need for any viability assessment in patients with left ventricular dysfunction.

Long-term outcome and the use of revascularization in patients with heart failure, suspected ischemic heart disease, and large reversible myocardial perfusion defects

BACKGROUND

The potential role of coronary revascularization in the management of patients with congestive heart failure and suspected ischemic heart disease remains to be defined. Myocardial perfusion imaging can identify patients with ischemic heart disease as the etiology for left ventricular dysfunction who might benefit from revascularization.

METHODS

We retrospectively identified heart failure patients with suspected ischemic heart disease who had large reversible perfusion defects to determine their long-term outcome and rate of revascularization. The study group consisted of 77 patients with congestive heart failure, left ventricular ejection fraction <45%, and suspected ischemic heart disease who underwent myocardial perfusion imaging during the period of January 1, 1991, to December 31, 1997, and had large reversible perfusion defects.

RESULTS

The 5-year mortality rate was 57.6%. The revascularization rate was only 13% for 5 years of follow-up. The number of patients undergoing revascularization was too small to assess its impact on outcome.

CONCLUSION

These results indicate a high 5-year mortality rate and a low utilization of coronary revascularization in patients with heart failure and large reversible perfusion defects. The low rate of revascularization reflects at least in part the absence of the generalizability of the existing literature to the optimal means of treating patients with heart failure and myocardial ischemia and points to the need for a randomized clinical trial.

Surgical treatments for heart failure

The surgical options for CHF are a part of a larger paradigm shift in management. Viable and effective surgical options other than cardiac transplant and ventricular assist devices clearly exist and are applicable to a large portion of patients with CHF. These surgical therapies are of acceptable risk before decompensated CHF develops. The rapidly evolving therapies for altering LV remodeling, which underlies CHF progression, are an exciting area that may be joined in the future by molecular advances in myoblast transfer and gene therapy. These therapies are the basis of the discipline of CHF surgery within cardiovascular surgery.

[The mechanisms of angiogenesis. Medical and therapeutic applications]

PURPOSE

Endothelial and smooth muscle cells interact with each other to form new blood vessels. In this review, the cellular and molecular mechanism underlying the formation of the primary vascular plexus (vasculogenesis), the sprouting of further blood vessels (angiogenesis) and their maturation via recruitment of smooth muscle cells (arteriogenesis) during physiological and pathological conditions are summarized.

CURRENT KNOWLEDGE AND KEY POINT

The concept of angiogenesis is studied in tumoral and cardiovascular pathology. Promoting the formation of new collateral vessels in ischemic tissues using angiogenic growth factors (therapeutic angiogenesis) is a promising approach in cardiovascular diseases. Conversely, inhibition of the action of key regulators of angiogenesis is a new pathway for the treatment of solid tumors and metastasis.

FUTURE PROSPECTS AND PROJECTS

These concepts are being tested now in clinical trials in the oncology or cardiovascular fields. Some trials are reported in this review with their potential adverse effects, limits and developments in the future.