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Thorac Cardiovasc Surg 2000; 48(1): 9-14
DOI: 10.1055/s-2000-8888
Original Cardiovascular
© Georg Thieme Verlag Stuttgart · New York

The Bad Ventricle - Revascularization Versus Transplantation

T. D. T. Tjan1 , M. Kondruweit1 , H. H. Scheld1, 6 , N. Roeder1 , M. Borggrefe2, 5 , C. Schmidt3 , O. Schober4 , M. C. Deng1, 6
  • 1Department of Cardiothoracic Surgery
  • 2Department of Cardiology and Angiology
  • 3Department of Anaesthesiology and Operative Intensive Care
  • 4Department of Nuclear Medicine
  • 5Institute for Arteriosclerosis Research
  • 6Transplantion Center, Westphalian Wilhelms University, Münster, Germany
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Publikationsverlauf

Publikationsdatum:
31. Dezember 2000 (online)

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Background: The proportion of patients with left-ventricular dysfunction (LVD) undergoing high risk revascularization is increasing. In this patient group, the perioperative risk is elevated because of the pre-existing pathophysiology. Detailed evaluation and interdisciplinary differential therapeutic considerations on the basis of the comparative benefit rationale, with cardiac transplantation alternative, is mandatory. Methods: Among 7275 patients who underwent coronary artery bypass grafting between 1990 and 1998 in our institution, we found 51 patients who had had an ejection fraction < 20 %, and thus were candidates for transplantation (group CABG); these were compared with 163 patients who were listed for cardiac transplantation because of ischemic cardiomyopathy (group HTX). The survival analysis was performed on the basis of the intention-to-treat principle independent of subsequent transplantation. Results: Both groups were comparable with regard to left-ventricular ejection fraction; pulmonary capillary wedge pressure and serum creatinine, but patients in the CAGB group were older (63 ± 11 vs 56 ± 8; p = 0.001) and included a higher percentage of women (m/f: 42/9 vs 152/11; p = 0.03). Nevertheless, there was a similar 1-year survival in both groups (group BP 71.9 % vs group HTX 66.3%; p = ns). Looking at the CABG group, the internal thoracic artery was used in 36/51 patients, an intra-aortic balloon pump was used preoperatively in 26 patients, and intraoperatively in 6. Left-ventricular assist devices had to be inserted in three patients, extracorporeal menbrane oxygenation once. Perioperative (30 day) survival was 88.2 %. An elevated preoperative serum creatinine and the nonusage of the internal thoracic artery predicted an adverse outcome. In the long-term course, the NYHA functional class improved in most cases from III preoperatively to I after 26 (2 - 66) months. Conclusion: We conclude that patients with ischemic cardiomyopathy, viable myocardium, and graftable vessels can be revascularized with acceptable risk. Since for these patients a standby of mechanical circulatory support must be anticipated perioperatively, this infrastructure should be established within the center.

Key words:

Heart transplantation - Bypass surgery - Indications - Differential indication

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Dr. med. Priv.-Doz. Mario C. Deng

Klinik und Poliklinik für Thorax-, Herz- und Gefäßchirurgie Westfälische Wilhelms-Universtität

Albert-Schweitzer-Straße 33

D-48129 Münster, Germany

eMail: deng@uni-muenster.de