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Surgical therapy for coronary artery disease in patients with a left ventricular ejection fraction of 25% or less.

BACKGROUND
In patients with advanced coronary artery disease (CAD) and markedly decreased left ventricular ejection fraction (EF) symptoms of myocardial ischemia and insufficiency may be complicated by ventricular arrhythmias. Appropriate surgical therapy must be tailored to the individual symptoms. The aim of this study was to compare the different current methods.


METHODS
From 9/1990 to 9/1994 138 patients with coronary artery disease and a left ventricular EF of < or = 25% were operated. Patients with dominating Angina pectoris and vital myocardium were revascularized (ACB; n = 17); two of these patients were 12 and 37 months p.o. transplanted. Because of dominating dyspnea, diffuse CAD and missing AP heart transplantation seemed indicated (HTX; n = 102). In two of these patients ventricular assist devices were implanted as a bridge to transplantation; both patients survived. Patients with malign tachycardias received either an implantable cardio-defibrillator (ICD; n = 16) or had arrhythmia surgery (ARS; n = 3). Patients of the HTX-Group were younger (54 vs 60 years; p < 0.05), had more often previous surgery (28% vs 20%) and were in worse conditions (NYHA 3.5 vs 3.0; p < 0.05).


RESULTS
The main cause of death after transplantation was multi-organ failure (MOF; 14/102; 13.8%). The best long-term survival (87% after 3.2 years, p < 0.01 vs HTX)-with low average functional classes (NYHA 2.9)-had the patients after ICD implantation. The best quality of live (NYHA 1.1; p < 0.01 vs ICD)-associated with a high mortality due to preoperatively impaired organ-systems (62% operative survival, 57% 4-years survival)-was achieved by transplantation. In patients with a history of ventricular arrhythmias, who are waiting for a transplantation, the implantation of an ICD should be considered. Bypass surgery as well as arrhythmia surgery showed good survival (1-year survival 82% and 66% respectively) and functional results (NYHA 1.7 and 1.5 respectively).