Ann Thorac Surg 1996;61:1434
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Irving L. Kron, MD
Department of Surgery, University of Virginia Health Sciences Center, Box 310, Charlottesville, VA 22908
See also page 1428.
One of the major problems in the revascularization of patients with ischemic cardiomyopathy is our inability to determine who will have a good long-term result. We, and many others, have demonstrated that coronary revascularization of such patients can be done safely but the individual results are often unpredictable. This article by Chan and colleagues is a superb attempt to predict which patients will do well. Chan and colleagues clearly operate well, with an enviable mortality of 1.7%. The long-term results were also excellent, with a 73% transplantation- free 5-year survival. Chan and colleagues performed thallium scintigraphy prospectively and noted 18 of the patients had large areas of redistribution. This group of 18 did exceedingly well. The ejection fraction in this group increased by 0.10 with no mortality at 1 year, and 15 had improvement of their congestive heart failure. Thirty-six other patients had little change demonstrated by thallium scintigraphy. In this subgroup, there was little or no improvement in the ejection fraction and there were six deaths within the first year. One other patient required cardiac transplantation.
Ragosta and colleagues from our group at the University of Virginia [8] have demonstrated similar results using the same noninvasive imaging. Clearly, patients who have evidence of large amounts of thallium redistribution have viable myocardium. The problem lies with the patients who do not have evidence of limited reversible ischemia. In Chan and colleagues' patients, despite lack of evidence of reversible ischemia, 19 had improvement of their heart failure symptoms. This occurred without any major improvement in ventricular function. One can conclude that even this subgroup of coronary bypass patients, though at higher risk, did have good long-term palliation. Although these patients may not have had improvement in ventricular function, they at least maintained their preoperative level of ventricular function. This may be the most important lesson to be learned from this study. It would seem that if there is any evidence of ischemia and graftable coronary arteries, then bypass should be considered if only to prevent attrition of residual ventricular function that is still present. Clearly, these patients cannot afford to lose any more myocardial tissue.
Related Article
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Prediction of Outcome After Revascularization in Patients With Poor Left Ventricular Function
- Robert K. M. Chan, Jai Raman, Kenneth J. Lee, Alexander Rosalion, Rodney J. Hicks, Sampanth Pornvilawan, Benjamin S. T. Sia, John D. Horowitz, Andrew M. Tonkin, and Brian F. Buxton
Ann. Thorac. Surg. 1996 61: 1428-1434.
[Abstract]
[Full Text]
