Ann Thorac Surg 1997;64:1302
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commenary
Edwin L. Alderman, MD
Cardiovascular Division-CVRC, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94304
See also page 1296.
This article reviews a large experience with coronary artery bypass grafting and cardiac transplantation for patients with advanced ischemic heart disease. The 225 patients who were referred for cardiac transplantation and ultimately received bypass grafting were distinctly different from the 788 patients who received heart transplantation. Patients who received bypass grafting were older and, in general, had not had a prior coronary operation. Most had angina pectoris (severe angina in 53%) and had on average substantially better left ventricular function than those who received heart transplantation. For those individuals with coronary ischemia and high probability of viable, but ischemic myocardium, the wait for operation was shorter, the operative mortality was less, and 6-year survival was better than that of heart transplantation. Hausmann and associates relied on the presence of angina pectoris or abnormal wall motion during stress echocardiography as criteria favoring a bypass operation rather than transplantation.
Prominently omitted from Hausmann and associates' analysis are the extent to which intensive vasodilator therapy was used and functional assessment of aerobic capacity. Nevertheless, the criteria that were used for selection of patients for bypass grafting rather than transplantation were consistent with our understanding of ischemic heart disease and its effect on myocardial function. This article also reminds one of the advantages of conventional bypass grafting over cardiac transplantation with regard to lessening the delay for operation. Additionally, the postoperative morbidity and mortality of heart transplantation exceeded the postoperative complications of coronary operations, even in the most advanced critically ill patients. Because this study extended over 8 years of patient selection for either coronary artery bypass grafting or transplantation, the two groups are necessarily mismatched. Hopefully, in future years, further refinement of objective and functional tests for assessing myocardial performance can better discriminate in borderline situations those individuals for whom cardiac transplantation can be deferred.
Related Article
-
Decision-Making in End-Stage Coronary Artery Disease: Revascularization or Heart Transplantation?
- Harald Hausmann, Hubert Topp, Henrik Siniawski, Sabine Holz, and Roland Hetzer
Ann. Thorac. Surg. 1997 64: 1296-1301.
[Abstract]
[Full Text]
