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European Journal of Heart Failure 1999 1(3):269-273; doi:10.1016/S1388-9842(99)00036-7
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© 1999 European Society of Cardiology

Revascularisation for chronic heart failure: a valid option?

D. Paganoa, P.G. Camicib and R.S. Bonsera,*

a Cardiothoracic Surgical Unit, Queen Elizabeth Hospital, Birmingham University Edgbaston, Birmingham B15 2TH, UK
b MRC Cyclotron Unit Imperial College School of Medicine, Hammersmith Hospital London, UK

* Corresponding author. Tel.: +44-121-6373559. E-mail address: r.s.bonser{at}bham.ac.uk (R.S. Bonser)

Key Words: Heart failure • Hibernating myocardium • Coronary heart disease

Received June 10, 1999; Revised July 5, 1999; Accepted July 5, 1999


   1. Introduction
Top
 1. Introduction
2. Impaired LV dysfunction...
 3. Impaired LV function...
 4. Conclusions
 References
 
Coronary artery disease is the commonest cause of heart failure in the western world accounting for up to 60% of cases [1]. Although the benefits of coronary artery surgery in patients with angina or evidence of exercise-inducible ischaemia have been defined, the role of revascularisation in patients with post-ischaemic heart failure remains unclear. There is a tendency to equate LV dysfunction with heart failure, and although the two conditions are often associated, there are many patients with markedly depressed LV function without significant heart failure. From a clinical point of view, therefore, we must distinguish between two possible clinical scenarios: (1) patients with severe LV dysfunction and predominant symptoms of angina; and (2) patients with severe LV dysfunction and predominant symptoms of heart failure.


   2. Impaired LV dysfunction and angina
Top
 1. Introduction
 2. Impaired LV dysfunction...
3. Impaired LV function...
 4. Conclusions
 References
 
The coronary surgery trials enrolled patients with EF greater than 35%, therefore, the results of surgical and medical therapy in patients with coronary artery disease and more severe LV dysfunction can only be extrapolated from non-randomised and/or retrospective reports.

Data from 651 patients with left ventricular ejection fraction ≤35% enrolled in the CASS registry [2] indicated a better 5-year survival rate for the surgical group (68%) compared to the medical (54%) group. In addition, a greater benefit from surgery was detected in the subgroup of patients with the most compromised ventricular function (ejection fraction <0.26) with a 5-year survival rate of 63% compared to 43% for the medical group. A study from Duke University (North Carolina) [3], reported the survival rate of 710 patients with significant coronary artery disease and left ventricular dysfunction (ejection fraction ≤40%) treated medically (n=400) or surgically (n=310). The 3-year survival rate in the surgical group (86%) was significantly higher than in the medical (68%) and the advantage of coronary revascularisation over medical therapy was more evident in the patients with the most compromised ventricular function. A number of other reports confirmed that patients with impaired left ventricular function, angina, and coronary artery disease have a survival advantage if treated by surgical revascularisation, and this benefit is more pronounced in the subgroup with lower ejection fractions (Table 1).


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  		Table 1 Survival rate of patients according to preoperative ejection fraction

 
Despite several limitations, it can be concluded that the advantages of CABG over medical treatment make it reasonable to consider such patients for revascularisation, in the absence of other medical contraindications.


   3. Impaired LV function and predominant symptoms of heart failure
Top
 1. Introduction
 2. Impaired LV dysfunction...
 3. Impaired LV function...
4. Conclusions
 References
 
Patients with predominant and severe heart failure symptoms constitute the group in whom the clinical decision to recommend coronary revascularisation, heart transplantation or continued medical therapy remains difficult. There are no randomised trials to date that have addressed this issue and most of the studies published include a variable number of patients with these clinical characteristics (Table 2).


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  		Table 2 Summary of studies of CABG in patients with heart failurea

 
The CASS registry data comparing the survival of patients with predominant symptoms of heart failure (72 treated medically and 19 surgically), showed a poor 5-year survival of 23% for both groups [2]. Despite the small size of the surgical group, it was concluded that in these patients surgery does not convey any long-term survival benefit. These observations and the finding that the presence of heart failure is a significant predictor of operative mortality [4], have largely dictated clinical practice in the 1980s and patients with isolated heart failure symptoms have been mostly considered for either medical therapy or transplantation.

In recent years it has become evident that chronic left ventricular dysfunction in patients with coronary artery disease, is not always an irreversible process and left ventricular function may improve in a large subset of patients after successful coronary revascularisation [5,6] due to the presence of hibernating myocardium. Given that hibernating myocardium can be present in patients without angina [7] and that LVEF is a strong prognostic indicator in patients with coronary artery disease [8], it has been proposed that patients with post-ischaemic heart failure and hibernating myocardium may gain functional and prognostic benefit from coronary revascularisation. However, before revascularisation for heart failure is considered a valid treatment option, a number of issues need to be discussed.

3.1. Incidence/prevalence of hibernating myocardium
Confirmation of hibernating myocardium can only be made retrospectively when improvement in contractile function of dysfunctional myocardium is documented following coronary revascularisation. Although the prevalence of recoverable LV dysfunction is largely unknown, data extrapolated from a number of studies indicate that 22–57% of dysfunctional LV segments improve contractile function following CABG [9–11] even in patients without angina and with Q-wave myocardial infarction [7]. The improvements in segmental wall motion are associated with clinically meaningful improvements in global LV ejection fraction in up to 50% of the patients enrolled [7,12,13]. These data however, come from highly selected patients, and, therefore, may overestimate the real prevalence of hibernating myocardium.

3.2. Identification of hibernating myocardium
The presence of hibernating myocardium can be predicted prior to revascularisation if hallmarks of cellular viability (i.e. inotropic contractile reserve, sarcolemmal integrity and/or preserved metabolic function) can be demonstrated in dysfunctional myocardium subtended by a stenotic coronary artery. A comprehensive review of the three most commonly used techniques used to identify hibernating myocardium, namely dobutamine echocardiography, thallium-201 scintigraphy and positron emission tomography (PET) with fluorodeoxyglucose (FDG), showed a similar predictive accuracy [14]. However, these data are extrapolated from studies of patients with moderately impaired LV function and angina, a group in whom decision for revascularisation had been made on conventional clinical criteria. Thus, the ability of these techniques to influence clinical management in patients with post-ischaemic heart failure remains untested. More recently, it has been shown that patients with severe LV dysfunction and advanced heart failure, dobutamine echocardiography may be associated with a significant higher false negative rate compared to PET or Thallium-201 scintigraphy [15,16]. This discrepancy seems to be due to the severity of the ultrastructural changes detected in hibernating myocardium [17].

A consistent relationship has been reported between the amount of viable myocardium detected preoperatively and the magnitude of LV functional improvement following revascularisation. Clinically meaningful improvements in LV ejection fraction after CABG are more likely to be detected in patients when at least 50% of the dysfunctional myocardium is viable, irrespective of the technique used to assess this [7,13].

3.3. Risks and benefits of CABG in heart failure
The surgical risks of performing CABG in these patients have decreased significantly in recent years, from 11 to 16% [18–20] to less than 6% [7,21,22] and this is probably due to improved anaesthetic, surgical and myocardial protection techniques. Nevertheless, the risk of revascularisation in patients with severe heart failure remains consistently higher than in patients with moderate impairment in LV function and the decision to revascularise must balance the risks of peri-operative mortality against all the benefits of revascularising hibernating myocardium.

The lack of substantial amount of hibernating myocardium has been identified as an independent risk factor for peri-operative mortality [15,23] and this could help select patients at ‘lower’ peri-operative risk. The potential benefits of performing CABG in patients with substantial amount of hibernating myocardium should be divided into functional and prognostic.

Recent observational studies have suggested that CABG in patients with a significant amount of viable myocardium is not only associated with convincing improvements in LV function [13,15,22], but also in a significant increase in exercise capacity [7,24] (Fig. 1) and improved quality of life [7]. Although these data are extrapolated from observational data in a small number of highly selected patients, the results compare favourably with medical treatment, the effects of which on some of these end points is disappointing [25].


Figure 1
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  		Fig. 1 Exercise data at baseline and 6 months after CABG on 21 patients with post-ischaemic heart failure (NYHA class ≥III, mean LVEF 24±7%), no angina and no evidence of exercise-inducible ischaemia. All patients had significant amount of viable myocardium (mean no viable segments 11±3). (With permission from D. Pagano et al. Coronary artery bypass grafting for ischemic heart failure. The predictive value of quantitative PET for symptomatic and functional outcome. J Thorac Cardiovasc Surg 1998;115:791–799).

 
A number of retrospective non-randomised studies have suggested that the presence of myocardial viability in patients with LV dysfunction and coronary artery disease may confer an adverse prognosis. Coronary revascularisation in this group may confer survival advantage compared to medical treatment [26,27]. More recently it has also been demonstrated that the extent of preoperative myocardial viability is a determinant of long-term outcome following CABG [23] even in patients with severe heart failure symptoms [7]. Five-year survival rates of 85% have been reported [28]. These figures are significantly better than those usually reported for patients with class III or IV heart failure treated medically [25,29,30].


   4. Conclusions
Top
 1. Introduction
 2. Impaired LV dysfunction...
 3. Impaired LV function...
 4. Conclusions
References
 
Enough evidence exists to justify CABG in patients with severe LV dysfunction and predominant symptoms of angina in the opinion of many. The data on patients with predominant and severe heart failure symptoms is not conclusive. CABG could confer substantial benefits in patients with a significant amount of hibernating myocardium. Randomised studies are required.


   References
Top
 1. Introduction
 2. Impaired LV dysfunction...
 3. Impaired LV function...
 4. Conclusions
 References
 

  1. Teerlink J., Goldhaber S., Pfeffer M. An overview of contemporary etiologies of congestive heart failure. Am Heart J (1991) 121:1852–1853.[CrossRef][Web of Science][Medline]
  2. Alderman E., Fisher L., Litwin P., et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation (1983) 4:785–795.
  3. Bounous EP, Mark DB, Pollock BG, et al. Surgical survival benefit for coronary disease patients with left ventricular dysfunction. Circulation (1988) 78((Suppl. I)):I-151–I-157.
  4. Wechsler AS, Junod FL. Coronary bypass grafting in patients with chronic congestive heart failure. Circulation (1989) 79((Suppl I)):I-92–I-96.
  5. Rahimtoola SH. A perspective on the three large multicenter randomized clinical trials of coronary artery bypass surgery for chronic stable angina. Circulation (1985) 72((Suppl V)):V-123–V-135.
  6. Braunwald E., Rutherford J. Reversible ischaemic left ventricular dysfunction: evidence for ‘hibernating myocardium’. J Am Coll Cardiol (1986) 8:1467–1470.[Web of Science][Medline]
  7. Pagano D., Townend J., Horton R., Littler W., Camici P.G., Bonser R.S. Coronary artery bypass grafting for ischemic heart failure. The predictive value of quantitative PET for symptomatic and functional outcome. J Thorac Cardiovasc Surg (1998) 115:791–799.[Abstract/Free Full Text]
  8. Edmond M. and Participants in the C.A.S.S. (CASS), Long-term survival of medically treated patients in the coronary artery surgery study (CASS). Circulation (1994) 90:2645–2657.[Abstract/Free Full Text]
  9. Arnese M., Cornel J., Salustri A., et al. Prediction of improvement of regional left ventricular function after surgical revascularisation. A comparison of low-dose dobutamine echocardiography with 201-Tl single photon emission computed tomography. Circulation (1995) 91:2748–2752.[Abstract/Free Full Text]
  10. Bax J., Cornel J., Visser F. Prediction of recovery of myocardial dysfunction after revascularization. Comparison of fluorine-18 Fluorodeoxyglucose/Thallium SPECT. Thallium-201 Stress-reinjection and dobutamine echocardiography. J Am Coll Cardiol (1996) 28:558–564.[Abstract]
  11. Wijns W., Vatner S., Camici P.G. Hibernating myocardium. N Engl J Med (1998) 339:173–181.[Free Full Text]
  12. Gerber B., Vanovershelde J.-L., Bol A., Michel C., Labar D., Wijns W., Melin J. Myocardial blood flow, glucose uptake, and recruitment of inotropic reserve in chronic left ventricular ischemic dysfunction. Implications for the pathophysiology of chronic myocardial hibernation. Circulation (1996) 94:651–659.[Abstract/Free Full Text]
  13. vom Dahl J., Eitzman D.T., al Aouar Z.R., et al. Relation of regional function, perfusion, and metabolism in patients with advanced coronary artery disease undergoing surgical revascularization. Circulation (1994) 90:2356–2366.[Abstract/Free Full Text]
  14. Bonow R. Identification of viable myocardium. Circulation (1996) 94:2674–2678.[Free Full Text]
  15. Pagano D., Bonser R.S., Townend J., Ordoubadi F., Lorenzoni R., Camici P.G. Predictive value of dobutamine echocardiography and positron emission tomography in identifying hibernating myocardium in patients with postischaemic heart failure. Heart (1998) 79:281–288.[Abstract/Free Full Text]
  16. Perrone-Filardi P., Pace L., Prastraro M., et al. Assessment of myocardial viability in patients with chronic coronary artery disease. Rest-4-hour-24-hour 201-Thallium tomography versus dobutamine echocardiography. Circulation (1996) 94:2712–2719.[Abstract/Free Full Text]
  17. Pagano D., Bonser R.S., Townend J., Parums D., Camici P.G. Histopathological correlates of dobutamine echocardiography in hibernating myocardium (Abstract). Circulation (1996) 94(Suppl I):231.[Free Full Text]
  18. Louie H, Laks H, Milgalter E, et al. Ischaemic cardiomyopathy. Criteria for myocardial revescularisation and cardiac transplantation. Circulation (1991) 86((Suppl III)):III-290–III-295.
  19. Luciani G.B., Faggian G., Razzolini R., Livi U., Bortolotti U., Mazzucco A. Severe ischaemic left ventricular failure: coronary operation or heart transplantation? Ann Thorac Surg (1993) 55:719–723.[Abstract]
  20. Milano C.A., White W.D., Smith L.R., et al. Coronary artery bypass in patients with severely depressed ventricular function. Ann Thorac Surg (1993) 56:487–493.[Abstract]
  21. Mickleborough L, Maruyama H, Tagaki T, Mohamed S, Sun Z, Ebisuzaki L. Results of revascularisation in patients with severe left ventricular dysfunction. Circulation (1995) 92((Suppl II)):II-73–II-79.
  22. Dreyfus G., Duboc D., Blasco A., et al. Myocardial viability assessment in ischaemic cardiomyopathy: benefits of coronary revascularisation. Ann Thorac Surg (1994) 57:1402–1408.[Abstract]
  23. Pagley P., Beller G., Watson D., Gimple L., Ragosta M. Improved outcome after coronary artery bypass surgery in patients with ischemic cardiomyopathy and residual myocardial viability. Circulation (1997) 96:793–800.[Abstract/Free Full Text]
  24. DiCarli M., Sherman T., Khanna S., et al. Myocardial viability in asynergic regions subtended by occluded coronary arteries: relation to the status of collateral flow in patients with chronic coronary artery disease. J Am Coll Cardiol (1994) 23:860–868.[Abstract]
  25. Cohn J., Johnson G., Ziesche S., et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med (1991) 325:303–310.[Abstract]
  26. Eitzman D., Aouar Z.A., Kanter H.L., et al. Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography (see comments). J Am Coll Cardiol (1992) 20:559–565.[Abstract]
  27. Lee S., Marwick T., Cook S., et al. Prognosis of patients with left ventricular dysfunction, with and without viable myocardium after myocardial infarction. Relative efficacy of medical therapy and revascularisation. Circulation (1994) 90:2687–2694.[Abstract/Free Full Text]
  28. Pagano D, Lewis ME, Townend J, Camici PG, Bonser RS. Revascularisation for post-ischaemic heart failure: how myocardial viability affects survival. Heart (1999) in press (Abstract).
  29. CONSENSUS Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study. N Engl J Med (1987) 316:1429–1435.[Abstract]
  30. Townend J., Littler W. Angiotensine converting enzyme inhibitors in heart failure: how good are they? Br Heart J (1993) 5:373–376.
  31. Faulkner S., Stoney W., Alford W., et al. Ischaemic cardiomyopathy medical versus surgical treatment. J Thorac Cardiovasc Surg (1977) 74:77–82.[Abstract]
  32. Kron I.L., Flanagan T.L., Blackbourne L.H., Schroeder R.A., Nolan S.P. Coronary revascularization rather than cardiac transplantation for chronic ischaemic cardiomyopathy. Ann Surg (1989) 210:348–354.[Web of Science][Medline]
  33. Elefteriades J.A., Tolis G. Jr, Levi E., Mills L.K., Zaret B.L. Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol (1993) 22:1411–1417.[Abstract]
  34. Lansman S., Cohen M., Galla J., et al. Coronary bypass with ejection fraction of 0.20 or less using centigrade cardioplegia: long term follow-up. Ann Thorac Surg (1993) 56:480–486.[Abstract]
  35. Gunning M., Chua T., Harringhton D., et al. Hibernating myocardium: clinical and functional response to revascularisation. Eur J Cardio-thorac Surg (1997) 11:1105–1112.[Abstract]

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