DECISION-MAKING IN END-STAGE CORONARY-ARTERY DISEASE - REVASCULARIZATION OR HEART-TRANSPLANTATION

Background. Left ventricular function if the most important predictor of survival in patients with coronary artery disease. Ii is also an im portant indicator for hospital and late mortality after operation for endstage coronary artery disease. Methods. Between April 1986 and Dece mber 1994, 514 patients with end-stage coronary artery disease and lef t ventricular ejection fraction between 0.10 and 0.30 underwent corona ry artery bypass grafting at the German Heart Institute Berlin. Two hu ndred twenty-five of these patients had been referred as possible cand idates for heart transplantation. The prime criterion for bypass graft ing was ischemia diagnosed by myocardial scintigraphy and echocardiogr aphy (''hibernating myocardium''). Results. Operative mortality for th e group was 7.1%. The actuarial survival rare was 90.8% after 2 years, 87.6% after 4, and 78.9% after 6. Left heart catheterizations perform ed I year after the operation showed that left ventricular ejection fr action had increased from a mean of 0.24 +/- 0.03 preoperatively to 0. 39 +/- 0.06 postoperatively (p < 0.0001). Preoperatively 91.6% of the patients were in New York Heart Association (NYHA) class III or IV; 6 months postoperatively 90.2% of the surviving patients were in NYHA cl ass I or II. Two hundred thirty-one patients with end-stage coronary a rtery disease and predominant heart failure underwent heart transplant ation. Their actuarial survival rate was 74.9% after 2 years, 73.2% af ter 4, and 68.9% after 6. All of the patients could be recategorized i nto NYHA class I or II after the operation. Conclusions. We conclude t hat coronary artery bypass grafting and heart transplantation can be u sed successfully to improve the life expectancy of patients with end-s tage coronary artery disease. Coronary artery bypass grafting leads to an excellent prognosis for these high-risk patients when the myocardi um is preoperatively identified as being viable. (C) 1997 by The Socie ty of Thoracic Surgeons.