OPERATION FOR CONGESTIVE-HEART-FAILURE - TRANSPLANTATION, CORONARY-ARTERY BYPASS, AND CARDIOMYOPLASTY

Transplantation is effective therapy for congestive heart failure (CHF ), but few donors are available and many patients are not candidates. We have therefore developed a surgical approach to CHF that offers sev eral options. Patients with no medical or psychosocial contraindicatio ns are listed for heart transplantation (HT). Patients with ischemia o n thallium scan and operable vessels have coronary artery bypass graft ing (CABG). Patients who are not candidates for either of these option s are evaluated for cardiomyoplasty (CMP). One hundred nineteen patien ts have now had operation for CHF: 61 had HT, 27 had CABG, and 31 had CMP. The mean ages of the three groups were 51 +/- 1 years, 59 +/- 3 y ears, and 56 +/- 2 years, respectively. Preoperative pulmonary capilla ry wedge pressure was 22 +/- 1.1 mm Hg in the HT group, 20 +/- 2.9 mm Hg in the CABG group, and 19 +/- 1.9 mm Hg in the CMP group. Left vent ricular ejection fraction improved in operative survivors in each grou p: 0.23 +/- 0.01 to 0.69 +/- 0.01 for the HT group, 0.31 +/- 0.01 to 0 .39 +/- 0.02 for the CABG group, and 0.26 +/- 0.01 to 0.33 +/- 0.03 fo r the CMP group (p < 0.01). The operative mortality rate was 7% for th e HT patients, 4% for the CABG patients, and 16% for the CMP patients, and 1-year survival rates for those discharged were 94%, 91%, and 65% , respectively. Long-term survivors of CMP and CABG are functionally i mproved but still require medical therapy for CHF. Survivors of HT do not have CHF but suffer the consequences of immunosuppression. Coronar y artery bypass grafting and HT are effective therapies for CHF in wel l-selected patients, but CMP remains an experimental therapy. Initial experience shows improvement in many patients, but mortality is higher than that with CABG or HT.