SURGICAL THERAPY FOR CORONARY-ARTERY DISEASE IN PATIENTS WITH A LEFT-VENTRICULAR EJECTION FRACTION OF 25-PERCENT OR LESS

Background. In patients with advanced coronary artery disease (CAD) an d markedly decreased left ventricular ejection fraction (EF) symptoms of myocardial ischemia and insufficiency may be complicated by ventric ular arrhythmias. Appropriate surgical therapy must be tailored to the individual symptoms. The aim of this study was to compare the differe nt current methods. Methods. From 9/1990 to 3/1994 138 patients with c oronary artery disease and a left ventricular EF of less than or equal to 25% were operated, Patients with dominating Angina pectoris and vi tal myocardium were revascularized (ACB; n = 17); two of these patient s were 12 and 37 months p.o. transplanted, Because of dominating dyspn ea, diffuse CAD and missing AP heart transplantation seemed indicated (HTX; n = 102), In two of these patients ventricular assist devices we re implanted as a bridge to transplantation; both patients survived, P atients with malign tachycardias received either an implantable cardio -defibrillator (ICD; n = 16) or had arrhythmia surgery (ARS; n = 3). P atients of the HTX-Group were younger (54 vs 60 years; p < 0.05), had more often previous surgery (28% vs 20%) and were in worse conditions (NYHA 3.5 vs 3.0; p < 0.05). Results. The main cause of death after tr ansplantation was multi-organ failure (MOF; 14/102; 13.8%). The best l ong-term survival (87% after 3.2 years, p < 0.01 vs HTX) - with low av erage functional classes (NYHA 2.9) - had the patients after ICD impla ntation, The best quality of live (NYHA 1.1; p < 0.01 vs ICD) - associ ated with a high mortality due to preoperatively impaired organ-system s (62% operative survival, 57% 4-years survival) - was achieved by tra nsplantation, In patients with a history of ventricular arrhythmias, w ho are waiting for a transplantation, the implantation of an ICD shoul d be considered. Bypass surgery as well as arrhythmia surgery showed g ood survival (1-year survival 82% and 66% respectively) and functional results (NYHA 1.7 and 1.5 respectively).