Surgical treatment of ischemic cardiomyopathy: Is it ever too late?

Abstract

The question posed in the title of this report can be answered both “yes” and “no.” For most patients with severe congestive heart failure due to end-stage ischemic heart disease, however, conventional surgical treatment by myocardial revascularization or unconventional treatment by cardiac transplantation can offer genuine therapeutic benefit by ameliorating symptoms and extending survival. Although the results of standard coronary artery bypass operations in patients with ischemic cardiomyopathy are limited by the magnitude of preexistent left ventricular damage, retrospective analysis of medical and surgical treatment at our institution has shown that most patients with predominant angina pectoris preoperatively can be expected to be alive and free of limiting angina 5 years postoperatively. However, relief of symptoms in patients with predominant congestive heart failure preoperatively was considerably less impressive. Nevertheless, long-term survival rates for surgically treated patients were significantly superior to those for medically treated patients, due possibly to the prevention of fatal myocardial infarction. When the severity of left ventricular dysfunction and clinically evident congestive heart failure preclude a reasonable expectation of benefit from myocardial revascularization, carefully selected candidates with ischemic cardiomyopathy may undergo cardiac transplantation with expectation of survival rates of 59 ± 7 percent at 1 year and 49 ± 7 percent at 3 years, in conjunction with highly satisfactory symptomatic benefit and rehabilitation. Furthermore, the quality of results after cardiac transplantation is highly likely to improve in the near future because of more effective and less toxic immunosuppression. This development should expand the applicability of cardiac transplantation and render even more uncommon the designation of a patient with ischemic cardiomyopathy as inoperable because it is “too late.”