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 several options. Patients with no medical or psychosocial contraindications are listed for heart transplantation (HT). Patients with ischemia on thallium scan and operable vessels have coronary artery bypass grafting (CABG). Patients who are not candidates for either of these options are evaluated for cardiomyoplasty (CMP). One hundred nineteen patients 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 years, and 56 +/- 2 years, respectively. Preoperative pulmonary capillary 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 ventricular ejection fraction improved in operative survivors in each group: 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 for the CMP group (p < 0.01). The operative mortality rate was 7% for the 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 improved but still require medical therapy for CHF. Survivors of HT do not have CHF but suffer the consequences of immunosuppression. Coronary artery bypass grafting and HT are effective therapies for CHF in well-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.