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European Journal of Cardio-Thoracic Surgery, Vol 11, 1105-1112, Copyright © 1997 by European Association for Cardio-thoracic Surgery
MG Gunning, TP Chua, D Harrington, CJ Knight, E Burman, DJ Pennell, J Pepper, K Fox and SR Underwood
OBJECTIVE: We assessed the effects of coronary bypass grafting on left
ventricular (LV) function, exercise capacity and symptom profile in
patients with LV impairment and evaluated the role of identifying
myocardial hibernation in a prospective non-randomised study. METHODS: Of
120 patients screened, 47 patients with LV ejection fraction < 35% and
three vessel coronary artery disease were studied. All underwent
stress/redistribution and separate day rest/redistribution T1-201 imaging
together with cine MRI at enrolment, and cine MRI at follow-up. Group 1, 30
patients undergoing bypass surgery, underwent symptom limited treadmill
exercise testing with peak VO2 measurement, and symptom profile evaluation
less than 3 months before, and 3-6 months after operation.
Revascularisation was assessed by post-operative T1- 201 imaging and repeat
coronary angiography. Group 2, 17 patients treated on medical therapy alone
underwent symptom profile assessment at enrolment and follow-up for those
who survived. Segmental hibernation was defined as the equivalent of
greater than 50% of maximal T1-201 uptake where wall motion was severely
impaired on resting imaging. Patients were considered to be hibernating
where two of nine LV segments fulfilled these criteria. RESULTS: In group
1, five patients died (17%), peri-or post-operatively, two defaulted and 23
attended follow-up studies. In group 2, three patients died prior to
follow-up (18%). In the surgical group there was an increase in mean LVEF
from 24.0 +/- 8% to 29.7 +/- 11% (P < 0.05) while in the medical group
there was a fall from 25.7 +/- 10% to 20.6 +/- 8% (P < 0.05). In group
1, the mean NYHA dyspnoea grade improved from 2.7 to 1.4 while in the
medical group it was unchanged, 2.6 to 2.5. In patients with myocardial
hibernation identified pre-operatively, 18/19 (95%) improved LVEF after
CABG compared with 2/4 (50%) of patients without hibernation. 17/19 (86%)
patients with hibernation improved NYHA dyspnoea class compared with 2/4
(50%) of patients without. 60/93 (65%) of hibernating segments improved
function after revascularisation while 47/53 (89%) hibernating segments
showed no improvement on medical therapy alone. CONCLUSION: In patients
with severe LV impairment with myocardial hibernation, coronary artery
bypass grafting improves both global and regional systolic LV function, and
symptom profile. Medical treatment of patients with LV impairment and
myocardial hibernation does not improve LV contractile function or
symptoms. Both surgical and medical therapy carry a high mortality rate.
ARTICLES
Hibernating myocardium: clinical and functional response to revascularisation
Magnetic Resonance Unit, Royal Brompton Hospital, London, UK.
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