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(Circulation. 2003;108:II-39.)
© 2003 American Heart Association, Inc.

Surgery for Coronary Artery Disease

Early Versus Delayed Revascularization in Patients With Ischemic Cardiomyopathy and Substantial Viability: Impact on Outcome

Jeroen J. Bax, MD; Arend F.L. Schinkel, MD; Eric Boersma, MSc; Vittoria Rizzello, MD; Abdou Elhendy, MD; Alexander Maat, MD; Jos R.T.C. Roelandt, MD; Ernst E. van der Wall, MD; Don Poldermans, MD

From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands (J.J.B., E.E.v.d.W.); the Department of Cardiology, ThoraxCenter Rotterdam (A.F.L.S., V.R., A.E., J.R.T.C.R., D.P.); the Department of Epidemiology and Statistics, ThoraxCenter Rotterdam (E.B.); and the Department of Thoracic Surgery, ThoraxCenter Rotterdam (A.M.), Rotterdam, The Netherlands.

Correspondence to Jeroen J. Bax, MD, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. Phone: +31-71-5262020, Fax: +31-71-5266809, E-mail: jbax{at}knoware.nl

Background— Patients with ischemic cardiomyopathy and viable myocardium may improve in function and prognosis following revascularization. Delayed revascularization may result in less favorable outcome, and therefore the impact of timing of revascularization on long-term outcome was evaluated.

Methods and Results— Patients (n=85) with ischemic cardiomyopathy and substantial viability (25% of the left ventricle) on dobutamine stress echocardiography underwent surgical revascularization. Based on the waiting time for revascularization, patients were divided into 2 groups: early (1 month) and late (>1 month) revascularization. Left ventricular ejection fraction (LVEF) was assessed before and 9 to 12 months after revascularization; follow-up data were acquired up to 2 years after revascularization. Hence, 40 patients underwent early (20±12 days) and 45 late (85±47 days) revascularization. Baseline characteristics of the two groups were comparable. Preoperative deaths were 0 in the early and 2 in the late group. Patients with early revascularization remained shorter time in the intensive care unit (2.4±1.5 days versus 5.9±2.1 days for the late group, P<0.05). Low output syndrome was observed more frequently in the late group (8% versus 22%, P=0.06). On long-term follow-up, mortality (5% versus 20%, P<0.05) and re-hospitalization for heart failure (10% versus 24%, NS) were higher in the late group. LVEF improved from 28±9% to 40±12% (P<0.05) in the early group and remained unchanged in the late group (27±10% versus 25±7%, NS).

Conclusion— Patients with ischemic cardiomyopathy and viable myocardium benefit from early revascularization (with improvement in LVEF and favorable prognosis), whereas delayed revascularization of these patients is associated with worse outcome.

Key Words: myocardial viability • hibernating myocardium • heart failure • surgical revascularization