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Is the outcome of ventricular assist device or heart transplantation after initial coronary artery bypass graft and mitral valve surgery in patients with severe ischemic cardiomyopathy a feasible option in well selected patients?
Jens Garbade, Rahel Kluttig, Joerg Seeburger, Markus J. Barten, Sven Lehmann, Denis R. Merk, Michael A. Borger, Friedrich-Wilhelm Mohr.
Cardiac Surgery, Heart Center University of Leipzig, Leipzig, Germany.

OBJECTIVE: Left ventricular assist device (LVAD) and heart transplantation (HTX) are end-stage therapies in patients with severe ischemic cardiomyopathy (ICM) following complex mitral valve surgery (MVS) and coronary artery bypass grafting (CABG). However, the incidence and outcome of this worse clinical scenario is completely unknown.
METHODS: During the last decade 475 patients with ICM (mean ejection fraction (EF) 25.0 ± 6.0 %) underwent MVS additional to CABG. Within this cohort 8 highly risk patients (6 male) at a mean age of 61.9 ± 5.6 years and with a mean EF of 20.6 ± 4.3% presented with impaired left ventricular (LV) function and further surgical therapy was needed. Patients treated by LVAD had an intermacs level 1 or 2, and the procedure was performed urgently, whereas the others were listed as high urgent for transplantation during follow up. Clinical data and information on complications, re-intervention and mortality were retrospectively gathered. Follow-up was made with a mean time span of 1210 days (range 13-3709 days).
RESULTS: Five patients received a LVAD at a mean postoperative time of 50.6 days (range 6-184 days). For one patient the device was a bridge to transplant therapy. All others were final destination therapy. Three patients received a HTX at a mean postoperative time of 1633 days (range 252-3470 days). Thirty day mortality of all LVAD patients was 20% with a follow up of 100%. Mortality at 60, 90 and 365 days was 40%, 80% and 80% respectively with a follow up of 100%. Mean support time was 57.8 days (range 0-146 days). The patient who survived received his HTX 146 days post LVAD surgery and is still alive at day 1977 post surgically. After HTX no patient died within 30 days. The long term mortality at 180 days, 1 and 5 years was 0%, 33.3% and 33.3% respectively with a follow up of 100%.
CONCLUSIONS: VAD and HTX are the last options in patients with impaired LV function after CABG with additional MV surgery. However patients who needed an assist device had a poor outcome but heart transplantation may offer the best alternative to these patients

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