High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure

Hiroyuki Kawajiri, Cedric Manlhiot, Heather Ross, Diego Delgado, Filio Billia, Michael McDonald, Vivek Rao

Research output: Contribution to journalArticle

Abstract

Objective Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure. Methods We identified patients with left ventricular ejection fraction <20% and VO2 max <14 mL/min/m2, who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era. Results A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12%. Actuarial survival at 5 and 10 years was 72% ± 4% and 39% ± 8%, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95% confidence interval, 0.66-3.2], P =.34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95% confidence interval, 0.16-1.50], P =.21). Conclusions Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.

Original languageEnglish (US)
Pages (from-to)517-525
Number of pages9
JournalJournal of Thoracic and Cardiovascular Surgery
Volume154
Issue number2
DOIs
StatePublished - Aug 1 2017
Externally publishedYes

Fingerprint

Thoracic Surgery
Heart Failure
Transplants
Survival
Heart-Assist Devices
Therapeutics
Transplantation
Confidence Intervals
Hospital Mortality
Left Ventricular Function
Stroke Volume
Mortality

Keywords

  • heart failure
  • high-risk surgery
  • mechanical circulatory support

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure. / Kawajiri, Hiroyuki; Manlhiot, Cedric; Ross, Heather; Delgado, Diego; Billia, Filio; McDonald, Michael; Rao, Vivek.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 154, No. 2, 01.08.2017, p. 517-525.

Research output: Contribution to journalArticle

Kawajiri, Hiroyuki ; Manlhiot, Cedric ; Ross, Heather ; Delgado, Diego ; Billia, Filio ; McDonald, Michael ; Rao, Vivek. / High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure. In: Journal of Thoracic and Cardiovascular Surgery. 2017 ; Vol. 154, No. 2. pp. 517-525.
@article{0f16a72506054615aa10d5293ae17b48,
title = "High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure",
abstract = "Objective Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure. Methods We identified patients with left ventricular ejection fraction <20{\%} and VO2 max <14 mL/min/m2, who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era. Results A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12{\%}. Actuarial survival at 5 and 10 years was 72{\%} ± 4{\%} and 39{\%} ± 8{\%}, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95{\%} confidence interval, 0.66-3.2], P =.34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95{\%} confidence interval, 0.16-1.50], P =.21). Conclusions Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.",
keywords = "heart failure, high-risk surgery, mechanical circulatory support",
author = "Hiroyuki Kawajiri and Cedric Manlhiot and Heather Ross and Diego Delgado and Filio Billia and Michael McDonald and Vivek Rao",
year = "2017",
month = "8",
day = "1",
doi = "10.1016/j.jtcvs.2017.03.040",
language = "English (US)",
volume = "154",
pages = "517--525",
journal = "Journal of Thoracic and Cardiovascular Surgery",
issn = "0022-5223",
publisher = "Mosby Inc.",
number = "2",

}

TY - JOUR

T1 - High-risk cardiac surgery as an alternative to transplant or mechanical support in patients with end-stage heart failure

AU - Kawajiri, Hiroyuki

AU - Manlhiot, Cedric

AU - Ross, Heather

AU - Delgado, Diego

AU - Billia, Filio

AU - McDonald, Michael

AU - Rao, Vivek

PY - 2017/8/1

Y1 - 2017/8/1

N2 - Objective Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure. Methods We identified patients with left ventricular ejection fraction <20% and VO2 max <14 mL/min/m2, who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era. Results A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12%. Actuarial survival at 5 and 10 years was 72% ± 4% and 39% ± 8%, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95% confidence interval, 0.66-3.2], P =.34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95% confidence interval, 0.16-1.50], P =.21). Conclusions Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.

AB - Objective Although the results of cardiac surgery in patients with poor left ventricular function have been widely published, the outcomes in patients with end-stage heart failure who meet criteria for advanced therapies are not well investigated. As access to transplantation and ventricular assist device therapy remains limited, we explored the possibility of conventional surgery as an alternative option for highly selected patients with end-stage heart failure. Methods We identified patients with left ventricular ejection fraction <20% and VO2 max <14 mL/min/m2, who were initially referred for advanced therapies but were instead offered a conventional procedure from 2002 to 2012. We examined the short- and midterm outcomes and compared survival with that after our advanced therapies in the same era. Results A total of 133 patients were identified; 68 were deemed to be transplant-eligible, whereas 65 were transplant-ineligible. Seventy-nine percent were in New York Heart Association class III/IV. In-hospital mortality was 12%. Actuarial survival at 5 and 10 years was 72% ± 4% and 39% ± 8%, respectively. Nonischemic etiology was identified as a predictor of late mortality. In the propensity-adjusted model, our transplant-eligible patients had comparable long-term survival to our transplantation patients (HR 1.48 [95% confidence interval, 0.66-3.2], P =.34), whereas the survival in our transplant-ineligible subset was comparable to the survival after our left ventricular assist device therapy (HR 0.49 [95% confidence interval, 0.16-1.50], P =.21). Conclusions Despite high perioperative risk, the midterm survival after conventional surgery in patients eligible for advanced therapies seems to be acceptable and may be an alternative option for highly selected patients with end-stage heart failure.

KW - heart failure

KW - high-risk surgery

KW - mechanical circulatory support

UR - http://www.scopus.com/inward/record.url?scp=85019015416&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85019015416&partnerID=8YFLogxK

U2 - 10.1016/j.jtcvs.2017.03.040

DO - 10.1016/j.jtcvs.2017.03.040

M3 - Article

C2 - 28495061

AN - SCOPUS:85019015416

VL - 154

SP - 517

EP - 525

JO - Journal of Thoracic and Cardiovascular Surgery

JF - Journal of Thoracic and Cardiovascular Surgery

SN - 0022-5223

IS - 2

ER -