tailieunhanh - THE ROLE OF SURGERY IN HEART FAILURE - part 9

Kinh nghiệm thực thế giới của một số lượng lớn các bệnh nhân được cho là cung cấp một hướng dẫn đáng tin cậy hơn và thực tế để điều trị bệnh nhân hơn tập hợp con nhỏ được lựa chọn ngẫu nhiên bệnh nhân trong thử nghiệm AWESOME. Một phân tích của cơ sở dữ liệu | REVASCULARIZATION FOR HF CORONARY BYPASS OR PCI 225 CABG see Table 9 . This real-world experience of a huge number of patients arguably provides a much more reliable and realistic guide for patient treatment than the super-selected small subset of patients randomized in the AWESOME trial. An analysis of the Canadian APPROACH database Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease 57 that began in 1995 and followed patients for up to 7 years included 4228 patients who had heart failure who underwent a cardiac catheterization 2538 patients underwent revascularization by CABG or PCI and 1690 patients were treated with medical management alone. No direct comparison between CABG and PCI was made. Risk-adjusted survival curves for CABG seem superior to PCI adjusted hazard ratio for cAbG 95 Ci versus for PCI 95 CI both calculated against medical management group Fig. 12 . Surgical revascularization for patients who have low LVEF remains a challenging procedure and in general should be attempted in centers able and willing to provide mechanical assist or heart transplant services. The oft-cited operative mortality of 5 to 8 is the mortality of centers with significant experience in handling such patients. Summary From the analysis of clinical series presented above we learn that selected patients who have low LVEF and CAD clearly benefit from coronary revascularization with CABG and that CABG offers a 5-year survival of 60 to 70 and a life extension of close to a year at 5 years follow-up compared with a strategy of initial medical management with an average perioperative mortality between 5 to 8 in experienced hands twice that of patients who have normal ejection fraction . Clinical improvement should be expected in most patients who undergo CABG. This is important for patients who have a limited life span that they could spend with a good functional status rather than being hospitalized for multiple repeat PCIs