[198] Mancini DM, Beniaminovitz A, Levin H, et al. Low incidence of myocardial recovery after left ventricular assist device implantation in patients with chronic heart failure. Circulation 1998; 98(22):2383–9. [199] Dang NC, Topkara VK, Leacche M, et al. Left ven- tricular assist device implantation after acute ante- rior wall myocardial infarction and cardiogenic shock: a two-center study. J Thorac Cardiovasc Surg 2005;130(3):693–8. [200] Lowe JE, Anstadt MP, Van Tright P, et al. First successful bridge to cardiac transplantation using direct mechanical ventricular actuation. Ann Thorac Surg 1991;52(6):1237–43. [201] Loisance D, Deleuze M, Hillion ML, et al. The real impact of mechanical bridge strategy in patients with severe acute infarction. ASAIO Trans 1990; 36:M135–7. [202] Levin HR, Burkhoff D, Oz MC, et al. Reversal of chronic ventricular dilation in pa- tients with end-stage cardiomyopathy by pro- longed mechanical unloading. Circulation 1995; 91:2717–20. [203] Nakatani T, Takano H, Noda H, et al. Therapeutic effect of a left ventricular assist device on acute myocardial infarction evaluated by magnetic reso- nance imaging. Trans Am Soc Artif Intern Organs 1986;32:201–6. [204] Oz MC, Rose EA, Slater J, et al. Malignant ventric- ular arrhythmias are well tolerated in patients re- ceiving long-term left ventricular assist devices. J Am Coll Cardiol 1994;24:1688–91. [205] Maggioni AP, Zuanetti G, Franzosi MG, et al. Prevalence and prognostic significance of ventricu- lar arrhythmias after acute myocardial infarction in the fibrinolytic era, GISSI-2 results. Circulation 1993;87:312–22. [206] Ratcliffe MB, Bavaria JE, Wenger RK, et al. Left ventricular mechanics of ejecting postische- mic hearts during left ventricular circulatory as- sistance. J Thorac Cardiovasc Surg 1991;101(2): 245–55. [207] DeRose JJ, Argenziano M, Sun BC, et al. Implant- able left ventricular assist devices: an evolving long- term cardiac replacement therapy. Ann Surg 1997; 226:461–8. [208] Oz MC, Goldstein DJ, Pepino P, et al. Screening scale predicts patients successfully receiving long- term, implantable left ventricular assist devices. Circulation 1995;92(Suppl II):169–73. [209] Argenziano M, Choudhri AF, Moazami N, et al. A randomized, placebo controlled trial of inhaled nitric oxide in LVAD recipients with pulmonary hypertension. Ann Thorac Surg 1998;65:340–5. [210] DiDonato M, Sabatier M, Dor V, et al. Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regur- gitation one year after surgery. J Thorac Cardio- vasc Surg 2001;121:91–6. [211] Ingels NB. Myocardial fiber architecture and left ventricular function. Technol Health Care 1997;5: 45–52. [212] Yamaguchi A, Adachi H, Kawahito K, et al. Left ventricular reconstruction benefits patients with di- lated ischemic cardiomyopathy. Ann Thorac Surg 2005;79:456–61. [213] Athanasuleas CL, Buckberg GD, Stanley AW, et al. Surgical ventricular restoration in the treat- ment of congestive heart failure due to post-infarc- tion ventricular dilation. J Am Coll Cardiol 2004; 44(7):1439–45. [214] Cooley DA, Frazier OH, Duncan JM, et al. Intra- cavitary repair of ventricular aneurysm and re- gional dyskinesia. Ann Surg 1992;215:417–23. [215] DiDonato M, Sabatier M, Dor V, et al. Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoven- tricular circular patch plasty repair. J Am Coll Car- diol 1997;29:1569–75. [216] DiDonato M, Sabatier M, Toso A, et al. Regional myocardial performance of non-ischemic zones re- mote from anterior wall left ventricular aneurysm: effects of aneursmectomy. Eur Heart J 1995;16: 1285–92. 210 COMAS et al Revascularization in Heart Failure: Coronary Bypass or Percutaneous Coronary Intervention? Sorin V. Pusca, MD, John D. Puskas, MD * Emory University School of Medicine, Atlanta, GA, USA Coronary artery disease (CAD) is currently the single most common cause of heart failure in adults [1]. The prognosis of patients who have severe CAD and left ventricular (LV) dysfunction remains poor despite new medical management algorithms [2–6]. Patients who have heart failure symptoms and a large area of ischemic myocar- dium treated medically may have a 5-year mortal- ity as high as 60% [7]. Such patients often show marked improvement in symptoms and ventricu- lar function following revascularization. Baseline left ventricular ejection fraction (LVEF) is the single most powerful variable pre- dictive of mortality after revascularization for acute myocardial infarction [8]. Its usefulness in se- lecting patients who have chronic disease for revascularization may not be as great, however. As an indicator of depressed LV function, ejection fraction alone does not distinguish between myo- cardium that is depressed because of reversible ischemia (ie, hibernating myocardium) and that which is replaced by fibrosis and scarring after pre- vious myocardial infarction. There is increasing evidence that chronic LV dysfunction resulting from hibernating myocardium in patients who have severe multivessel disease is not uncommon [9]. Furthermore, even if some studies suggest that revascularization, particularly early revasculari- zation (less than 6 months after testing), could help all patients who have decreased LVEF and coronary artery disease regardless of myocardial vi- ability [10], observational evidence suggests that myocardial revascularization results in stabiliza- tion or even improvement in ventricular function most commonly in patients who have viable, hiber- nating myocardium [11,12]. This article focuses primarily on the use of coronary artery bypass grafting (CABG) in CAD patients who have low LVEF (with or without congestive symptoms) and compares it with per- cutaneous coronary interventions (PCI) in this setting. Alternative modalities for the surgical treatment of ischemic heart failure, such as heart transplantation, surgical ventricular restoration, the Dor procedure, cardiomyoplasty, and the use of mechanical assist device for destination ther- apy, are not addressed in this article. Results of coronary artery bypass grafting in patients who have low left ventricular ejection fraction Many retrospective studies [13–17] and a large meta-analysis [18] have investigated the use of CABG in patients who have low LVEF. Several more recent studies are summarized in Table 1 [19–25]. Most of these document an operative mortality between 5% and 12% and a 5-year survival ranging from 60% to 80%. One of the largest retrospective studies of CABG in patients who had advanced left ventric- ular dysfunction came from Emory University [26]. The study investigated short- and long-term survival and relief of angina among all patients who underwent cardiac catheterization followed by primary CABG at Emory University Hospitals from January 1981 to December 1995. A total of 11,830 patients were identified and stratified in * Corresponding author. Emory Heart Center, Divi- sion of Cardiothoracic Surgery, Emory University School of Medicine, Emory Crawford Long Hospital, 6th Floor Medical Office Tower, 550 Peachtree Street NE, Atlanta, GA 30308. E-mail address: john.puskas@emoryhealthcare.org (J.D. Puskas). 1551-7136/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.hfc.2007.05.002 heartfailure.theclinics.com Heart Failure Clin 3 (2007) 211–228 . [1 98] Mancini DM, Beniaminovitz A, Levin H, et al. Low incidence of myocardial recovery after left ventricular assist device implantation in patients with chronic heart failure. Circulation 19 98; 98( 22):2 383 –9. [199]. an evolving long- term cardiac replacement therapy. Ann Surg 1997; 226:461 8. [2 08] Oz MC, Goldstein DJ, Pepino P, et al. Screening scale predicts patients successfully receiving long- term,. MD * Emory University School of Medicine, Atlanta, GA, USA Coronary artery disease (CAD) is currently the single most common cause of heart failure in adults [1]. The prognosis of patients who have severe