title: Management of severe ischemic cardiomyopathy: left ventricular assist device as destination therapy versus conventional bypass and mitral valve surgery.
abstract: OBJECTIVE
  Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe ischemic mitral regurgitation have a poor survival with medical therapy alone. Left ventricular assist device as destination therapy is reserved for patients who are too high risk for conventional surgery. We evaluated our outcomes with conventional surgery within this population and the comparative effectiveness of these 2 therapies.
  
  
  METHODS
  We identified patients who underwent conventional surgery or left ventricular assist device as destination therapy for severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe mitral regurgitation. The era for conventional surgery spanned from 1993 to 2009 and from 2007 to 2011 for left ventricular assist device as destination therapy. We compared baseline patient characteristics and outcomes in terms of end-organ function and survival.
  
  
  RESULTS
  A total of 88 patients were identified; 55 patients underwent conventional surgery (63%), and 33 patients (37%) received a left ventricular assist device as destination therapy. Patients who received left ventricular assist device as destination therapy had the increased prevalence of renal failure, inotrope dependency, and intra-aortic balloon support. Patients undergoing conventional surgery required longer ventilatory support, and patients receiving a left ventricular assist device required more reoperation for bleeding. Mortality rates were similar between the 2 groups at 30 days (7% in the conventional surgery group vs 3% in the left ventricular assist device as destination therapy group, P = .65) and at 1 year (22% in the conventional surgery group vs 15% in the left ventricular assist device as destination therapy group, P = .58). There was a trend toward improved survival in patients receiving a left ventricular assist device compared with the propensity-matched groups at 1 year (94% vs 71%, P = .171).
  
  
  CONCLUSIONS
  The operative mortality and early survival after conventional surgery seem to be acceptable. For inoperable or prohibitive-risk patients, left ventricular assist device as destination therapy can be offered with similar outcomes.
authors.affiliation: Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Simon
authors.initials: S
authors.lastname: Maltais
authors.affiliation: Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Vahtang
authors.initials: V
authors.lastname: Tchantchaleishvili
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Daly
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
authors.forename: Yan
authors.initials: Y
authors.lastname: Topilsky
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: John M
authors.initials: JM
authors.lastname: Stulak
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Lyle D
authors.initials: LD
authors.lastname: Joyce
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn. Electronic address: Park.Soon@mayo.edu.
authors.forename: Soon J
authors.initials: SJ
authors.lastname: Park
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D005260:Female; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications / Q000601:surgery*; D012189:Retrospective Studies; D012720:Severity of Illness Index