Revascularization strategies in patients with low left ventricular function
Summary
Patients with ischaemic left ventricular dysfunction have a poor prognosis and an impaired quality of life. Pharmacological and device therapy remain the cornerstones of treatment, but revascularisation should be offered to patients with impaired left ventricular function who present with acute coronary syndromes or angina refractory to medical therapy. There is limited randomised evidence to support revascularisation in patients with stable coronary disease and minimal ischaemic symptoms. Coronary artery bypass grafting improved survival in the STICH trial, but because of significant early harm, the benefits only become apparent after 10 years. Percutaneous coronary intervention did not improve prognosis in stable patients in the REVIVED-BCIS2 trial. Evidence-informed shared decision-making and Heart Team discussion are essential.
Severe left ventricular dysfunction is one of the main determinants of increased procedural mortality and morbidity following surgical or percutaneous revascularisation. Therefore, when there is a clear indication for revascularisation, a multidisciplinary approach should be deployed to optimise patient selection, procedural planning, operative management and postoperative care. Mechanical circulatory support devices may be beneficial in selected cases where the procedural risk is considered particularly high, but as yet, there is a paucity of evidence to support the routine use of such strategies.
Introduction
Ischaemic heart...
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