Refractory heart failure. Myocardial revascularization as alternative to heart transplantation

Coronary artery disease is the most common cause of heart failure in the western world. Due to shortage of donors, heart transplantation is not a realistic treatment for the great majority of patients with heart failure, while surgical revascularization is a valuable alternative in selected patients. Several variables have to be taken into account in order to appropriately identify patients with severe left ventricular dysfunction who are likely to benefit from myocardial revascularization. The recovery of cardiac function can be expected only in patients with sufficiently large areas of hibernating myocardium, particularly when the contractile reserve is documented. The anatomy of the coronary arteries should be suitable for coronary bypass grafting and provide a good run-off. Patients with an excessively dilated heart, with signs and symptoms of right heart failure and significant pulmonary hypertension are not candidates for myocardial revascularization. An appropriate surgical strategy, also including the reduction of the left ventricular volume and/or the correction of mitral insufficiency if needed, is the key factor for a successful revascularization procedure in patients with coronary artery disease and heart failure as the predominant symptom