0
November 16, 1994, Vol 272, No. 19 >
ARTICLE | November 16, 1994

Management of Heart Failure: Title and subTitle BreakIII. The Role of Revascularization in the Treatment of Patients With Moderate or Severe Left Ventricular Systolic Dysfunction FREE

David W. Baker, MD, MPH; Robert Jones, MD; Jim Hodges, PhD; Barry M. Massie, MD; Marvin A. Konstam, MD; Eric A. Rose, MD
[+] Author Affiliations

The views expressed herein are those of the authors and do not reflect the position of the Agency for Health Care Policy and Research, the US Public Health Service, or the US Department of Health and Human Services.

Reprint requests to Health Sciences Program, RAND, 1700 Main St, PO Box 2138, Santa Monica, CA 90407-2138 (Dr Baker).


JAMA. 1994;272(19):1528-1534. doi:10.1001/jama.1994.03520190074038
Text Size: A A A
Published online
Article
References

Objective.  —This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline.

Data Sources.  —Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty.

Study Selection.  —All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed.

Data Extraction and Synthesis.  —Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws.

Conclusion.  —Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting.(JAMA. 1994;272:1528-1534)

REFERENCES

1 +
SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
2 +
CONSENSUS Trial Study Group.  Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med . 1987;;316:1429-1435.
3 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310, 351-353.
4 +
Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group.  Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med . 1984;;311:1333-1339.
5 +
Killip T, Passamam E, Davis K, et al.  Coronary Artery Surgery Study (CASS): a randomized trial of coronary bypass surgery: eight years follow-up and survival in patients with reduced ejection fraction. Circulation . 1985;:72( (suppl V) ):V102-V109.
6 +
Alderman EL, Fischer P, Litwin GC, et al.  Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation . 1983;;68:785-795.
7 +
Vliestra RE, Assad-Morell JL, Frye RL, et al.  Survival predictors in coronary artery disease: medical and surgical comparisons. Mayo Clin Proc . 1977;; 52:85-90.
8 +
Manley J, King J, Zeft H, Johnson WD.  The 'bad' left ventricle: results of coronary surgery and effect on late survival. J Thorac Cardiovasc Surg . 1976;;72:841-848.
9 +
Yatteau RF, Peter RH, Behar VS, Bartel AG, Rosati RA, Kong Y.  Ischemic cardiomyopathy: the myopathy of coronary artery disease. Am J Cardiol . 1974;;34:520-525.
10 +
Hammermeister KE, DeRouen TA, Dodge HT.  Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study. Circulation . 1982;; 65:53-59.
11 +
Faulkner SL, Stoney WS, Alford WC, et al.  Ischemic cardiomyopathy: medical versus surgical treatment. J Thorac Cardiovasc Surg . 1977;;74:77-82.
12 +
Pigott J, Kouchoukos N, Oberman A, Cutter GR.  Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function. J Am Coll Cardiol . 1985;;5:1036-1045.
13 +
Bounous E, Mark D, Pollock B, et al.  Surgical survival benefits for coronary disease patients with left ventricular dysfunction. Circulation . 1988;;78 ( (suppl I) ):I151-I157.
14 +
Hammermeister KE.  The effect of coronary bypass surgery on survival. Prog Cardiovasc Dis . 1983;;25:297-334.
15 +
Califf R, Harrell F Jr, Lee K, et al.  The evolution of medical and surgical therapy for coronary artery disease: a 15-year perspective. JAMA . 1989;; 261:2077-2086.
16 +
Bedard P, Keon WJ, Taylor G, Akyurekli Y.  Surgery for coronary artery disease and congestive heart failure. Can J Surg . 1975;;18:237-239, 241.
17 +
Quyyumi A, Wright C, Mockus L, Fox KM.  How important is a history of chest pain in determining the degree of ischemia in patients with angina pectoris? Br Heart J . 1985;;54:22-26.
18 +
Beckman CB, Khachane VB, Wilson GL, Carter MG.  Coronary artery bypass at the Hospital of St. Raphael: early and late results of the cardiothoracic group of New Haven. Conn Med . 1980;; 44:618-621.
19 +
Ben DY, Shefer A, Weiss AT, et al.  Early postoperative assessment of coronary artery bypass surgery using nuclear left ventriculography and atrial pacing. Thorac Cardiovasc Surg . 1983;;31:377-381.
20 +
Solignac A, Lesperance J, Grondin P, Campeau L.  Aorta-to-coronary artery bypass operation for chronic intractable congestive heart failure. Can J Surg . 1974;;17:76-79.
21 +
Spencer FC, Green GE, Tice DA, Wallsh E, Mills NL, Glassman E.  Coronary artery bypass grafts for congestive heart failure: a report of experiences with 40 patients. J Thorac Cardiovasc Surg . 1971;;62:529-542.
22 +
Akins CW, Phost GM, De Sanctis RW, Block PC.  Selection of angina-free patients with severe left ventricular dysfunction in myocardial revascularization. Am J Cardiol . 1980;;46:695-670.
23 +
Luu M, Stevenson LW, Brunken RC, Drinkwater DM, Schelbert HR, Tillisch JH.  Delayed recovery of revascularized myocardium after referral for cardiac transplantation. Am Heart J . 1990;;119: 668-670.
24 +
Tillisch J, Brunken R, Marshall R, et al.  Reversibility of cardiac wall motion abnormalities predicted by positron tomography. N Engl J Med . 1986;;314:884-888.
25 +
Solignac A, Campeau L, Lesperance J.  Chronic heart failure due to ischemic cardiopathy and aortocoronary bypasses: study of the operative results in 11 patients. Arch Mal Coeur Vaiss . 1973;;66:117-125.
26 +
Mochtar B, Laird-Meeter K, Brower RW, Verbaan N, Haalebos MMP, Bos E.  Aorto-coronary bypass surgery in 62 patients with severe left ventricular dysfunction: a follow-up study. Thorac Cardiovasc Surg . 1985;;33:30-33.
27 +
Lawrie GM, Morris GC Jr, Earle N.  Long-term results of coronary bypass surgery: analysis of 1698 patients followed 15 to 20 years. Ann Surg . 1991;; 213:377-387.
28 +
Coles JG, Del Campo C, Ahmed SN, et al.  Improved long-term survival following myocardial revascularization in patients with severe left ventricular dysfunction. J Thorac Cardiovasc Surg . 1981;;81:846-850.
29 +
Brockman SK, Goldman SM.  Operative management of coronary artery disease with poor left ventricular function. Cardiovasc Clin . 1987;;17:65-72.
30 +
Uretzky G, Elami A, Appelbaum A, Gotsman MS, Borman JS.  Exercise performance in patients with impaired left ventricular function following aortocoronary bypass. Adv Cardiol . 1986;;34:195-207.
31 +
Shearn D, Brent B.  Coronary artery bypass surgery in patients with left ventricular dysfunction. Am J Med . 1986;;80:405-411.
32 +
Fox HE, May IA, Ecker RR.  Long-term functional results of surgery for coronary artery dis ease in patients with poor ventricular function. J Thorac Cardiovasc Surg . 1975;;70:1064-1072.
33 +
Jones EL, Hurst JW, King SB, Hatcher CR.  Clinical factors influencing survival and adequacy of revascularization after coronary bypass operation. Int J Cardiol . 1982;;2:109-123.
34 +
Hung J, Kelly DT, Baird DK, et al.  Aorta-coronary bypass grafting in patients with severe left ventricular dysfunction. J Thorac Cardiovasc Surg . 1980;;79:718-723.
35 +
Mitchel BF, Alivizatos PA, Adam M, Geisler GF, Thiele PJ, Lambert CJ.  Myocardial revascularization in patients with poor ventricular function. J Thorac Cardiovasc Surg . 1975;;69:52-62.
36 +
Blakeman BM, Pifarre R, Sullivan H, Costanzo-Nordin MR, Zucker MJ.  High-risk heart surgery in the heart transplant candidate. J Heart Transplant . 1990;;5:468-472.
37 +
Cukingnan RA Jr, Brown BG, Wittig JH, Carey JS.  Hemodynamic effect of myocardial revascularization on the impaired ventricle. J Thorac Cardiovasc Surg . 1982;;83:711-717.
38 +
Zubiate P, Kay JH, Mendez AM.  Myocardial revascularization for the patient with drastic impairment of function of the left ventricle. J Thorac Cardiovasc Surg . 1977;;73:84-86.
39 +
Adler DS, Goldman L, O'Neill A, et al.  Longterm survival of more than 2000 patients after coronary artery bypass grafting. Am J Cardiol . 1986;; 58:195-202.
40 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation . 1981;;63:793-802.
41 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS). J Thorac Cardiovasc Surg . 1980;;80: 876-887.
42 +
Myers WO, Davis K, Foster ED, Maynard C, Kaiser GC.  Surgical survival in the Coronary Artery Surgery Study (CASS) registry. Ann Thorac Surg . 1985;;40:245-260.
43 +
Stahle E, Bergstrom R, Nystrom SO, Hansson HE.  Predictive value of factors affecting early results and complications in eight years of coronary artery bypass surgery. J Thorac Cardiovasc Surg . 1989;;37:355-360.
44 +
Pelletier C, Cossette R, Dontigny L, Mercier C, Page A, Verdant A.  Determinants of mortality following coronary bypass surgery. Can J Surg . 1980;; 23:199-204.
45 +
Lea R, Tector A, Flemma R, Johnson WD, Beddingfield GW, Lepley D.  Prognostic significance of a reduced left ventricular ejection fraction in coronary artery surgery. Circulation . 1972;;46( (suppl II) ):II49. Abstract.
46 +
Bjork VO, Ivert T.  Five-year survival after coronary bypass surgery. Scand J Thorac Cardiovase Surg . 1981;;15:31-37.
47 +
Cohn P, Gorlin R, Herman M, et al.  Relation between contractile reserve and prognosis in patients with coronary artery disease and a depressed ejection fraction. Circulation . 1975;;51:414-420.
48 +
Khan SS, Nessim S, Gray R, Czer LS, Chaux A, Matloff J.  Increased mortality of women in coronary artery bypass surgery: evidence for referral bias. Ann Intern Med . 1990;;112:561-567.
49 +
Christakis G, Ivanov J, Weisel R, Birnbaum PL, David TE, Salerno TA, and the Cardiovascular Surgeons of the University of Toronto.  The changing pattern of coronary artery bypass surgery. Circulation . 1989;;80( (suppl I) ):I151-I161.
50 +
Hannan EL, Kilburn H, O'Donnell JF, Lukacik G, Shields EP.  Adult open heart surgery in New York State. JAMA . 1990;;264:2768-2774.
51 +
Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L.  Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. JAMA . 1992;;267:2344-2348.
52 +
Wechsler A, Junod F.  Revascularization for heart failure: coronary bypass grafting in patients with chronic congestive heart failure. Circulation . 1989;;79( (suppl I) ):I92-I96.
53 +
New York State Dept of Health. Coronary Artery Bypass Surgery in New York State, 1990-1992 . Albany: New York State Dept of Health; 1993;.
54 +
New York State Dept of Health. Cardiac Surgery in New York State: Cardiac Mortality Declines . Albany: New York State Dept of Health; 1993;.
55 +
Kron IL, Flanagan TL, Blackbourne LH, Schroeder RA, Nolan SP.  Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy. Ann Surg . 1989;;210:348-354.
56 +
Williams S, Nash D, Goldfarb N.  Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals. JAMA . 1991;;266: 811-815.
57 +
Cohen M, Charney R, Hershman R, Fuster V, Gorlin R, with the technical assistance of Francis X.  Reversal of chronic ischemic myocardial dysfunction after transluminal coronary angioplasty. J Am Coll Cardiol . 1988;;12:1193-1198.
58 +
Hartzler GO, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV.  'High-risk' percutaneous transluminal coronary angioplasty. Am J Cardiol . 1988;;87:475-482.
59 +
Klein HH, Neuhous KL.  Delayed improvement of myocardial function after recanalization of a chronic coronary occlusion in a patient with intractable heart failure. Eur Heart J . 1990;;II:280-286.
60 +
Reinfeld HB, Samet P, Hildner FJ.  Resolution of congestive heart failure, mitral regurgitation, and angina after percutaneous transluminal coronary angioplasty of triple vessel disease. Cathet Cardiovasc Diagn . 1985;;11:273-277.
61 +
Serota H, Deligonul U, Lee W-H, et al.  Predictors of cardiac survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction. Am J Cardiol . 1991;;67:367-372.
62 +
Taylor GJ, Rabinovich E, Mikell FL, et al.  Percutaneous transluminal coronary angiography as palliation for patients considered poor surgical candidates. Am Heart J . 1986;;111:840-844.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
SOLVD Investigators.  Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;;325:293-302.
2 +
CONSENSUS Trial Study Group.  Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med . 1987;;316:1429-1435.
3 +
Cohn JN, Johnson G, Ziesche S, et al.  A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991;;325:303-310, 351-353.
4 +
Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group.  Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med . 1984;;311:1333-1339.
5 +
Killip T, Passamam E, Davis K, et al.  Coronary Artery Surgery Study (CASS): a randomized trial of coronary bypass surgery: eight years follow-up and survival in patients with reduced ejection fraction. Circulation . 1985;:72( (suppl V) ):V102-V109.
6 +
Alderman EL, Fischer P, Litwin GC, et al.  Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation . 1983;;68:785-795.
7 +
Vliestra RE, Assad-Morell JL, Frye RL, et al.  Survival predictors in coronary artery disease: medical and surgical comparisons. Mayo Clin Proc . 1977;; 52:85-90.
8 +
Manley J, King J, Zeft H, Johnson WD.  The 'bad' left ventricle: results of coronary surgery and effect on late survival. J Thorac Cardiovasc Surg . 1976;;72:841-848.
9 +
Yatteau RF, Peter RH, Behar VS, Bartel AG, Rosati RA, Kong Y.  Ischemic cardiomyopathy: the myopathy of coronary artery disease. Am J Cardiol . 1974;;34:520-525.
10 +
Hammermeister KE, DeRouen TA, Dodge HT.  Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study. Circulation . 1982;; 65:53-59.
11 +
Faulkner SL, Stoney WS, Alford WC, et al.  Ischemic cardiomyopathy: medical versus surgical treatment. J Thorac Cardiovasc Surg . 1977;;74:77-82.
12 +
Pigott J, Kouchoukos N, Oberman A, Cutter GR.  Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function. J Am Coll Cardiol . 1985;;5:1036-1045.
13 +
Bounous E, Mark D, Pollock B, et al.  Surgical survival benefits for coronary disease patients with left ventricular dysfunction. Circulation . 1988;;78 ( (suppl I) ):I151-I157.
14 +
Hammermeister KE.  The effect of coronary bypass surgery on survival. Prog Cardiovasc Dis . 1983;;25:297-334.
15 +
Califf R, Harrell F Jr, Lee K, et al.  The evolution of medical and surgical therapy for coronary artery disease: a 15-year perspective. JAMA . 1989;; 261:2077-2086.
16 +
Bedard P, Keon WJ, Taylor G, Akyurekli Y.  Surgery for coronary artery disease and congestive heart failure. Can J Surg . 1975;;18:237-239, 241.
17 +
Quyyumi A, Wright C, Mockus L, Fox KM.  How important is a history of chest pain in determining the degree of ischemia in patients with angina pectoris? Br Heart J . 1985;;54:22-26.
18 +
Beckman CB, Khachane VB, Wilson GL, Carter MG.  Coronary artery bypass at the Hospital of St. Raphael: early and late results of the cardiothoracic group of New Haven. Conn Med . 1980;; 44:618-621.
19 +
Ben DY, Shefer A, Weiss AT, et al.  Early postoperative assessment of coronary artery bypass surgery using nuclear left ventriculography and atrial pacing. Thorac Cardiovasc Surg . 1983;;31:377-381.
20 +
Solignac A, Lesperance J, Grondin P, Campeau L.  Aorta-to-coronary artery bypass operation for chronic intractable congestive heart failure. Can J Surg . 1974;;17:76-79.
21 +
Spencer FC, Green GE, Tice DA, Wallsh E, Mills NL, Glassman E.  Coronary artery bypass grafts for congestive heart failure: a report of experiences with 40 patients. J Thorac Cardiovasc Surg . 1971;;62:529-542.
22 +
Akins CW, Phost GM, De Sanctis RW, Block PC.  Selection of angina-free patients with severe left ventricular dysfunction in myocardial revascularization. Am J Cardiol . 1980;;46:695-670.
23 +
Luu M, Stevenson LW, Brunken RC, Drinkwater DM, Schelbert HR, Tillisch JH.  Delayed recovery of revascularized myocardium after referral for cardiac transplantation. Am Heart J . 1990;;119: 668-670.
24 +
Tillisch J, Brunken R, Marshall R, et al.  Reversibility of cardiac wall motion abnormalities predicted by positron tomography. N Engl J Med . 1986;;314:884-888.
25 +
Solignac A, Campeau L, Lesperance J.  Chronic heart failure due to ischemic cardiopathy and aortocoronary bypasses: study of the operative results in 11 patients. Arch Mal Coeur Vaiss . 1973;;66:117-125.
26 +
Mochtar B, Laird-Meeter K, Brower RW, Verbaan N, Haalebos MMP, Bos E.  Aorto-coronary bypass surgery in 62 patients with severe left ventricular dysfunction: a follow-up study. Thorac Cardiovasc Surg . 1985;;33:30-33.
27 +
Lawrie GM, Morris GC Jr, Earle N.  Long-term results of coronary bypass surgery: analysis of 1698 patients followed 15 to 20 years. Ann Surg . 1991;; 213:377-387.
28 +
Coles JG, Del Campo C, Ahmed SN, et al.  Improved long-term survival following myocardial revascularization in patients with severe left ventricular dysfunction. J Thorac Cardiovasc Surg . 1981;;81:846-850.
29 +
Brockman SK, Goldman SM.  Operative management of coronary artery disease with poor left ventricular function. Cardiovasc Clin . 1987;;17:65-72.
30 +
Uretzky G, Elami A, Appelbaum A, Gotsman MS, Borman JS.  Exercise performance in patients with impaired left ventricular function following aortocoronary bypass. Adv Cardiol . 1986;;34:195-207.
31 +
Shearn D, Brent B.  Coronary artery bypass surgery in patients with left ventricular dysfunction. Am J Med . 1986;;80:405-411.
32 +
Fox HE, May IA, Ecker RR.  Long-term functional results of surgery for coronary artery dis ease in patients with poor ventricular function. J Thorac Cardiovasc Surg . 1975;;70:1064-1072.
33 +
Jones EL, Hurst JW, King SB, Hatcher CR.  Clinical factors influencing survival and adequacy of revascularization after coronary bypass operation. Int J Cardiol . 1982;;2:109-123.
34 +
Hung J, Kelly DT, Baird DK, et al.  Aorta-coronary bypass grafting in patients with severe left ventricular dysfunction. J Thorac Cardiovasc Surg . 1980;;79:718-723.
35 +
Mitchel BF, Alivizatos PA, Adam M, Geisler GF, Thiele PJ, Lambert CJ.  Myocardial revascularization in patients with poor ventricular function. J Thorac Cardiovasc Surg . 1975;;69:52-62.
36 +
Blakeman BM, Pifarre R, Sullivan H, Costanzo-Nordin MR, Zucker MJ.  High-risk heart surgery in the heart transplant candidate. J Heart Transplant . 1990;;5:468-472.
37 +
Cukingnan RA Jr, Brown BG, Wittig JH, Carey JS.  Hemodynamic effect of myocardial revascularization on the impaired ventricle. J Thorac Cardiovasc Surg . 1982;;83:711-717.
38 +
Zubiate P, Kay JH, Mendez AM.  Myocardial revascularization for the patient with drastic impairment of function of the left ventricle. J Thorac Cardiovasc Surg . 1977;;73:84-86.
39 +
Adler DS, Goldman L, O'Neill A, et al.  Longterm survival of more than 2000 patients after coronary artery bypass grafting. Am J Cardiol . 1986;; 58:195-202.
40 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation . 1981;;63:793-802.
41 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS). J Thorac Cardiovasc Surg . 1980;;80: 876-887.
42 +
Myers WO, Davis K, Foster ED, Maynard C, Kaiser GC.  Surgical survival in the Coronary Artery Surgery Study (CASS) registry. Ann Thorac Surg . 1985;;40:245-260.
43 +
Stahle E, Bergstrom R, Nystrom SO, Hansson HE.  Predictive value of factors affecting early results and complications in eight years of coronary artery bypass surgery. J Thorac Cardiovasc Surg . 1989;;37:355-360.
44 +
Pelletier C, Cossette R, Dontigny L, Mercier C, Page A, Verdant A.  Determinants of mortality following coronary bypass surgery. Can J Surg . 1980;; 23:199-204.
45 +
Lea R, Tector A, Flemma R, Johnson WD, Beddingfield GW, Lepley D.  Prognostic significance of a reduced left ventricular ejection fraction in coronary artery surgery. Circulation . 1972;;46( (suppl II) ):II49. Abstract.
46 +
Bjork VO, Ivert T.  Five-year survival after coronary bypass surgery. Scand J Thorac Cardiovase Surg . 1981;;15:31-37.
47 +
Cohn P, Gorlin R, Herman M, et al.  Relation between contractile reserve and prognosis in patients with coronary artery disease and a depressed ejection fraction. Circulation . 1975;;51:414-420.
48 +
Khan SS, Nessim S, Gray R, Czer LS, Chaux A, Matloff J.  Increased mortality of women in coronary artery bypass surgery: evidence for referral bias. Ann Intern Med . 1990;;112:561-567.
49 +
Christakis G, Ivanov J, Weisel R, Birnbaum PL, David TE, Salerno TA, and the Cardiovascular Surgeons of the University of Toronto.  The changing pattern of coronary artery bypass surgery. Circulation . 1989;;80( (suppl I) ):I151-I161.
50 +
Hannan EL, Kilburn H, O'Donnell JF, Lukacik G, Shields EP.  Adult open heart surgery in New York State. JAMA . 1990;;264:2768-2774.
51 +
Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L.  Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. JAMA . 1992;;267:2344-2348.
52 +
Wechsler A, Junod F.  Revascularization for heart failure: coronary bypass grafting in patients with chronic congestive heart failure. Circulation . 1989;;79( (suppl I) ):I92-I96.
53 +
New York State Dept of Health. Coronary Artery Bypass Surgery in New York State, 1990-1992 . Albany: New York State Dept of Health; 1993;.
54 +
New York State Dept of Health. Cardiac Surgery in New York State: Cardiac Mortality Declines . Albany: New York State Dept of Health; 1993;.
55 +
Kron IL, Flanagan TL, Blackbourne LH, Schroeder RA, Nolan SP.  Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy. Ann Surg . 1989;;210:348-354.
56 +
Williams S, Nash D, Goldfarb N.  Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals. JAMA . 1991;;266: 811-815.
57 +
Cohen M, Charney R, Hershman R, Fuster V, Gorlin R, with the technical assistance of Francis X.  Reversal of chronic ischemic myocardial dysfunction after transluminal coronary angioplasty. J Am Coll Cardiol . 1988;;12:1193-1198.
58 +
Hartzler GO, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV.  'High-risk' percutaneous transluminal coronary angioplasty. Am J Cardiol . 1988;;87:475-482.
59 +
Klein HH, Neuhous KL.  Delayed improvement of myocardial function after recanalization of a chronic coronary occlusion in a patient with intractable heart failure. Eur Heart J . 1990;;II:280-286.
60 +
Reinfeld HB, Samet P, Hildner FJ.  Resolution of congestive heart failure, mitral regurgitation, and angina after percutaneous transluminal coronary angioplasty of triple vessel disease. Cathet Cardiovasc Diagn . 1985;;11:273-277.
61 +
Serota H, Deligonul U, Lee W-H, et al.  Predictors of cardiac survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction. Am J Cardiol . 1991;;67:367-372.
62 +
Taylor GJ, Rabinovich E, Mikell FL, et al.  Percutaneous transluminal coronary angiography as palliation for patients considered poor surgical candidates. Am Heart J . 1986;;111:840-844.

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Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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