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Results of revascularization in patients with severe left ventricular dysfunction
L L Mickleborough1, S Carson, M Tamariz
1University of Toronto, Toronto, Ontario, Canada. lmickelborough@torhosp.toronto.on.ca
Insights
Coronary artery bypass grafting is effective for patients with poor left ventricular function. Temperature mapping during cardioplegia significantly reduced hospital morbidity and mortality, improving long-term survival.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Left Ventricular Dysfunction Management
Background:
- Coronary artery disease with severe left ventricular dysfunction presents surgical challenges.
- Traditional patient selection for bypass grafting may exclude those with ejection fractions below 20%.
Purpose of the Study:
- To evaluate the safety and efficacy of coronary artery bypass grafting (CABG) in patients with ejection fraction < 20%.
- To assess the impact of temperature mapping-guided cardioplegia on outcomes in this high-risk group.
Main Methods:
- Prospective data collection from 125 consecutive patients with ejection fraction < 20%.
- Comparison with case-matched controls receiving standard cardioplegia.
- Temperature mapping guided an integrated approach to cold cardioplegia during surgery.
Main Results:
- The study group (temperature mapping) showed significantly lower hospital morbidity (15% vs. 30%) and mortality (4% vs. 11%) compared to controls.
- Five-year actuarial survival was 72% in the study group.
- Significant improvement in anginal and heart failure symptoms was observed among survivors.
Conclusions:
- Coronary artery bypass grafting is feasible and beneficial for patients with severe left ventricular dysfunction, irrespective of viability studies or distal vessel visualization.
- Temperature mapping-guided cardioplegia is associated with reduced hospital morbidity and mortality.
- The procedure offers encouraging long-term survival and symptomatic improvement for this challenging patient population.
Objective:
In patients with coronary disease and poor left ventricular function, bypass grafting remains a surgical challenge. This study evaluates experience in 125 consecutive patients with ejection fraction less than 20% (study group).
Methods:
Preoperative viability studies were not used for patient selection. Clinical data were prospectively collected. The average age of the study subjects was 59 +/- 9 years, and 112 (90%) were male. Most patients (108 [86%]) were in symptom class III or IV. Main indications for surgery included angina in 62 (50%), heart failure and angina in 36 (29%), heart failure in 9 (7%), ventricular arrhythmia in 2 (2%), and critical anatomy in 16 (13%). Significant mitral regurgitation was present in 48 (38%), and distal vessels were poorly visualized in 67 (54%). At surgery, temperature mapping guided an integrated approach to cold cardioplegia. Results in this group were compared with those obtained in case-matched control subjects receiving cardioplegia without temperature mapping (matched for age, sex, functional class, and urgency of operation).
Results:
Hospital morbidity (intra-aortic balloon pump support) and mortality rates were significantly lower in the study group versus those of control subjects (15% vs 30%, P =. 004; and 4% vs 11%, P =.03, respectively). In study patients the 5-year actuarial survival was 72%. Among survivors, both anginal class and heart failure class improved significantly. By means of multivariate analysis, survival was adversely affected by older age, class IV symptoms, and poorly visualized distal vessels.
Conclusions:
These results support the use of coronary artery bypass grafting in patients with severe left ventricular dysfunction without case selection on the basis of viability studies or visibility of distal vessels. Low hospital morbidity and mortality rates have been achieved when temperature mapping guides cardioplegia. Symptoms are improved in most patients, and long-term survival is encouraging.
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