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Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in
F Bouchart1, A Tabley, P Y Litzler
1Department of Thoracic and Cardiovascular Surgery, Hôpital Charles Nicolle, C.H.U. de Rouen, F76031 Rouen, France. francois.bouchart@chu-rouen.fr
Insights
Coronary artery bypass grafting in patients with severely reduced ejection fraction (EF ≤25%) is feasible. This procedure improves left ventricular function and offers good medium-term survival rates, making it a viable option for carefully selected patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Research
Background:
- Coronary artery bypass grafting (CABG) in patients with left ventricular ejection fraction (EF) ≤25% is controversial.
- Concerns exist regarding operative mortality, morbidity, and the functional and survival benefits of myocardial revascularization in this high-risk group.
Purpose of the Study:
- To evaluate the safety and efficacy of CABG in patients with severely impaired left ventricular function (EF ≤25%).
- To assess operative outcomes, including mortality, morbidity, and long-term survival, as well as functional improvements post-surgery.
Main Methods:
- A retrospective analysis of 141 patients with coronary artery disease and EF ≤25% who underwent CABG between 1988 and 1998.
- Assessment of left ventricular function using ejection fraction (EF), left ventricular end-diastolic pressure (LVEDP), and cardiac index (CI).
- Identification of operative risk factors associated with mortality, including emergency surgery, female sex, LVEDP, CI, and NYHA class IV.
Main Results:
- The operative mortality rate was 7%.
- Postoperative EF improved significantly from 22.2% to 33.5% (P<0.001).
- Two-year, five-year, and seven-year survival rates were 84%, 70%, and 50%, respectively. Lower NYHA class and absence of cardiomegaly were associated with improved long-term survival.
Conclusions:
- Myocardial revascularization can be performed relatively safely in patients with significant left ventricular dysfunction.
- CABG offers good medium-term survival and improvements in quality of life and left ventricular function.
- Careful patient selection is crucial, assessing potentially reversible dysfunction when considering CABG for patients with impaired ventricular function.
Objectives:
The present study evaluates our experience with coronary bypass grafting in patients with EF < or =25%. Myocardial revascularization in this setting remains controversial because of concerns over operative mortality and morbidity and lack of functional and survival benefit.
Materials And Methods:
One hundred and forty-one patients with coronary artery disease and left ventricular ejection fraction < or =25% underwent coronary artery bypass graft between January 1988 and December 1998. Mean age at operation was 63.3 years and 81.4% were male. The major indication for surgery was angina (114 patients, 80.8%). Ejection fraction (EF), left ventricular end diastolic pressure (LVEDP) and cardiac index (CI) were used to assess left ventricular function. The number of graft was 2.7+/-1.6/patient. Internal mammary artery was used in 119 patients (84.3%). Intra aortic balloon pump was placed preoperatively in 25 patients (17.7%). Five operative risk factors were associated with a higher mortality: emergency, female sex, LVEDP, CI and NYHA class IV.
Results:
The operative mortality was 7% (10 patients). Left ventricular ejection fraction (assessed post operatively in 83 patients) improved from 22.2% preoperatively to 33.5% post operatively (P<0.001), mean end diastolic volume index fell from 98 to 83 ml/m(2) following surgery. Survival at 2, 5 and 7 years was respectively 84+/-3%, 70+/-4% and 50+/-5%. Two variables were associated with increased long term survival: congestive heart failure (NYHA class lower than IV (P=0.035) and cardiomegaly (P=0.04)
Conclusion:
In patients with left ventricular dysfunction, myocardial revascularization can be performed relatively safely with good medium term survival and improvement in quality of life and in left ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection and management when considering these patients for operation should assess potentially reversible dysfunction.
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