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Surgical survival benefits for coronary disease patients with left ventricular dysfunction
E P Bounous1, D B Mark, B G Pollock
1Department of Medicine, Duke University Medical Center, Durham, NC 27710.
Insights
Coronary bypass surgery significantly improves survival for patients with coronary artery disease and left ventricular dysfunction. The sicker the patient, the greater the survival benefit from surgical intervention.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Outcomes
Background:
- Patient selection for coronary bypass surgery in those with coronary artery disease and left ventricular dysfunction remains debated.
- Left ventricular dysfunction, defined as ejection fraction ≤40%, presents unique challenges in surgical candidates.
Purpose of the Study:
- To evaluate the survival benefits of coronary bypass surgery versus medical management in patients with coronary artery disease and left ventricular dysfunction.
- To identify predictors of survival in this patient population.
Main Methods:
- A study of 710 patients with coronary artery disease and ejection fraction ≤40%.
- Comparison of survival rates between surgically treated (n=301) and medically treated (n=409) patients at 3 years.
- Cox survival models were used to adjust for baseline differences and identify predictors of survival.
Main Results:
- Unadjusted 3-year survival was 84% for surgical patients and 64% for medical patients.
- After adjustment for baseline factors, 3-year survival was 86% for surgical and 68% for medical groups.
- Predictors of survival included ejection fraction, extent of coronary artery disease, myocardial infarction, angina, and conduction disturbances.
Conclusions:
- Coronary bypass surgery offers significant survival advantages for patients with coronary artery disease and left ventricular dysfunction.
- The greatest survival benefits of surgery were observed in patients with the most severe left ventricular dysfunction, extensive coronary artery disease, and severe angina.
Abstract:
Controversy still exists about the proper selection of patients with coronary artery disease and left ventricular dysfunction for coronary bypass surgery. To examine this issue, we studied 710 patients with significant coronary artery disease and left ventricular dysfunction (ejection fraction less than or equal to 40%). Of 301 patients treated surgically, 232 had bypass grafts; 17, left ventricular surgery; and 52, both procedures. At 3 years after treatment, unadjusted survival was 84% for surgical patients and 64% for medical patients. At baseline, medical patients had more left ventricular dysfunction than surgical patients, but surgical patients had more coronary artery disease and angina than medical patients. In Cox survival models, two invasive factors (ejection fraction and extent of coronary artery disease) and three noninvasive indexes (assessment of myocardial infarction, angina, and conduction disturbances) were the five best predictors of survival (p less than 0.001). After adjustment for these factors between the two treatment groups, overall surgical survival at 3 years after treatment was 86%, and medical survival was 68%. Long-term surgical survival benefits appeared greatest in patients with the most severe left ventricular dysfunction, most extensive coronary artery disease, and most severe anginal symptoms. We conclude that surgery provides significant survival benefits for coronary disease patients with left ventricular dysfunction; in general, the sicker the patient, the greater the benefit.