CABG in patients with left ventricular dysfunction: indications, techniques and outcomes
Andrea Garatti1, Serenella Castelvecchio1, Alberto Canziani1
1Department of Cardiovascular Disease "E. Malan", Cardiac Surgery Unit, IRCCS Policlinico S. Donato Hospital, San Donato Milanese, Via Morandi 30, 20097 Milan, Italy.
Insights
Coronary artery bypass grafting (CABG) may improve survival in patients with ischemic heart failure and viable myocardium. Long-term follow-up of the STICH trial suggests CABG reduces mortality and readmissions compared to optimal medical therapy.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Heart Failure Management
Background:
- Ischemic chronic heart failure (CHF) presents significant morbidity, mortality, and healthcare costs.
- The role of coronary artery bypass grafting (CABG) in improving outcomes for CHF patients with viable myocardium remains debated.
- Historical studies like CASS showed benefits, while the initial STICH trial results were inconclusive.
Purpose of the Study:
- To review current evidence on the effectiveness of CABG in patients with ischemic left ventricular dysfunction (LVD).
- To clarify the role of CABG in managing ischemic heart failure by analyzing observational studies and randomized trials.
- To discuss operative techniques and controversial aspects related to CABG for ischemic LVD.
Main Methods:
- Review of existing literature, including observational studies and randomized controlled trials (RCTs).
- Analysis of data from the Coronary Artery Surgery Study (CASS) and the Surgical Treatment for Ischemic Heart Failure (STICH) trial and its extension (STICHES).
- Inclusion of discussions on surgical techniques and controversial issues in CABG for ischemic heart failure.
Main Results:
- The STICH extension study (STICHES) showed a significant long-term reduction in all-cause mortality, cardiovascular mortality, and heart readmissions with CABG compared to optimal medical therapy (OMT).
- Early results from the STICH trial did not show a significant difference between CABG and OMT in terms of all-cause mortality.
- The presence of viable myocardium is a key factor influencing the potential benefit of revascularization.
Conclusions:
- CABG may offer significant long-term survival benefits for selected patients with severe ischemic left ventricular dysfunction.
- Further clarification of CABG's role requires careful consideration of patient selection, myocardial viability, and long-term outcome data.
- The review aims to guide the current management of ischemic heart failure patients with LVD.
Abstract:
Ischemic chronic heart failure (CHF) represents one of the cardiovascular diseases with the worst degree of morbidity and mortality in the western world, and with the highest health care costs. Despite several studies demonstrated that surgical revascularization (CABG), especially in the presence of viable myocardium, improve heart function, and therefore, survival, the matter remains unclear and controversial. In the late 1970s, the Coronary Artery Surgery Study showed that a subgroup of patients with coronary artery disease, angina, and reduce LV function had a significant survival benefit after CABG compared to those treated medically. The key concept behind this observation was the presence of viable myocardium, which can resume function following revascularization. In contrary, the surgical treatment for ischemic heart failure (STICH) trial, which randomized patients with CAD and LV dysfunction to evidence-based medical therapy or CABG plus medical therapy, failed to demonstrate at a median follow-up of 56 months a significant difference between the CABG group and the medical therapy group in the rate of death from any cause. However, the results of the STICH extension study (STICHES) at 10 years follow-up demonstrated that CABG is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and readmission for heart compared to optimal medical therapy (OMT) in patients with severe ischemic LV dysfunction. Therefore, this review discusses the available evidences in literature, from observational studies to randomized trials, including operative techniques and controversial issues, in order to better clarify the role of CABG in the current management of ischemic patients with LVD.
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