Coronary artery bypass grafting in left ventricular dysfunction: when and how
Gabriele M Iacona1, Jules J Bakhos, Michael Z Tong
1Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Coronary artery bypass grafting (CABG) for patients with low ejection fraction requires careful surgical management. This review covers current evidence and best practices for optimizing outcomes in these high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
Background:
- Coronary artery bypass grafting (CABG) in patients with low ejection fraction presents significant perioperative risks, including postcardiotomy shock.
- Preoperative optimization, potentially including mechanical support, is crucial for patients with cardiogenic shock.
Approach:
- This review synthesizes the latest evidence and best practices for surgical management of CABG in patients with reduced ejection fraction.
- It emphasizes the importance of rapid and complete revascularization.
- The role of multiple arterial revascularization and alternative CABG techniques (off-pump, beating heart) is discussed with respect to their uncertain benefits.
Key Points:
- Advancements in CABG enable revascularization for patients with severe left ventricular dysfunction and multivessel disease.
- Despite progress, robust long-term outcome data are lacking.
- Individualized assessment and a heart team approach are essential for determining optimal surgical strategies.
Conclusions:
- Surgical management of CABG in low ejection fraction patients demands meticulous technique and judgment.
- A multidisciplinary heart team approach is vital for personalized treatment strategies.
- Further research is needed to fully elucidate long-term outcomes of modern CABG techniques in this population.
Purpose Of Review:
The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients.
Recent Findings:
CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG.
Summary:
Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.
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