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Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy
Sameer K Singh1, Alice Vinogradsky1, Michael Kirschner1
1Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York.
Insights
Perioperative mechanical circulatory support (MCS) can be safely used in patients undergoing coronary artery bypass grafting (CABG) for ischemic cardiomyopathy. While preoperative MCS shows acceptable survival, postoperative MCS is linked to increased mortality.
Area of Science:
- Cardiology
- Cardiac Surgery
- Mechanical Circulatory Support
Background:
- Ischemic cardiomyopathy poses challenges for surgical revascularization.
- Mechanical circulatory support (MCS) is increasingly considered for high-risk cardiac surgery patients.
Purpose of the Study:
- To evaluate the utilization and outcomes of perioperative mechanical circulatory support (MCS) in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG).
Main Methods:
- Retrospective analysis of 378 patients with ejection fraction <35% undergoing isolated CABG (2015-2021).
- Patients categorized into no MCS, preoperative MCS, or postoperative MCS groups.
- Primary outcome: operative mortality. Secondary outcomes: 3-year survival.
Main Results:
- Overall operative mortality was 3.4%, with 3-year survival at 87.0%.
- Preoperative MCS (n=31) showed no significant difference in operative mortality (7.7% vs 2.9%) or long-term survival compared to no MCS.
- Postoperative MCS (n=30) was associated with significantly increased operative (16.7%) and late mortality (63%).
Conclusions:
- Selective perioperative MCS use is safe for CABG in ischemic cardiomyopathy.
- Preoperative MCS is associated with acceptable short- and long-term survival despite disease severity.
- Postoperative MCS use indicates increased morbidity and mortality risk.
Background:
This study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization.
Methods:
Patients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality.
Results:
The median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01).
Conclusions:
CABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.
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