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The effects of coronary revascularization on left ventricular function in ischemic heart disease
Insights
Coronary artery bypass grafting significantly improves resting ventricular performance in most patients with ischemic heart disease, reversing myocardial dysfunction. Successful revascularization and aneurysmectomy enhance ejection fraction, improving overall cardiac function.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Imaging
Background:
- Coronary revascularization's effect on resting ventricular function post-surgery remains debated.
- Ischemic heart disease impacts resting ventricular performance, necessitating evaluation of surgical interventions.
Purpose of the Study:
- To assess the impact of coronary artery bypass grafting (CABG) on resting left ventricular (LV) performance.
- To evaluate the reversibility of ischemic myocardial dysfunction and the role of aneurysmectomy.
Main Methods:
- Retrospective analysis of 149 patients undergoing CABG with pre- and post-operative ventriculograms.
- Regional wall motion assessed using the 100-segment method; significant improvement defined by specific criteria.
- Graft patency evaluated via arteriography; hospital mortality and outcomes analyzed.
Main Results:
- Overall early graft patency was 95.9% (mammary artery 100%, vein grafts 93.7%).
- Significant postoperative improvement in regional wall motion observed in 37% of patients, with an average ejection fraction increase of 0.18.
- Left ventricular aneurysmectomy also improved ejection fraction, suggesting enhanced LV performance.
Conclusions:
- Reversible ischemic myocardial dysfunction is common in patients undergoing CABG.
- Successful revascularization and aneurysmectomy significantly improve resting left ventricular performance.
- CABG offers substantial benefits for patients with stable and unstable angina, improving cardiac function.
Abstract:
Although it is well established that coronary revascularization can reverse exercise-induced ischemic dysfunction, the effects on resting ventricular performance are controversial. From a group of 183 patients receiving surgical therapy for ischemic heart disease, 166 underwent bypass graft arteriography at an average of 7 to 14 days postoperatively. In 149 patients, satisfactory preoperative and postoperative biplane left ventriculograms were obtained. Regional wall motion was assessed by the 100 segment method of Sheehan and Dodge, and a perioperative change in shortening greater than 2 standard deviations of normal variability over 20 or more adjacent segments was considered significant. Ninety-five patients had stable or progressive angina, 88 had medically refractory unstable angina, 155 were in New York Heart Association Class IV, and 37 had a preoperative left ventricular ejection fraction of less than 0.4. Myocardial integrity was preserved with crystalloid cardioplegia and topical hypothermia. Seven hundred ninety-eight bypass grafts were performed (522 vein grafts and 276 mammary artery grafts), and 13 patients had concomitant left ventricular aneurysmectomy. Hospital mortality was 2.2%. The overall early graft patency rate was 95.9% (93.7% for vein grafts and 100% for mammary arteries). Only one patient had a decrement in regional wall motion, and 51 (37%) had significant postoperative improvement (27 in the unstable angina group and 24 in the stable angina group); in the patients with improved regional wall motion, ejection fraction increased by an average of 0.18 (p less than 0.01). Ejection fraction also improved after aneurysmectomy, and the increment seemed to result from both a reduction in end-diastolic volume and improved regional wall motion. Thus, reversible ischemic myocardial dysfunction appears to be common in the general population of patients undergoing coronary artery bypass grafting; 40% of patients with unstable angina and 34% of those with stable angina can be expected to have improved regional wall motion after successful revascularization. Finally, ventricular aneurysm resection significantly enhances left ventricular performance as assessed by ventriculographic ejection fraction.