The surgical management of coronary artery disease with myocardial dysfunction

The prognosis of patients with coronary artery disease and severe left ventricular dysfunction (ischemic cardiomyopathy) is grim and medical therapy has not significantly altered its course. To evaluate the results of aortocoronary saphenous vein bypass grafting in patients with ischemic cardiomyopathy, 51 consecutive patients with left ventricular ejection fractions under 0.35 were analyzed. The average ejection fraction was 0.24. All patients had angina pectoris. Clinical congestive heart failure was present in 43 percent of the patients. Ninety percent of the patients had one or more previous myocardial infarctions. Forty-seven patients had three vessel disease and four patients had two vessel disease. Twenty-one percent of the patients had critical left main coronary artery obstruction. Twelve percent of the patients had unstable angina pectoris. Two patients had recent myocardial infarction. Improvements in operative management and surgical techniques, particularly the use of cardioplegic solution for operative myocardial protection and the judicious use of the intra-aortic balloon, have been clearly beneficial. The period of followup was 6 to 33 months. The operative mortality rate was 2 percent (one patient). There have been no late deaths. Significant improvement in angina pectoris and congestive heart failure was found in over 90 percent of the patients postoperatively. Patients with severe preoperative congestive heart failure had remarkable relief of symptoms after operation. The aortocoronary saphenous vein bypass operation can be performed in patients with coronary artery disease and severe left ventricular dysfunction with a low operative mortality rate, with marked relief of angina pectoris, and with dramatic improvement in the symptoms of congestive heart failure.