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Results of revascularization in patients with severe left ventricular dysfunction
L L Mickleborough1, H Maruyama, Y Takagi
1Department of Surgery, University of Toronto, Ontario, Canada.
Insights
Coronary artery bypass grafting is a viable option for patients with severe left ventricular dysfunction, offering encouraging long-term survival and symptom relief. This surgical approach demonstrates low hospital mortality and good outcomes for managing complex coronary artery disease.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Anesthesia
Background:
- Coronary artery disease (CAD) with severely impaired left ventricular (LV) function (ejection fraction < 20%) presents significant surgical challenges.
- Isolated revascularization is evaluated as a treatment option for these high-risk patients.
Purpose of the Study:
- To assess the safety and efficacy of isolated bypass grafting in patients with coronary artery disease and ejection fraction below 20%.
- To evaluate perioperative outcomes, long-term survival, and symptom relief following revascularization in this specific patient cohort.
Main Methods:
- A consecutive series of 79 patients with severe LV dysfunction underwent isolated bypass grafting.
- Surgical techniques included temperature mapping for cardioplegia delivery, with an average of 3.6 grafts per patient.
- Perioperative support involved intra-aortic balloon pumps and antiarrhythmic drugs as needed.
Main Results:
- Hospital mortality was 3.8%, with low rates of perioperative myocardial infarction (2.5%) and stroke (2.5%).
- Actuarial survival rates at 1, 2, and 5 years were 94%, 82%, and 68%, respectively.
- Significant symptom improvement was observed, with 84% experiencing relief from angina and 26% from heart failure.
Conclusions:
- Bypass graft surgery is supported in patients with severe LV dysfunction, demonstrating low hospital mortality with meticulous cardioplegic techniques.
- Long-term survival is encouraging, with substantial symptom relief for the majority of patients.
- Perioperative ventricular arrhythmias are manageable with medical treatment, and long-term freedom from sudden death is high (91% at 5 years).
Background:
In patients with coronary artery disease and poor ventricular function (ejection fraction, < 20%), bypass grafting remains a surgical challenge. This study evaluates experience with isolated revascularization in such patients.
Methods And Results:
In 79 consecutive patients (69 men, 10 women; average age, 59 +/- 9 years), preoperative ejection fraction was 18 +/- 5%. Indications for surgery were congestive heart failure (CHF) in 5 of 79 patients (6%), CHF and angina in 19 (24%), angina in 41 (52%), ventricular arrhythmias (VAs) in 8 (10%), and critical anatomy in 6 (8%). Some patients had prior VAs (23 of 79; 29%) or mitral regurgitation (18; 23%) and required emergent surgery (25; 32%). At surgery, temperature mapping ensured adequate distribution of antegrade cold cardioplegia, with 3.6 +/- 0.7 grafts per patient, including left internal mammary artery graft in 60 of 79 (76%) and endarterectomy in 14 (18%). Hospital mortality was 3.8%. Perioperative support included intra-aortic balloon pump in 18 of 79 (23%) and drugs for VAs in 28 (35%). Morbidity included myocardial infarction in 2 of 79 (2.5%) and stroke in 2 (2.5%). During follow-up, there were 19 late deaths. Actuarial survival was 94%, 82%, and 68% at 1, 2, and 5 years, respectively, and was similar in patients with severe angina, CHF, mitral regurgitation, or VAs. Freedom from sudden death was 100%, 98%, and 91% at 1, 2, and 5 years, respectively. Among survivors, angina improved in 84% and heart failure improved in 26%.
Conclusions:
These data support bypass graft surgery in patients with severe LV dysfunction. With careful cardioplegic techniques, hospital mortality was low (3.8%). Long-term survival is encouraging, with good relief of symptoms in most patients. Perioperative VAs are frequent but respond to medical treatment, with only 23% of patients discharged on antiarrhythmic drugs. Five-year freedom from sudden death is 91%, with only 3 late sudden deaths in this series.