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Coronary bypass with ejection fraction of 0.20 or less using centigrade cardioplegia: long-term follow-up
S L Lansman1, M Cohen, J D Galla
1Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY 10029.
Insights
Coronary artery bypass grafting using "centigrade cardioplegia" showed acceptable short-term outcomes for patients with severe left ventricular dysfunction. This myocardial protection method improved cardiac function and symptoms, aiding in predicting long-term survival benefits.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Cardiomyopathy Research
Background:
- Severe left ventricular dysfunction poses significant risks for coronary artery bypass grafting (CABG).
- Optimizing myocardial protection during CABG is crucial for high-risk patients.
Purpose of the Study:
- To evaluate the efficacy of a novel myocardial protection strategy, "centigrade cardioplegia," in patients with ejection fraction ≤ 0.20 undergoing CABG.
- To assess short-term and long-term outcomes, including mortality, morbidity, and functional recovery.
- To identify clinical predictors of long-term survival in this high-risk cohort.
Main Methods:
- Forty-two patients with ejection fraction ≤ 0.20 underwent CABG between 1986-1990.
- "Centigrade cardioplegia" involved single-dose cold crystalloid cardioplegia, systemic hypothermia, and local hypothermia.
- Outcomes assessed included 30-day mortality, perioperative complications, postoperative ventricular function, New York Heart Association (NYHA) class, Canadian class, and long-term survival.
Main Results:
- Thirty-day mortality was 4.8% (2/42); perioperative myocardial infarction and stroke rates were 4.8% and 2.4%, respectively.
- Significant improvements were observed in left ventricular ejection fraction (0.157 to 0.226, p < 0.0002), NYHA class (3.4 to 1.8, p < 0.0001), and Canadian class (3.3 to 0.61, p < 0.0001).
- One-year survival was 88%, declining to 34% at 6 years. Predictors of long-term survival included chest pain only, unstable angina history, and NYHA/Canadian class < IV.
Conclusions:
- "Centigrade cardioplegia" provides adequate intraoperative myocardial protection, leading to acceptable short-term results in high-risk CABG patients.
- The technique facilitates significant functional recovery and symptom improvement.
- Specific clinical factors can help predict which patients with severe left ventricular dysfunction may benefit from revascularization.
Abstract:
Forty-two patients with an ejection fraction of 0.20 or less underwent coronary artery bypass grafting from 1986 to 1990 using a method of myocardial protection we term "centigrade cardioplegia," combining single-dose, cold, crystalloid cardioplegia, systemic hypothermia, and local hypothermia. Thirty-day mortality was 4.8% (2/42). Perioperative morbidity included two myocardial infarctions (4.8%) and one stroke (2.4%), which fully resolved. Postoperative left ventricular function improved (left ventricular ejection fraction, 0.157 +/- 0.028 to 0.226 +/- 0.085; p < 0.0002), as did New York Heart Association class (3.4 +/- 0.73 to 1.8 +/- 0.63; p < 0.0001) and Canadian class (3.3 +/- 0.81 to 0.61 +/- 0.92). Survival, 88% at 1 year, declined to 68% at 3 years and 34% at 6 years. This high-risk group had very acceptable short-term results, indicating adequate intraoperative myocardial protection. Four clinical variables were associated with long-term survival: (1) chief complaint of pain only (p = 0.05), (2) history of unstable angina (p = 0.04), (3) Canadian class less than IV (p = 0.05), and (4) New York Heart Association class less than IV (p = 0.05). Reduced survival, although not statistically significant (p = 0.07), was noted for right ventricular ejection fraction of 0.30 or less. These factors may help predict which patients with severe left ventricular dysfunction will benefit from revascularization.