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Coronary artery bypass in patients with severely depressed ventricular function
C A Milano1, W D White, L R Smith
1Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710.
Insights
Coronary artery bypass grafting improves survival and quality of life for patients with coronary artery disease and severely depressed ejection fraction. This surgical intervention offers benefits over medical therapy alone, with specific factors influencing outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Medical Therapy Comparison
Background:
- Coronary artery disease (CAD) with severely depressed left ventricular ejection fraction (LVEF) presents a significant therapeutic challenge.
- Optimal management strategies for these high-risk patients remain a subject of ongoing research and clinical debate.
Purpose of the Study:
- To evaluate the efficacy and outcomes of isolated coronary artery bypass grafting (CABG) in patients with CAD and severely depressed LVEF (≤0.25).
- To identify preoperative factors associated with increased mortality and prolonged hospitalization after CABG in this patient cohort.
Main Methods:
- Retrospective analysis of 118 consecutive patients who underwent isolated CABG for CAD with LVEF ≤0.25 between 1981 and 1991.
- Kaplan-Meier survival analysis and univariate/multivariate Cox regression models were used to assess survival and factors influencing outcomes.
Main Results:
- Operative mortality was 11%, with ventricular arrhythmia and low cardiac output state as common complications.
- Five-year survival was 57.5%, exceeding estimated survival with medical therapy alone.
- Survivors showed significant improvements in angina class, congestive heart failure class, and ejection fraction.
- Preoperative factors associated with higher mortality included other vascular disease, female sex, hypertension, elevated left ventricular end-diastolic pressure, and depressed cardiac index.
- Prolonged cardiopulmonary bypass time, acute presentation, and female sex were linked to longer hospitalizations.
Conclusions:
- Coronary artery bypass grafting provides significant survival and symptomatic benefits for patients with coronary artery disease and severely depressed ejection fraction.
- Identification of specific preoperative risk factors can aid in tailoring treatment strategies and managing patient expectations.
Abstract:
This study evaluates whether patients with coronary artery disease and severely depressed left ventricular ejection fraction benefit from coronary artery bypass grafting. From 1981 to 1991, 118 consecutive patients with ejection fraction less than or equal to 0.25 underwent isolated coronary artery bypass grafting at Duke University Medical Center. Operative mortality was 11%. Ventricular arrhythmia requiring treatment was the most common postoperative complication (27%), followed by low cardiac output state (22%). Median length of postoperative hospitalization was 9 days. Kaplan-Meier estimate of survival at 1 year and 5 years was 77.2% and 57.5%, and was better than estimated survival with medical therapy alone. Survivors experienced significant improvement in angina class (p < 0.0001), congestive failure class (p < 0.0001), and follow-up ejection fraction (p < 0.005). Of 22 preoperative factors evaluated by univariate survival analysis, five were associated with significantly greater mortality: other vascular disease (p < 0.005), female sex (p < 0.005), hypertension (p < 0.005), elevated left ventricular end-diastolic pressure (p < 0.05), and depressed cardiac index (p < 0.05). Considering length of hospitalization, three factors showed significant adverse effect in a multivariate Cox model: time on cardiopulmonary bypass (p < 0.005), acute presentation (p < 0.005), and female sex (p < 0.01). These data and review of the literature suggest that patients with coronary artery disease and severely depressed ejection fraction benefit from coronary artery bypass grafting, and specific preoperative factors may help determine optimal treatment.