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[Surgical treatment of ischemic heart disease complicated with severe left ventricular dysfunction: experience in 200
P Di Biasi1, R Scrofani, S Moriggia
1Divisione di Chirurgia Toracica e Cardiovascolare, Ospedale L. Sacco, Milano.
Insights
Coronary artery bypass graft (CABG) offers significant long-term benefits for patients with coronary artery disease and low ejection fraction. Careful patient selection and perioperative management reduce mortality and improve outcomes in this high-risk group.
Area of Science:
- Cardiology
- Cardiac Surgery
Context:
- Coronary artery disease (CAD) with severely depressed left ventricular ejection fraction (LVEF) represents a high-risk surgical subgroup.
- Evaluating the efficacy and safety of coronary artery bypass graft (CABG) in this population is critical.
Purpose:
- To assess the short- and long-term benefits of CABG in patients with CAD and LVEF ≤ 0.30.
- To identify preoperative risk factors associated with increased mortality in this patient cohort.
Summary:
- A study of 200 patients (mean age >70 years, 31% NYHA class III/IV) undergoing CABG with LVEF ≤ 0.30 revealed an operative mortality of 9%.
- Key mortality predictors included low cardiac index (< 2.1 L/min/m²), urgent operation, high contractility score (> 80), and additional surgical procedures.
- Survivors demonstrated significant improvements in congestive heart failure class and ejection fraction, with 8-year survival at 54%.
Impact:
- Despite the high-risk profile, CABG can be safely performed in carefully selected patients with depressed LVEF.
- Improved perioperative management and risk factor assessment enhance patient outcomes, reducing morbidity and mortality.
Background:
The study was designed to evaluate short and long-term benefits of coronary artery bypass graft in patients with coronary artery disease and severely depressed left ventricular ejection fraction and to identify contemporary risk factors associated with significantly greater mortality in this high-risk subgroup.
Methods:
From 1985 to 1995, 200 consecutive pts with EF < or = 0.30 underwent CABG. Among these patients, 60% were older than 70 years. NYHA functional class III/IV was present in 31% of pts. Preoperative mean cardiac index was 2.7 +/- 7 l/min/m2, mean pulmonary artery pressure was 29.9 +/- 7 mm Hg and contractility score (generated by appropriate software for left ventricular kinesis analysis) mean value was 50.1 +/- 11.6 points. Urgent operation was required in 32 pts (16%). The majority of pts were completely revascularized.
Results:
Operative mortality was 9% (18 pts). Low output syndrome was the most common postoperative complication (13.5%) followed by ventricular arrhythmia (8%), mean length of postoperative hospitalization for survivors was 13 +/- 10 days. Of 23 possible operative risk factors evaluated, four were associated with significantly greater mortality: cardiac index < or = 2.1 l/min/m2, urgent operation, contractility score > or = 80 and associated surgical procedures. Survivors experienced significant improvement in CHF class (p < 0.001) and follow up EF (p < 0.001). Kaplan-Meier estimate of survival at 1 year, 5 years and 8 years was 85%, 65% and 54%.
Conclusion:
Through more careful assessment of preoperative risk factors, patients selection and perioperative management, actually coronary artery bypass graft may be offered to pts with low ejection fraction with reduced morbidity and mortality.