[Operations in limited left ventricular pump function]

The proportion of patients with left ventricular dysfunction (LVD) undergoing open heart surgery is increasing. In this patient group, the perioperative risk is elevated because of the preexisting pathophysiology. Detailed evaluation, interdisciplinary differential therapeutic considerations on the basis of the comparative benefit rationale as well as hemodynamic, antiischemic and antiarrhythmic optimization is mandatory. To plan the operation in patients with coronary artery disease, the issue of reversibility of LVD has to be resolved by sophisticated viability testing. The ultimate decision on revascularization versus aneurysmectomy and scar excision has to be met by the operating surgeon. If the patient's hemodynamics is severely compromised, the perioperative risk may be too high and cardiac transplantation, possibly with mechanical bridging, should be considered. If, in addition, intractable malignant tachyarrhythmias are encountered, antitachycardia operation and defibrillator implantation may be performed. During extracorporeal circulation which is associated with a systemic inflammatory response syndrome the compensatory potential is reduced in patients with LVD, and therefore, the risk of complications such as low-output syndrome, respiratory and renal failure is elevated. Advances in the understanding of pathophysiological mechanisms, an individualized preoperative tailored medical and mechanical therapy for preparation of the operation, anesthesiologic management, cardioprotection and postoperative intensive care have contributed to improvement of outcome in this patient group. Specifically patients with documented evidence of myocardial viability such as angina have profited from surgical revascularization as compared to medical therapy in large scale prospective trials. Perioperative mortality has been lowered to 2-20%. In the absence of angina and presence of overt heart failure and arrhythmias, however, the postoperative 3- and 5-year prognosis of 60% and 35%, respectively, continues to be reduced. Improvement of ejection fraction, angina class, functional capacity and quality of life has been documented in all studies. In conclusion, cardiac operations in patients with left ventricular dysfunction can nowadays be performed with a reasonable risk-benefit ratio, if a careful individualized preoperative evaluation and optimal pre-, intra-and postoperative management is performed.