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[Coronary bypass in patients with severe left ventricular dysfunction (EF < or = 25%). Apropos of 111 patients]
F Bouchart1, J P Bessou, M Redonnet
1Service de chirurgie thoracique et cardiovasculaire, hôpital Charles-Nicolle, Rouen.
Insights
Coronary bypass surgery in patients with severe left ventricular dysfunction (EF ≤ 25%) showed a 9% operative mortality. Despite progressive myocardial deterioration, surgical indication was justified for selected patients with severe angina.
Area of Science:
- Cardiovascular Surgery
- Cardiology
- Cardiac Surgery
Context:
- Severe left ventricular dysfunction (ejection fraction ≤ 25%) presents significant surgical challenges.
- Patients often experience disabling angina and signs of heart failure.
- Coronary artery disease typically involves multiple vessels, including the left main stem.
Purpose:
- To evaluate the outcomes of coronary bypass surgery in patients with severe left ventricular dysfunction.
- To identify operative risk factors and long-term survival rates.
- To assess the functional results and justify surgical indications in this high-risk group.
Summary:
- 111 patients with EF ≤ 25% underwent coronary bypass surgery.
- Operative mortality was 9%, with risk factors including advanced heart failure and low cardiac index.
- Long-term survival was 88% at 1 year, decreasing to 56% at 6 years.
- Functional results correlated with preoperative cardiac failure stage and hemodynamic parameters (LVEDP, CI).
Impact:
- Coronary bypass surgery can be a justified option for selected patients with severe left ventricular dysfunction and disabling angina.
- Despite potential for medium-term myocardial deterioration and heart failure, surgery offers satisfactory results.
- Understanding risk factors and long-term outcomes is crucial for patient selection and management.
Abstract:
One hundred and eleven patients with severe left ventricular dysfunction (EF < or = 25%) underwent coronary bypass surgery between January 1984 and December 1994. The selection criteria were based on the measurement of an EF < or = 25%, LVEDP and CI. All patients had angina and 83 had signs of pulmonary oedema or episodes of congestive failure. Patients with valvular disease, left ventricular aneurysms, reoperations, surgery for arrhythmias and prior angioplasty, were excluded. The coronary disease usually involved all three vessels. Seventeen patients had lesions of the left main stem associated with lesions of the right coronary artery. The average number of bypass grafts was 2.6 +/- 1.6 per patient. The average duration of aortic clamping was 60 +/- 19 minutes. Operative mortality (first month after surgery) was 10 patients (9%). The operative risk factors were: gender, stage of cardiac failure, emergency surgery, LVEDP > 23 mmHg (p < 0.05), CI < 21/min/m2 (p < 0.05). The mean follow-up period was 42 +/- months (3 lost to follow-up). Late mortality was 42 patients. The one year actuarial survival was 88 +/- 5.3%, 76 +/- 9% at 3 years, and 56 +/- 18% at 6 years. Long-term functional results were related to: preoperative stage of cardiac failure (NYHA stage IV) and the association of raised LVEDP and low CI. Surgical results remained satisfactory, however, and the surgical indication was justified in selected patients despite severe left ventricular dysfunction in cases usually with stable invalidating or unstable angina, in the knowledge that myocardial deterioration is progressive in the medium-term with a high incidence of cardiac failure.