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[Severe chronic ischemic ventricular dysfunction. Determinants of surgical risk and long-term clinical outcome]
J S Guisasola1, J M González Santos, M Ruiz Fernández
1Servicio de Cirugía Cardiovascular, Hospital General Universitario Gregorio Marañón, Madrid.
Insights
Surgical revascularization is a viable option for patients with severe ventricular dysfunction due to coronary artery disease. Elective surgery offers acceptable risk and satisfactory long-term outcomes, improving survival and functional capacity.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Outcomes Research
Background:
- Severe ventricular dysfunction in chronic ischemic heart disease increases operative risk and worsens long-term prognosis.
- Surgical revascularization can improve ventricular function, functional capacity, and survival in selected patients with viable myocardium.
Purpose of the Study:
- To evaluate long-term results of isolated coronary artery bypass surgery in patients with ejection fraction ≤ 0.30.
- To identify clinical factors predicting favorable outcomes (survival and symptom-free status).
Main Methods:
- Analysis of 100 patients (ejection fraction ≤ 0.30) undergoing isolated coronary artery bypass surgery.
- Predominant symptoms included angina and congestive heart failure; many patients were in functional class III/IV.
Main Results:
- In-hospital mortality was 10%, with emergency surgery being a significant predictor (p < 0.0001).
- Elective surgery had a 4.9% mortality rate. Age and functional class also predicted early mortality.
- Actuarial survival was 65% at 5 years and 52% at 8 years. Favorable long-term outcomes were observed in 66% of patients.
Conclusions:
- Elective surgical revascularization is associated with acceptable risk and satisfactory long-term results in patients with severe ventricular dysfunction.
- Preoperative clinical manifestations have limited value in patient selection; mitral insufficiency was a predictor of poor outcome.
Introduction:
In patients with chronic ischemic heart disease, a severe ventricular dysfunction is associated with a higher operative risk and to a worse late clinical outcome. However, when there is sufficient viable myocardium, surgical revascularization can improve ventricular performance and above all the functional capacity and survival of these patients.
Objectives:
To analyze long-term results of a large series of patients with an ejection fraction < or = 0.30 that underwent isolated coronary artery bypass surgery and to investigate factors, mainly clinical, that determined favorable clinical results: being that the patient was alive and free of incapacitating symptoms.
Patients And Methods:
This series included 100 patients, 93 males and 7 females, with a mean age of 62 +/- 8 years. The predominant clinical manifestation was angina in 37, congestive heart failure in 22 and both in 41. Seventy-nine patients were in functional class III or IV, and 19 had emergency surgery.
Results:
There were 10 in-hospital deaths, 6 of which occurred in patients who had emergency surgery. Mortality in the elective cases was 4.9%. Only age (p < 0.05), functional class (p < 0.05) and emergency surgery (p < 0.0001) were identified as independent predictors of early mortality. Actuarial survival rates after 5 and 8 years were 65 and 52% respectively. Long-term clinical outcome was considered favorable in 66 patients. We did not find any preoperative clinical variables that were predictors of the clinical outcome. Only preoperative mitral insufficiency correlated with a poor long-term clinical result.
Conclusions:
Patients with chronic and severe ventricular dysfunction secondary to coronary artery disease have an acceptable surgical risk when they are operated on electively, before their clinical condition deteriorates. Long-term results are satisfactory in the majority of the patients. In these types of patients clinical manifestations are of limited value in the selection process for surgical revascularization.