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Coronary artery bypass grafting in patients with profound ventricular dysfunction
F J Baumgartner1, B O Omari, S Goldberg
1Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, Torrance 90509, USA.
Insights
Coronary artery bypass grafting in patients with severe ventricular dysfunction has an acceptable mortality risk. Left internal mammary artery use did not improve outcomes, but intraaortic balloon pumps may benefit those with ejection fractions below 20%.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Ventricular Dysfunction Management
Background:
- Patients with severe ventricular dysfunction undergoing coronary artery bypass grafting (CABG) face high risks but also significant survival benefits.
- This subset requires careful consideration of surgical strategies and support devices.
Purpose of the Study:
- To evaluate the outcomes of CABG in patients with severely reduced left ventricular ejection fractions (LVEF).
- To compare the impact of different graft types and the utility of intraaortic balloon pumps (IABP) in this high-risk population.
Main Methods:
- A retrospective study of 61 consecutive CABG patients with preoperative LVEF ≤ 25%.
- Patients were stratified into three groups based on LVEF: 21-25% (Group I), 16-20.9% (Group II), and 10-15.9% (Group III).
- Outcomes, including mortality, graft usage (left internal mammary artery vs. saphenous vein), and IABP use, were analyzed.
Main Results:
- Overall mortality was 8% (5/61), with no deaths in the lowest LVEF group (Group III).
- Left internal mammary artery conduits were associated with higher mortality, though not statistically significant compared to saphenous vein grafts.
- Intraaortic balloon pump use was significantly higher in patients with poorer ventricular function (P < 0.05), often placed intraoperatively.
Conclusions:
- Coronary artery bypass grafting is a viable option for patients with poor ventricular function, offering acceptable mortality rates.
- Left internal mammary artery grafting did not demonstrate a perioperative survival benefit and may carry early risks.
- Prophylactic intraaortic balloon pump use should be considered for patients with LVEF < 20%.
Abstract:
Patients with severe ventricular dysfunction make up a special subset of patients who undergo coronary artery bypass procedures. For these patients, the risk associated with the bypass procedure is relatively high, but the opportunity-for-survival benefit is also greater. We studied 61 consecutive coronary artery bypass patients with preoperative ejection fractions < or = 25%, and further compared several subgroups: Group I (n = 30) ejection fractions ranged from 21% to 25%; Group II (n = 23) ejection fractions ranged from 16% to 20.9%; and Group III (n = 8) ejection fractions ranged from 10% to 15.9%. The overall mortality rate was 8% (5/61), with no deaths in Group III. The 41% (25/61) of patients who received left internal mammary artery conduits experienced a higher mortality rate, yet it did not differ significantly from that of patients who received only saphenous vein conduits. Intraaortic balloon pumps were placed in 48% (29/61) of the patients, with a progressively higher incidence in patients with poorer ventricular function (P < 0.05). Most intraaortic balloon pumps (59%) were placed intraoperatively. Two patients underwent placement of left ventricular assist devices, and 1 of these survived. Coronary artery bypass grafting in patients with poor ventricular function carries a substantial, but acceptable, mortality risk. Use of the left internal mammary artery did not improve perioperative mortality, and may have a negative impact in the early postoperative period. Intraaortic balloon pump use was most common in those patients with the worst ventricular function. Prophylactic intraaortic balloon pump use may be justified in candidates with ejection fractions < 20%.