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Functional outcome after myocardial revascularization in ischemic left ventricular failure
G B Luciani1, G Montalbano, G Casali
1Division of Cardiac Surgery, University of Verona.
Insights
Coronary artery bypass grafting (CABG) improves survival in patients with severe left ventricular failure (LVEF < 30%). However, those with congestive heart failure experience poor symptom-free survival, necessitating further research.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Severe left ventricular failure (LVEF < 30%) presents a challenge in cardiac surgery.
- Coronary artery bypass grafting (CABG) offers survival rates comparable to heart transplantation in these patients.
- Functional outcomes after CABG in patients with severely reduced ejection fraction require detailed assessment.
Purpose of the Study:
- To evaluate the clinical results and functional outcomes of CABG in patients with LVEF < 30%.
- To compare outcomes between patients presenting with angina versus congestive heart failure.
Main Methods:
- Retrospective review of 101 consecutive patients undergoing CABG between 1/91 and 1/97.
- Stratification into two groups: 65 patients with angina (Group 1) and 36 with congestive heart failure (Group 2).
- Analysis of perioperative data, survival rates, and symptom-free survival during a mean follow-up of 29 months.
Main Results:
- Low perioperative mortality (1%) and comparable baseline characteristics between groups.
- Actuarial survival at 5 years was 74% for Group 1 and 78% for Group 2 (p=ns).
- Symptom-free survival at 5 years was significantly lower in the congestive heart failure group (28%) compared to the angina group (49%) (p=0.05), despite improvements in LVEF and functional class.
Conclusions:
- CABG improves survival in patients with ischemic left ventricular failure.
- Patients with congestive heart failure as the primary presentation experience unsatisfactory symptom-free survival post-CABG.
- Further studies are needed to define optimal treatment strategies (revascularization vs. transplantation) for this specific patient subgroup.
Background:
Myocardial revascularization in patients with left ventricular failure (ejection fraction < 30%) offers survival comparable to heart transplantation. The functional outcome, however, has yet to be determined. In order to assess the clinical results in patients with LVEF < 30% undergoing coronary artery bypass grafts (CABG), 101 consecutive patients operated between 1/91 and 1/97 were reviewed retrospectively.
Methods:
The patients were stratified according to presentation: 65 pts had angina (Group 1) and 36 congestive failure (Group 2). Mean age (62 +/- 7 vs 60 +/- 8 yrs), sex (90 vs 88% male), LVEF (0.28 +/- 0.04 vs 0.29 +/- 0.04), prior myocardial infarction (1.2 +/- 0.4 vs 1.2 +/- 0.5 episodes/pt), presence of vital myocardium at scintiscan or low-dose dobutamine echocardiography (92 vs 93%), need for preoperative IABP (3.1 vs 8.3%), aortic cross-clamp (53 +/- 21 vs 60 +/- 21 min) and cardiopulmonary bypass (104 +/- 31 vs 114 +/- 36 min) times were comparable.
Results:
There was only 1 (1%) perioperative death due to low-output syndrome. Eleven pts (6 vs 5, Group 1 vs Group 2) had postoperative low-output syndrome, requiring IABP in 7 pts (4 vs 3). There were 14 (10 vs 4, Group 1 vs Group 2) deaths during follow-up (29 +/- 19 months, range 2-67), with an overall actuarial survival of 91 +/- 4 vs 100% at 1 yr and 74 +/- 9 vs 78 +/- 10% at 5 yrs in Group 1 vs Group 2, respectively (p = ns). Actuarial symptom-free survival was 89 +/- 4 vs 84 +/- 6% at 1 yr and 49 +/- 9 vs 28 +/- 11% at 5 yrs, respectively (p = 0.05). Despite the high recurrence of congestive failure (22 vs 66% in Group 1 vs Group 2, p = 0.004), improvement in functional class (3.1 +/- 0.8 vs 1.5 +/- 0.7 in Group 1 and 2.7 +/- 0.7 vs 1.8 +/- 0.5 in Group 2) and LVEF (0.28 +/- 0.04 vs 0.38 +/- 0.04 in Group 1 and 0.29 +/- 0.04 vs 0.40 +/- 0.06 in Group 2) was found in both groups at follow-up.
Conclusions:
In spite of improving early and late survival after revascularization for ischemic left ventricular failure, patients presenting with congestive failure have an unsatisfactory symptom-free survival. Further studies are necessary to ascertain the relative indications to revascularization or transplantation in this specific patient subgroup.