Results of coronary artery bypass grafting by a single surgeon in patients with left ventricular ejection fractions < or = 30%

Early and Mid-Term Outcomes of Patients Undergoing Coronary Artery Bypass Grafting in Ischemic Cardiomyopathy

Background Many observational studies and trials have shown that coronary artery bypass grafting improves the survival in patients with ischemic cardiomyopathy. However, these results are based on data generated from developed countries. Poor socioeconomic statuses, lack of uniformity in healthcare delivery, differences in risk profile, and affordability to access optimal health care are some factors that make the conclusions from these studies irrelevant to patients from India. Methods and Results One-hundred and sixty-two patients with severe left ventricular dysfunction (ejection fraction ≤35%) who underwent coronary artery bypass grafting from 2009 to 2017 were enrolled for this study. Mean age of the study population was 58.67±9.70 years. Operative mortality was 11.62%. Thirty day/in-house composite outcome of stroke and perioperative myocardial infarction were 5.8%. The percentage of survival for 1 year was 86.6%, and 5-year survival was 79.9%. Five-year event-free survival was 49.3%. The mean ejection fraction improved from 30.7±4.08% (range 18-35) to 39.9±8.3% (range 24-60). Lack of improvement of left ventricular function was a strong predictor of late mortality (hazard ratio, 21.41; CI 4.33-105.95). Even though there was a trend towards better early outcome in off-pump CABG , the 5-year survival rates were similar in off-pump and on-pump group (73.4% and 78.9%, respectively; P value 0.356). Conclusions We showed that coronary artery bypass grafting in ischemic cardiomyopathy was associated with high early composite outcomes. However, the 5-year survival rates were good. Lack of improvement of left ventricular function was a strong predictor of late mortality.

Coronary bypass in left ventricular dysfunction and differential cardiac recovery

Background

We aimed to examine the efficacy of surgical revascularization with respect to improvement in ventricular function and survival in patients with ischemic cardiomyopathy and poor left ventricular function.

Methods

We retrospectively analyzed the data of 429 patients (median age 64.6 years, 81.1% male) with ejection fractions <40% undergoing isolated primary coronary artery bypass grafting from 2000 to 2016. Techniques included on-pump cardioplegic arrest ( n = 312), off-pump ( n = 75), and on-pump beating heart ( n = 42). Propensity matching was performed to compare the cardioplegic arrest group ( n = 114) with the combined off-pump and beating heart groups ( n = 114).

Results

Postoperatively, ejection fraction increased by 10.1% ± 13.1% (from 31.4% ± 7.1% to 41.6% ± 13.6%; p < 0.001) and mitral regurgitation grade improved ( p < 0.001) but right ventricular function on echocardiographic assessment worsened over time ( p = 0.04). No difference in ejection fraction improvement was seen in the time periods <1 (9.8% ± 11.2%), 1–5 (11.6% ± 14.5%), and >5 (8.8% ± 14.2%) years ( p = 0.442). Following propensity matching, there was no significant difference between the combined off-pump/beating heart and cardioplegic arrest groups with respect to survival or postoperative complications.

Conclusions

Patients with moderate to severe left ventricular dysfunction experience long-term improvement in left ventricular ejection fraction after coronary artery bypass. However, right ventricular function often continues to decline, contributing to persistent or worsening heart failure symptoms and late mortality. No difference in survival was seen between the 2 techniques.

The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem

Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.

Off-Pump Revascularization for Significant Left Ventricular Dysfunction

Left ventricular dysfunction is a predictor of perioperative morbidity and mortality in on-pump coronary artery bypass grafting. Obligatory global myocardial ischemia and injury induced during crossclamping as well as adverse systemic effects of cardiopulmonary bypass may induce a disproportionately greater overall physiologic insult in patients with poor ventricular function. All patients undergoing nonemergency off-pump coronary artery bypass by a single surgeon during an 18-month period were retrospectively analyzed. Two groups with preoperative ejection fraction classified as poor (10%–35%; n = 31) or normal (55%–80%; n = 60) were compared. The mean ejection fractions were 26% ± 1% and 63% ± 1% respectively, p < 0.000001. In those with significant left ventricular dysfunction, there were 2.8 ± 0.1 grafts per patient, time to extubation was 8.4 ± 1.2 hours, and discharge was after 4.9 ± 0.6 days. These results were statistically equivalent to those in the group with normal left ventricular function. There was no intraaortic balloon pump insertion or mortality in either group. This technique provides an effective means of safely revascularizing patients with significant left ventricular dysfunction, and it may provide a valuable alternative approach in patients with ischemic cardiomyopathy.

New Insights in the Diagnosis and Treatment of Heart Failure

Cardiovascular disease is the leading cause of mortality in the US and in westernized countries with ischemic heart disease accounting for the majority of these deaths. Paradoxically, the improvements in the medical and surgical treatments of acute coronary syndrome are leading to an increasing number of “survivors” who are then developing heart failure. Despite considerable advances in its management, the gold standard for the treatment of end-stage heart failure patients remains heart transplantation. Nevertheless, this procedure can be offered only to a small percentage of patients who could benefit from a new heart due to the limited availability of donor organs. The aim of this review is to evaluate the safety and efficacy of innovative approaches in the diagnosis and treatment of patients refractory to standard medical therapy and excluded from cardiac transplantation lists.

Multi Versus Single Arterial Coronary Bypass Graft Surgery Across the Ejection Fraction Spectrum

BACKGROUND

Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF).

METHODS

We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons.

RESULTS

Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results.

CONCLUSIONS

MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction.

Coronary Bypass Surgery in Patients with Pulmonary Hypertension: Assessment of Early and Long Term Results

PURPOSE

We aimed to evaluate the effects of preoperative pulmonary hypertension (PH) on early and long term results in patients undergoing coronary bypass surgery and the effects of coronary bypass surgery on PH.

METHODS

Among 2325 patients who underwent elective isolated coronary artery bypass surgery between March 2003 and March 2012, 287 patients with high preoperative pulmonary arterial pressure (PAP) ≥30 mmHg were examined. Patients' data were obtained by retrospective examination of our clinic's database. 69 patients who had complete parameters included in the study.

RESULTS

There was no increase in the New York Heart Association (NYHA) functional classification 84% of cases. Preoperative and postoperative values of the mean ejection fraction and mean PAP of patients was respectively 45.28 ± 9.67 (25-65), 46.03 ±12.4 (20-65) (p = 0.447), 36.67 ± 6.81 (30-60) mmHg, 37.81 ± 10.07 (20-70) mmHg (p = 0.378). The late mortality of cases was 5.79%. In our study, during 33.9 ± 17 (9-100) months follow up period, life expectancy was calculated as 94.7 months.

CONCLUSION

Preoperative evaluation of these patients for appropriate medical treatment at peroperative and postoperative period, coronary bypass can be performed with low morbidity and mortality rates. In the late period after surgical revascularization PH showed no significant change and had no adverse effect on quality of life.

Long-term outcomes after off-pump coronary artery bypass grafting in left ventricular dysfunction

PURPOSE

We assessed the long-term clinical, angiographic, and echocardiographic outcomes of patients with left ventricular dysfunction (ejection fraction ≤40%) who underwent isolated off-pump coronary artery bypass grafting.

METHODS

One hundred sixty one patients were included. Mean age was 67.2 ± 11.4 years, and 20 patients (12.4%) were female. Eighty-eight patients (54.7%) were New York Heart Association functional class 3 or 4. Early postoperative and follow-up angiography and echocardiography findings were analyzed, and mid-term survival rates (mean follow-up 40.7 ± 25.6 months) were calculated.

RESULTS

Mean number of distal anastomoses was 4.4 ± 1.3. Bilateral internal thoracic artery grafts were used in 84.5% of patients. Operative mortality was 2.5%. Early patency rate of anastomoses was 98.3%. Early postoperative ejection fraction improved from 33.1 ± 5.6% preoperatively to 36.9 ± 9.5% (p <0.001). Seven-year survival rate was 73.9 ± 5.3%, and freedom from cardiac events rate was 68.5 ± 5.2%. One-year patency rate of anastomoses was 85.8%. Follow-up ejection fraction was 39.1 ± 10.7% (p <0.001).

CONCLUSIONS

Early and long-term outcomes of off-pump coronary artery bypass grafting in patients with left ventricular dysfunction were favorable, including early postoperative and follow-up patency rates of anastomoses and echocardiographic recovery of ejection fraction.

[Results of coronary artery bypass grafting with left ventricular dysfunction (comparison of off-pump versus on-pump)]

BACKGROUND

The aim of this study was to compare the results of myocardial revascularisation with or without cardiopulmonary bypass in patients with impaired left ventricular function.

PATIENTS AND METHODS

Five hundred and sixteen consecutive patients who underwent coronary artery bypass grafting from January 2000 through December 2007 were analyzed retrospectively. One hundred and eight cases had a left ventricular EF (ejection fraction) of 45% or less. Of these patients, 78 underwent conventional coronary artery bypass (CCABG) and 30 underwent off-pump procedure (OCABG). The CCABG group received 300IU/kg of heparin while the OCABG received 100IU/kg. The off-pump coronary surgery was carried out using a tissue stabilizer Octopus II. Different pre-, per- and postoperative variables were evaluated among both groups. Statistical analysis was performed by SPSS 11.5. The variables were compared between these two groups using univariate analysis (Chi(2) test, Fisher's test exact) for qualitative variable and (Student's t test, Mann-Whitney's test) for quantitative variable.

RESULTS

Patients profiles and risk factors were similar among both groups except for age (CCABG: 57.8±9.2 year vs OCABG: 52±9.9 year; P=0.004) and left ventricular EF (CCABG: 37.4±6.3% vs OCABG: 34±7.8%; P=0.02). The number of grafts performed per patient was significantly more among patients who underwent extracorporeal circulation (CCABG: 2.53±0.7 graft/patient vs OCABG: 1.77±0.8 graft/patient; P<0.0001). The hospital mortality was more among CCABG group 9% vs 3.3% in OCABG but the difference was not significant (P=0.3). However, the operative time and the operative room stay were long in CCABG (252±61min vs 175±38min; P<0.0001 - 389±70min vs 298±54min; P<0.0001). The ventilation time was also long in CCABG (32.3±67hour vs 10.4±5.9hour; P=0.15). There was more postoperative myocardial infarction in CCABG (P=0.008), but the EF increased and was better in CCABG.

CONCLUSION

Off-pump coronary artery bypass surgery provides satisfactory operative results for most patients with reduced left ventricular function. Prospective and randomly study will be necessary before concluding.

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up

OBJECTIVE

Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied.

METHODS

Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm.

RESULTS

There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001).

CONCLUSIONS

Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

Surgical Therapy of End-Stage Heart Failure: Understanding Cell-Mediated Mechanisms Interacting with Myocardial Damage

Worldwide, cardiovascular disease results in an estimated 14.3 million deaths per year, giving rise to an increased demand for alternative and advanced treatment. Current approaches include medical management, cardiac transplantation, device therapy, and, most recently, stem cell therapy. Research into cell-based therapies has shown this option to be a promising alternative to the conventional methods. In contrast to early trials, modern approaches now attempt to isolate specific stem cells, as well as increase their numbers by means of amplifying in a culture environment. The method of delivery has also been improved to minimize the risk of micro-infarcts and embolization, which were often observed after the use of coronary catheterization. The latest approach entails direct, surgical, transepicardial injection of the stem cell mixture, as well as the use of tissue-engineered meshes consisting of embedded progenitor cells.

Do Patients in Congestive Cardiac Failure Undergoing Cardiac Surgery Demonstrate Worse Outcomes Compared with Those with a History of Cardiac Failure?

<p><b>Objectives:</b> Cardiac surgery in patients with symptoms of congestive cardiac failure (CCF) carries a significant risk of mortality and morbidity. Except for emergencies and in unstable cases, the recommendation has been to delay the operation until the patient is fully recovered. The objective of this study was to determine the consequences of cardiac surgery in patients with acute decompensated heart failure and to compare their outcomes with the results of the operation in patients with previous CCF.</p><p><b>Methods:</b> We compared the outcomes of patients with CCF (n = 707) at the time of cardiac surgery (valve replacement or coronary artery bypass grafting [CABG]) with those with a history of CCF (n = 1583). The EuroSCORE was significantly higher in CCF patients (<i>P</i> < .001). Impaired renal function was also more commonly observed in patients with CCF (<i>P</i> < .001). After adjusting for preoperative characteristics, we compared the 2 groups with respect to postoperative complications, postoperative creatine kinase MB values, and in-hospital mortality.</p><p><b>Results:</b> Before adjusting for preoperative characteristics, we found that in-hospital mortality (15.5%) and postoperative complications, such as arrhythmias (31%), renal failure (19%), stroke (4.7%), and myocardial infarction (MI) (3%), were significantly higher in the CCF group than in those with a previous history of CCF. When the patients were matched for preoperative characteristics, the rates of postoperative MI and arrhythmia were the main complications that were significantly higher in the CCF group, compared with the patients with previous CCF. The 2 groups were not significantly different with respect to in-hospital mortality. The results were not affected by the type of procedure (valve or CABG), and the main factor influencing mortality was the EuroSCORE.</p><p><b>Conclusion:</b> Despite the significant risk of mortality and morbidity in patients with current CCF, cardiac surgery to reverse the cause should not be delayed in these patients, because doing so may lead to further deterioration. Other risk factors, however, should be taken into consideration on an individual basis.</p>

Revascularization among patients with severe left ventricular dysfunction: a meta-analysis of observational studies

AIMS

Coronary artery bypass graft (CABG) surgery is the standard of care for the management of patients with severe three-vessel and left main coronary artery disease (CAD). However, the optimal strategy for management of patients with CAD and severe left ventricular (LV) dysfunction [ejection fraction (EF) ≤35%] is not clear. A meta-analysis of observational studies was performed to determine the operative mortality and long-term (5-year actuarial survival) outcomes among patients with severe LV dysfunction undergoing CABG.

METHODS AND RESULTS

A systematic computerized literature search was performed and observational studies consisting of patients undergoing isolated CABG for CAD and severe LV dysfunction were included. Studies that did not report operative mortality, long-term (≥1 year) survival data, or pre-operative EF and multiple studies from the same group were excluded. In total, 4119 patients from 26 observational clinical studies were included. The estimated mean age was 63.9 years and 82.4% of patients were men. The mean (estimate) pre-operative EF was 24.7% (95% CI 22.5-27.0%). The operative mortality among patients (26 studies, n= 3621) who underwent on-pump CABG was 5.4%, n= 189 (95% CI 4.5-6.4%). The 5-year actuarial survival among patients (13 studies, n= 1980) who underwent on-pump CABG was 73.4%, n= 1483 (95% CI 68.7-77.7%). Patients who underwent off-pump CABG (7 studies, n= 498) tended to have reduced operative mortality of 4.4%, n= 20 (95% CI 2.8-6.4%). The mean (estimate) post-operative EF was 35.19% (95% CI 31.95-38.43%).

CONCLUSION

The present meta-analysis demonstrates that based on data from available observational clinical studies, CABG can be performed with acceptable operative mortality and 5-year actuarial survival in patients with severe LV dysfunction.

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction: Is There a Long-Term Survival Advantage?

Objective

Long-term survival after off-pump surgery in patients with low ejection fraction was investigated.

Methods

Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery.

Results

The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients.

Conclusions

OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.

Long-term outcome of coronary artery bypass grafting in patients with left ventricular dysfunction

BACKGROUND

Coronary artery bypass grafting (CABG) is a well-accepted therapeutic strategy for patients with multivessel coronary artery disease and left ventricular dysfunction. The aim of the study was to evaluate long-term results after CABG in patients with preoperative left ventricular ejection fraction (LVEF) of 0.35 or less.

METHODS

Data from 302 consecutive patients (mean age, 62 +/- 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome.

RESULTS

Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% +/- 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% +/- 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 +/- 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 +/- 0.09 versus 0.28 +/- 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% +/- 3%.

CONCLUSIONS

Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.

Surgical coronary revascularization in severe left ventricular dysfunction

Surgical revascularization in patients with coronary artery disease and severe left ventricular dysfunction is a common practice and poses a surgical challenge. From September 2002 to May 2004, 50 patients (47 men and 3 women; mean age, 59 +/- 9 years) with a mean preoperative ejection fraction of 19.7% +/- 3.2% underwent surgical revascularization. The mean EuroSCORE was 7.2 +/- 3.4. Indications for surgery were congestive heart failure in 8 patients (16%), angina in 20 (40%), ventricular arrhythmias in 4 (8%), and critical left main stem disease in 12 (24%). Twenty-two patients (44%) had emergency surgery for critical anatomy and unstable symptoms. The number of grafts per patient was 3.7 +/- 0.8. Seventeen patients (34%) required intra-aortic balloon pump support, 16 (32%) needed pacing, and 48 (96%) had inotropic support postoperatively. Morbidity included re-operation for bleeding (2%), acute renal failure (10%), hemodialysis (4%), and fatal multiorgan failure (4%). Postoperative (4.9 +/- 3.7 months) 2-dimentional echocardiography was available in 18 patients of whom 11 (61%) showed improved left ventricular function (range, 5% to 45%). Thirty-day hospital mortality was 8%. These data indicate that surgical revascularization can be performed safely with acceptable hospital mortality in high-risk patients with severe left ventricular dysfunction.

Clinical results of coronary revascularization in left ventricular dysfunction

BACKGROUND

In the present study 15 years of experience with surgical coronary artery bypass grafting (CABG) in patients with left ventricular (LV) dysfunction were retrospectively analyzed.

METHODS AND RESULTS

Between August 1990 and May 2005, a total of 120 patients with severe LV dysfunction (LV ejection fraction (EF)<or=30%) caused by coronary artery disease underwent CABG (mean age 60.3 years, 94 males) Among the 120 patients, 102 had 3-vessel or left main disease. Mean LVEF was 23.5%, and 75% of patients were New York Heart Association functional class III or IV. CABG was performed in all patients with a mean of 2.9 distal grafts/patient. There were 13 hospital deaths (11%). Mean LVEF improved to 32% postoperatively, and further improved to 39% at a mean follow-up of 57.6 months (p<0.05). During the follow-up period, 2 cardiac-related deaths occurred. Kaplan-Meier survival rates at 1, 5 and 10 years were 87.7%, 80.9%, and 44.4%, respectively, and respective freedom from cardiac-related event rates were 96.5%, 90.3% and 63.5%.

CONCLUSIONS

CABG in patients with severe LV dysfunction provides optimal survival with an improved EF and functional state, and may provide a good alternative to transplantation in selected patients.

Long-term survival and functional recovery after isolated coronary artery bypass grafting in patients with severe left ventricular dysfunction

OBJECTIVE

Coronary artery bypass grafting (CABG) in patients with left ventricular dysfunction has been considered to be a challenging operation. We assessed the early angiographic and long-term clinical and functional outcomes of patients with poor left ventricular function who underwent isolated CABG.

METHODS

We retrospectively reviewed the records of 78 patients with a poor left ventricular ejection fraction (35% or less) who underwent isolated CABG between January 1991 and November 2006. The mean age of the patients was 66.1+/-9.4 years, and their mean New York Heart Association functional class was 3.1+/-0.8. Their mean end-diastolic left ventricular diameter was 57.4+/-8.1 mm, and their mean grade of mitral regurgitation was 0.7+/-1.0. Early postoperative angiograms were performed at 32.5+/-33.5 days after the operation. Interval echocardiographic data were analyzed, and the long-term survival rate was evaluated.

RESULTS

The average number of distal anastomoses per patient was 3.2 +/-1.1. The operative mortality rate was 7.7%. Stroke occurred in 1.3% of patients. The overall patency rates for arterial and venous grafts were 100% and 97.2%, respectively. The left ventricular ejection fraction significantly improved from 28.2%+/-5.1% to 34.4%+/-8.4%. Both the end-diastolic and end-systolic left ventricular dimensions significantly decreased from 57.4+/-8.1 to 55.1+/-8.8 mm and from 47.4+/-8.4 to 45.1+/-9.7, re spectively. The actuarial patient survival rate at 10 years was 73.1%.

CONCLUSION

CABG in patients with left ventricular dysfunction was effective, with favorable early graft patency rates. The long-term outcome was also acceptable, with echocardiographic functional recovery.

Revascularization in Heart Failure: Coronary Bypass or Percutaneous Coronary Intervention?

Coronary artery disease (CAD) is the most common cause of heart failure in Western countries. Selected patients who have low left ventricular ejection fraction (LVEF) and CAD clearly benefit from coronary revascularization with coronary artery bypass grafting (CABG). CABG results seem to be superior to percutaneous coronary intervention (PCI) in the few comparative studies of the two approaches in patients who have CAD and low LVEF completed to date. Clinical improvement should be expected in most patients who undergo CABG. This is important for patients who have a limited life span that they could spend with a good functional status rather than being hospitalized for multiple repeat PCIs or symptomatic deterioration.

Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction-Early and Mid-Term Outcomes

BACKGROUND

The prevalence of patients with severe left ventricular dysfunction (LVD) referred for coronary artery bypass grafting (CABG) is increasing. The aim of the present study was to assess the outcomes of patients with severe LVD undergoing CABG.

METHODS

Outcomes of 115 consecutive patients with severe LVD (left ventricular ejection fraction [LVEF]</= 30%, mean 22 +/- 6%) undergoing isolated CABG between 1995 and 2000 were compared to 2335 patients with LVEF >30% (HEF). To further evaluate the LVD patients, they were divided into three subgroups base on LVEF: 0% to 10%, 11% to 20%, and 21% to 30%. Data were collected prospectively and entered into the departmental database of the Society of Thoracic Surgeons.

RESULTS

Patients in the LVD group had increased incidence of diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, prior myocardial infarction (MI), congestive heart failure, and less elective procedures compared to the HEF group. Despite this greater risk profile, operative mortality (LVD 2.6% vs. HEF 1.2%, p = 0.19), the incidence of stroke (2.6% vs. 1.0%, p = 0.13), and perioperative MI (0.9% vs. 0.7%) were not statistically different between the groups. The incidence of respiratory (14.8% vs. 1.9%, p < 0.001), renal (5.2% vs. 1.0%, p < 0.001), and vascular (5.2% vs. 0.5%, p < 0.001) complications was significantly higher in the LVD group, resulting in a longer hospital length of stay (8 +/- 8 vs. 6 +/- 4 days, p < 0.0001). In a multivariate analysis, advanced age was as an independent predictor of hospital mortality. Average follow-up in 108 (94%) LVD patients was 36 +/- 22 months (range 2 to 78 months). Twenty-one patients expired during the follow-up, for nine the causes were cardiac-related. Three- and 5-year survival rates were 91 +/- 3% and 76 +/- 6%, respectively. Independent predictors of mid-term mortality in the LVD group by a multivariate analysis included female gender, renal failure, respiratory complications, and grade I/II mitral regurgitation (MR). At the time of follow-up, 72% of LVD patients were in functional class I/II. There were no statistically significant differences in short- and mid-term outcomes among the LVD subgroups.

CONCLUSION

CABG in patients with severe LVD can be performed with a low mortality, albeit with higher morbidity and longer length of hospital stay, than patients with LVEF >30%. Low ejection fraction per se was not a predictor of hospital mortality. CABG should be considered a safe and effective therapy for low ejection fraction patients with ischemic heart disease. Mitral valve repair/replacement in the presence of moderate degree of MR should be considered at the time of the initial operation.

[Surgical revascularisation of the heart in patients with chronic ischaemic cardiomyopathy and leftventricular ejection fraction of less than 30%]

INTRODUCTION

Patients suffering from chronic ischaemic cardiomyopathy and left ventricular ejection fraction (LVEF) lower than 30% represent a difficult and controversial population for surgical treatment.

OBJECTIVE

The aim of this study was to evaluate the effects of surgical treatment on the early and long-term outcome of these patients.

METHOD

The patient population comprised 50 patients with LVEF < 30% (78% male, mean age: 58.3 years, range: 42-75 years) who underwent surgical myocardial revascularisation during the period 1995-2000. Patients with left ventricular aneurysms or mitral valve insufficiency were excluded from the study. The following echocardiography parameters were evaluated as possible prognostic indicators: LVEF, fraction of shortening (FS), left ventricular systolic and diastolic diameters (LVEDD, LVESD) and volumes (LVEDV, LVESV), as well as their indexed values (LVESVI).

RESULTS

Fifteen patients (30%) died during the follow-up, 2/50 intraoperatively (4%). The presence of diabetes mellitus, previous myocardial infarction, main left coronary artery disease, and three-vessel disease, correlated significantly with the surgical outcomes. The patient's age, family history, smoking habits, hypertension, hyperlipidaemia, history of stroke, peripheral vascular disease, and renal failure, did not correlate with the mortality rate. A comparison of preoperative echocardiography parameters between survivors and non-survivors revealed significantly divergent LVEF, LVEDD, LVESD, LVEDV, LVESV, and LVESVI values. Preoperative LVESVI offered the highest predictive value (R = 0.595).

CONCLUSION

Diabetes mellitus, history of myocardial infarction, stenosis of the main branch, and three-vessel disease, significantly affected the perioperative and long-term outcome of surgical revascularisation in patients with ischaemic cardiomyopathy and LVEF < 30%. In survivors, LVEF, FS, and systolic and diastolic echocardiography parameters, as well as their indexed values, significantly improved after surgical revascularisation. LVESVI provided the highest predictive value for mortality.

Coronary artery bypass grafting in patients with low ejection fraction

BACKGROUND

Patients with low ejection fraction (EF) are at a higher risk for postoperative complications and mortality. Our objective was to assess the effect of low EF on clinical outcomes after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

We analyzed 55,515 patients from New York State database who underwent CABG between 1997 and 1999. Patients were stratified into 1 of the 4 EF groups: Group I (EF< or =20%), Group II (EF 21% to 30%), Group III (EF 31% to 40%), and Group IV (EF>40%). History of previous myocardial infarction, renal failure, and congestive heart failure were higher in patients with low EF (all P<0.001). Group I experienced a higher incidence of postoperative respiratory failure (10.1% versus 2.9%), renal failure (2.5% versus 0.6%), and sepsis (2.5% versus 0.6%) compared with Group IV. In-hospital mortality was significantly higher in Group I (6.5% versus 1.4%; P<0.001). Multivariate analysis showed hepatic failure [odds ratio (OR), 11.2], renal failure (OR, 4.1), previous myocardial infarction (OR, 3.4), reoperation (OR, 3.4), emergent procedures (OR, 3.2), female gender (OR, 1.7), congestive heart failure (OR, 1.6), and age (OR, 1.04) as independent predictors of in-hospital mortality in the low EF group. The discharges to home rate were significantly lower in Group I versus Group IV (73.1% and 87.7%, respectively; P<0.001).

CONCLUSIONS

Patients with low EF are sicker at baseline and have >4 times higher mortality than patients with high EF. However, outcomes are improving over time and are superior to historical data. Therefore, CABG remains a viable option in selected patients with low EF.

Dissociation Between Improvement in Left Ventricular Performance and Functional Class in Patients With Chronic Heart Failure

Resting left ventricular ejection fraction (LVEF) and functional capacity do not correlate in chronic heart failure patients treated with digitalis, diuretics, and angiotensin-converting enzyme inhibitors. We sought to determine whether substantial improvement in LVEF, as may occur during long-term beta-blockade or after coronary artery bypass graft (CABG) surgery, leads consistently to improvement in functional class. Doppler echocardiogram and assessment of functional class were obtained at baseline and 12 months after initiation of beta-blockade (87 patients) or CABG surgery (51 patients). At 12 months the effects of beta-blockade were variable: LVEF increased greatly by >or=11% (median value) in 45 patients (52%) and by <11% in 19 (22%), but it decreased or remained unchanged in 23 patients (26%). In contrast, functional class was unchanged or worsened in 59 patients (68%) and improved in only 28 (32%). Similarly, surgery had variable effects on LVEF. LVEF increased by >or=12% (median) in 28 patients (55%) and by <12% in 14 (27%), whereas it decreased or remained unchanged in 9 patients (18%). Functional class was unchanged or worsened in 41 patients (80%) and improved in only 10 (20%). Changes in functional class and LVEF were unrelated for both interventions. Both beta-blockade and CABG surgery improve LVEF in the majority of patients. However, significant improvement in LVEF does not enhance functional capacity consistently in chronic heart failure.

Surgical therapies for heart failure

A variety of invasive procedures have been utilized to reduce the burden on the left ventricle in order to slow or reverse the progressive changes of structural remodeling. These include mitral valve repair, left ventricular assist devices, left ventricular chamber reduction surgery, endovascular patchplasty, dynamic cardiomyoplasty, and a variety of prosthetic implants designed to inhibit remodeling either by constraining chamber enlargement or reducing wall stress to inhibit further growth. Resynchronization therapy also may favorably affect remodeling. The potential of these procedures to slow the progression of heart failure needs to be confirmed in prospective studies.

[Prognosis scores to help revascularization for ischemic heart failure]

AIMS

Patients suffering from coronary heart disease with ventricular systolic dysfunction present a bad prognosis and should be potentially revascularized. Up to now, surgery appeared to be the most feasible revascularization technique for such patients. Aims of this study were to assess the influence of different treatments (surgery, angioplasty or exclusively medical treatment) on clinical outcome and to establish a prognostic score practitioners to select the most appropriate therapy adapted to their patient profiles.

METHOD

From 1995 to 2000, 492 patients were included in this cohort: 365 in the angioplasty group, 96 in the surgical group and 31 in the medical group. Kaplan Meier curves were made with a multivariate analysis to determine the significant predictive factors of mortality and major adverse cardiac events.

RESULTS

After a mean follow-up of 32 +/- 19 months, there was no statistical difference in mortality rate between the groups. However, the survival rate without MACE is higher in the surgical group, intermediate in the angioplasty group and lower in the medical group. Using the significant predictive factors of MACE in multivariate analysis, a prognostic score has been established in order to discriminate three categories of severity. For each category, angioplasty was compared with surgery in terms of the event-free-survival rate. For the two extreme categories (severe and non-severe), both treatments were equal. For the intermediate category, surgery obtained greater results.

CONCLUSION

This prognostic score could help physicians in choosing the appropriate revascularization technique to treat patients with severe ischemic heart failure.

Incidence of recovery of contractile function following revascularization in patients with ischemic left ventricular dysfunction

Contractile function in patients with ischemic left ventricular (LV) dysfunction may improve after myocardial revascularization. Currently, the incidence of contractile function recovery after revascularization in these patients is unclear. The aim of this study was to assess the incidence of function improvement after myocardial revascularization in patients with ischemic LV dysfunction. A total of 258 consecutive patients (aged 59 +/- 12 years) with severely depressed LV ejection fractions (EFs) due to chronic coronary artery disease and heart failure symptoms were studied. All patients underwent radionuclide ventriculography and 2-dimensional echocardiography at rest before and 3 to 6 months after revascularization. At baseline, 1,330 segments (32%) were normal and 2,775 segments (68%) were dysfunctional. Improvement after revascularization occurred in 736 of the 2,775 dysfunctional segments (27%). Overall, LVEF improved from 29 +/- 7 to 32 +/- 9 (p <0.0001). A clinically significant improvement of LVEF (>/=5% postrevascularization) was present in 101 patients (39%). Improvement of LVEF after revascularization was frequently observed in patients with a more severely impaired baseline LVEF. At least 3 segments with improvement of function were needed for an improvement of LVEF of >/=5%.

Coronary artery bypass surgery in patients with severe left ventricular dysfunction

OBJECTIVE

The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated.

METHODS

Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7).

RESULTS

Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival.

CONCLUSION

CABG on patients with poor left ventricular function: (1). Can be performed with an acceptable mortality. (2). Mid term results are encouraging. (3). Preoperative IABP support improves the chance of survival.

Surgical therapy in advanced heart failure

Congestive heart failure (CHF) affects about 1% of adults in the United States and is a contributing factor in >250,000 deaths per year. In an increasingly elderly population, the surgical treatment of CHF made great progress during the past 3 decades, consuming enormous health care resources. Heart transplantation is still the most effective therapy for end-stage heart disease, with the 10-year survival rate after transplantation approaching 50%. Efforts to increase the supply of donor organs have failed to improve the shortage, underscoring the crucial need for alternatives to cardiac allotransplantation. Alternative surgical options to end-stage heart transplantation are rapidly evolving. Left ventricular assist devices have been used as a bridge to heart transplantation for patients who otherwise might die awaiting a new heart. There is also continued interest in the use of these devices either to bridge patients to full recovery or to destination therapy, without the need for heart replacement. Left ventricular reconstruction, including the Batista and Dor procedures, along with mitral valve repair, cardiomyoplasty, and extreme coronary artery bypass graft surgery, are now being increasingly performed as alternative options. The history, status, and personal experience of surgical treatment of end-stage heart disease are discussed.

Coronary artery bypass grafting for patients with poor left ventricular function

Patients undergoing isolated first-time elective coronary bypass surgery were classified according to their preoperative ejection fraction: group 1 comprised 131 patients with poor left ventricular function (ejection fraction < 40%); group 2 was 1,496 control patients. The mean number of distal anastomoses was not significantly different in the 2 groups, however, clamp time, pump time, and operative time were longer in group 1. Patient recovery was significantly slower in group 1. Morbidity (14.5% in group 1 versus 7.4% in group 2, p < 0.005) and mortality (2.3% versus 0.1%, p < 0.0001) were higher in group 1. During late follow-up, the 5-year survival rate (70.1% versus 90.5%) and 5-year event-free rate (65.6% versus 81.9%) were significantly inferior in group 1 compared to group 2. The results of bypass surgery in cases of decreased left ventricular function were poor, and such patients need to be carefully followed up.

Prognosis of patients with chronic coronary artery disease and severe left ventricular dysfunction. The importance of myocardial viability

BACKGROUND AND AIM

The choice of optimal treatment strategy in patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction is often difficult. The aim of this study was to compare long-term results of patients with chronic CAD, severe heart failure and a defined scope of myocardial viability treated with coronary revascularization, heart transplantation, or kept on medical therapy.

METHODS

From 1993 to 2000, viability evaluation using low-dose dobutamine echocardiography was performed in 124 patients with CAD and LV ejection fraction <or=30%. The dysfunctional myocardial segments were defined as viable if they exhibited improvement in their thickening at any dose of dobutamine or worsening without initial improvement. The patients were divided into five groups and followed up for a mean period of 27+/-23 months. Group A consisted of 39 patients with viability (at least two dysfunctional but viable segments) who were revascularized. Group B consisted of 29 patients with viability treated medically. Groups C (n=23) and D (n=22) comprised patients with non-viable dysfunctional myocardial segments who were revascularized or kept on medical therapy, respectively. Eleven patients referred for heart transplantation after dobutamine echocardiography and 62 patients with ischemic cardiomyopathy transplanted in the same time interval were included in the group of transplanted patients (Group E).

RESULTS

The Kaplan-Meier survival analysis demonstrated a significantly better survival of group A patients as compared with group B patients (P<0.05). The prognostic benefit of revascularization in patients with viability was not manifested until 3 years after the procedure. At 5 years, survival in groups A, B, C, D and E was 89, 60, 67, 50 and 78%, respectively.

CONCLUSION

In patients with CAD, severe LV dysfunction, and the evidence of viability in dysfunctional myocardium, coronary revascularization improves survival. At least 3-years follow-up is necessary to objectively assess the prognostic effect of coronary revascularization.

Evolving strategies for surgical management of patients with severe left ventricular dysfunction

As a result of an increasing population with advanced congestive heart failure and the lack of growth in cardiac transplantation, surgical treatments for heart failure have been re-examined. These therapies represent the evolution of well-known operations such as coronary bypass surgery and valve surgeries, and the more novel left ventricular reconstruction and operations aimed at inhibiting left ventricular remodeling. When performed by surgeons with experience in this evolving speciality within cardiovascular surgery, surgery for advanced heart failure is a treatment of choice for many patients.

Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation

BACKGROUND

Whether or not to perform adjunctive mitral repair in patients undergoing coronary artery bypass grafting (CABG) for advanced ischemic cardiomyopathy with moderately severe mitral regurgitation (MR) remains controversial.

METHODS

We examine the clinical and echocardiographic outcome after isolated CABG in 49 patients with ischemic cardiomyopathy and 1+ to 3+ MR undergoing surgical revascularization. The patients were identified for analysis of mitral valve-related issues from a larger series of 183 patients with ischemic cardiomyopathy (MUGA ejection fraction < or = 30%) undergoing CABG by a single surgeon from 1986 to 1996. Patient age was 66.3 years (mean, range 45 to 83 years). There were 5 women (10.2%) and 44 men (89.8%). Mean ejection fraction was 22.4% with a range of 10% to 30%. Thirty-four patients had preoperative congestive heart failure (70%) and 12 (25%) had pulmonary edema. Number of grafts was 2.8 (mean, range 1 to 5). The MR was 1+ in 18 patients (37.5%), 2+ in 26 (52%) and 3+ in 5 patients (10.5%).

RESULTS

Hospital mortality was 2.0% (1 of 49 patients). Ejection fraction improved from 22.0% to 31.5% (p < 0.05) after CABG. Mean degree of MR improved with CABG alone from 1.73 to 0.54 (p < 0.05) as measured at a mean interval of 36.9 months from CABG. New York Heart-Association congestive heart failure class improved from 3.3 to 1.8 (p < 0.05). Long-term survival was 88%, 65%, and 50% at 1, 3, and 5 years postoperatively. No patient required subsequent mitral valve operation or heart transplantation in long-term follow-up.

CONCLUSIONS

We conclude that, in patients with advanced ischemic cardiomyopathy and mild-to-moderate MR, isolated CABG (without mitral valve, repair) suffices, producing dramatic improvement in ejection fraction, in congestive heart failure, and in degree of MR, with excellent (relative) long-term survival. The improvement in MR likely results from improved left ventricular function and size consequent upon revascularization.

Coronary bypass in left heart failure

Clinical experience is accumulating that coronary artery bypass grafting is of great benefit in patients with advanced ischemic cardiomyopathy. At Yale University, we have analyzed short- and long-term results in 188 consecutive patients with an ejection fraction (EF) of 30% or less undergoing coronary artery bypass grafting by a single surgeon. This experience permits the following conclusions: (1) Surgery can be performed safely (mortality 2.8% in elective patients); (2) Major improvement in left ventricular (LV) function is objectively demonstrable (EF change from 23.3% to 33.2%); (3) Symptomatic improvement is noted by patients (NYHA class change from 3.1 to 1.4); and (4) Good long-term survival is realized, relative to expectations with medical management alone (88%, 77%, and 60% at 1, 3, and 5 years). If coronary artery disease is severe and proximally situated and there are adequate target arteries, we do not deny patients surgery based on EF or LV size criteria, nor do we require objective demonstration of reversible ischemia. In fact, hearts in the largest size range (left ventricular end-systolic volume index > 100 mL) actually showed beneficial reverse remodeling subsequent to coronary artery bypass grafting. Surgical revascularization is recommended strongly for patients with advanced ischemic cardiomyopathy. Results rival those of transplantation.

Influence of wall motion score on mortality after coronary bypass surgery in the CABG-patch trial

BACKGROUND

It was hypothesized that a wall motion score (WMS) of <or=16% determined by chordal analysis (WMS=% of chords analyzed with normal or hyperkinetic motion) from a right anterior oblique (RAO) left ventriculogram would be a predictor for perioperative (30-day or in-hospital) or long-term mortality in patients from the CABG-Patch Trial.

METHODS AND RESULTS

One hundred and eighty-nine patients from the trial with a LVEF of <or=36% were retrospectively studied. Patients were divided into two groups according to a WMS of <or=16% (n=81) or >16% (n=108), respectively, calculated from a preoperative RAO ventriculogram. There was no difference in EF between the two groups (26.5+/-5.5 vs. 27.8+/-5.3%, respectively). Eight (9.9%) versus three (2.8%) patients died perioperatively in the low versus the high WMS group, respectively. The relative risk for perioperative death in the low WMS group was 3.6 (P<0.04). Kaplan-Meier estimates of cumulative survival did not reveal any statistical difference between the two groups over 4 years (P=0.11). Subgroup analysis revealed that patients with a WMS of <or=16% had a better survival when treated with an ICD at the time of surgery compared to those not treated with an ICD (P=0.046).

CONCLUSIONS

These data indicate that poor LV function, as assessed by a WMS of <or=16%, can identify a subgroup of low EF patients who are at increased risk for perioperative mortality after bypass surgery. Conversely, long-term estimates of survival in patients with WMS <or=16 and >16% were not significantly different, although subgroup analysis revealed that patients with a WMS <or=16% may benefit from implantation of an ICD at the time of surgery.