Results of revascularization in patients with severe left ventricular dysfunction.
BACKGROUND
In patients with coronary artery disease and poor ventricular function (ejection fraction, < 20%), bypass grafting remains a surgical challenge. This study evaluates experience with isolated revascularization in such patients.


RESULTS
In 79 consecutive patients (69 men, 10 women; average age, 59 +/- 9 years), preoperative ejection fraction was 18 +/- 5%. Indications for surgery were congestive heart failure (CHF) in 5 of 79 patients (6%), CHF and angina in 19 (24%), angina in 41 (52%), ventricular arrhythmias (VAs) in 8 (10%), and critical anatomy in 6 (8%). Some patients had prior VAs (23 of 79; 29%) or mitral regurgitation (18; 23%) and required emergent surgery (25; 32%). At surgery, temperature mapping ensured adequate distribution of antegrade cold cardioplegia, with 3.6 +/- 0.7 grafts per patient, including left internal mammary artery graft in 60 of 79 (76%) and endarterectomy in 14 (18%). Hospital mortality was 3.8%. Perioperative support included intra-aortic balloon pump in 18 of 79 (23%) and drugs for VAs in 28 (35%). Morbidity included myocardial infarction in 2 of 79 (2.5%) and stroke in 2 (2.5%). During follow-up, there were 19 late deaths. Actuarial survival was 94%, 82%, and 68% at 1, 2, and 5 years, respectively, and was similar in patients with severe angina, CHF, mitral regurgitation, or VAs. Freedom from sudden death was 100%, 98%, and 91% at 1, 2, and 5 years, respectively. Among survivors, angina improved in 84% and heart failure improved in 26%.


CONCLUSIONS
These data support bypass graft surgery in patients with severe LV dysfunction. With careful cardioplegic techniques, hospital mortality was low (3.8%). Long-term survival is encouraging, with good relief of symptoms in most patients. Perioperative VAs are frequent but respond to medical treatment, with only 23% of patients discharged on antiarrhythmic drugs. Five-year freedom from sudden death is 91%, with only 3 late sudden deaths in this series.
Mickleborough
L L
LL
Department of Surgery, University of Toronto, Ontario, Canada.
Maruyama
H
H
Takagi
Y
Y
Mohamed
S
S
Sun
Z
Z
Ebisuzaki
L
L
D000206:Actuarial Analysis; D000368:Aged; D000787:Angina Pectoris / Q000503:physiopathology / Q000601:surgery; D001145:Arrhythmias, Cardiac / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006324:Heart Arrest, Induced; D006333:Heart Failure / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology / Q000601:surgery*