title: Early risk of mortality after coronary artery revascularization in patients with left ventricular dysfunction and potential role of the wearable cardioverter defibrillator.
abstract: BACKGROUND
  Implantation of implantable cardioverter defibrillator for prevention of sudden cardiac death is deferred for 90 days after coronary revascularization, but mortality may be highest early after cardiac procedures in patients with ventricular dysfunction. We determined mortality risk in postrevascularization patients with left ventricular ejection fraction ≤35% and compared survival with those discharged with a wearable cardioverter defibrillator (WCD).
  
  
  RESULTS
  Hospital survivors after surgical (coronary artery bypass graft surgery) or percutaneous (percutaneous coronary intervention [PCI]) revascularization with left ventricular ejection fraction ≤35% were included from Cleveland Clinic and national WCD registries. Kaplan-Meier, Cox proportional hazards, propensity score-matched survival, and hazard function analyses were performed. Early mortality hazard was higher among 4149 patients discharged without a defibrillator compared with 809 with WCDs (90-day mortality post-coronary artery bypass graft surgery 7% versus 3%, P=0.03; post-PCI 10% versus 2%, P<0.0001). WCD use was associated with adjusted lower risks of long-term mortality in the total cohort (39%, P<0.0001) and both post-coronary artery bypass graft surgery (38%, P=0.048) and post-PCI (57%, P<0.0001) cohorts (mean follow-up, 3.2 years). In propensity-matched analyses, WCD use remained associated with lower mortality (58% post-coronary artery bypass graft surgery, P=0.002; 67% post-PCI, P<0.0001). Mortality differences were not attributable solely to therapies for ventricular arrhythmia. Only 1.3% of the WCD group had a documented appropriate therapy.
  
  
  CONCLUSIONS
  Patients with left ventricular ejection fraction ≤35% have higher early compared to late mortality after coronary revascularization, particularly after PCI. As early hazard seemed less marked in WCD users, prospective studies in this high-risk population are indicated to confirm whether WCD use as a bridge to left ventricular ejection fraction improvement or implantable cardioverter defibrillator implantation can improve outcomes after coronary revascularization.
authors.affiliation: Departments of Cardiovascular Medicine, Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
authors.forename: Edwin T
authors.initials: ET
authors.lastname: Zishiri
authors.forename: Sarah
authors.initials: S
authors.lastname: Williams
authors.forename: Edmond M
authors.initials: EM
authors.lastname: Cronin
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Ellis
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.forename: Jo Ann
authors.initials: JA
authors.lastname: Glad
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Tchou
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Szymkiewicz
authors.forename: Mina K
authors.initials: MK
authors.lastname: Chung
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality*; D003324:Coronary Artery Disease / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D047548:Defibrillators; D004554:Electric Countershock / Q000295:instrumentation*; D004867:Equipment Design; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality*; D057216:Propensity Score; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000401:mortality* / Q000503:physiopathology; D016277:Ventricular Function, Left