Perioperative changes in left ventricular systolic function following surgical revascularization

Abstract

Background Nearly 1/3rd of patients undergoing coronary artery bypass graft surgery (CABG) have left ventricular systolic dysfunction. However, the extent, direction and implications of perioperative changes in left ventricular ejection fraction (LVEF) have not been well characterized in these patients. Methods We studied the changes in LVEF among 549 patients with left ventricular systolic dysfunction (LVEF <50%) who underwent CABG as part of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Patients had pre- and post-CABG (4 month) LVEF assessments using identical cardiac imaging modality, interpreted at a core laboratory. An absolute change of >10% in LVEF was considered clinically significant. Results Of the 549 patients (mean age 61.4±9.55 years, and 72 [13.1%] women), 145 (26.4%) had a >10% improvement in LVEF, 369 (67.2%) had no change and 35 (6.4%) had >10% worsening of LVEF following CABG. Patients with lower preoperative LVEF were more likely to experience an improvement after CABG (odds ratio 1.36; 95% CI 1.21–1.53; per 5% lower preoperative LVEF; p <0.001). Notably, incidence of postoperative improvement in LVEF was not influenced by presence, nor absence, of myocardial viability (25.5% vs. 28.3% respectively, p = 0.67). After adjusting for age, sex, baseline LVEF, and NYHA Class, a >10% improvement in LVEF after CABG was associated with a 57% lower risk of all-cause mortality (HR: 0.43, 95% CI: 0.26–0.71). Conclusions Among patients with ischemic cardiomyopathy undergoing CABG, 26.4% had >10% improvement in LVEF. An improvement in LVEF was more likely in patients with lower preoperative LVEF and was associated with improved long-term survival.

Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era

“…However, the primary purpose for performing mitral repair along with CABG in patients with functional MR is perioperative hemodynamic stabilization and early symptom improvement 50 . This approach has not been associated with improved long‐term survival, as this is largely driven by the degree of improvement in ventricular function following CABG 50,51 . Furthermore, advanced therapies may have more favorable outcomes for appropriately selected patients 52 .…”

“…50 This approach has not been associated with improved long-term survival, as this is largely driven by the degree of improvement in ventricular function following CABG. 50,51 Furthermore, advanced therapies may have more favorable outcomes for appropriately selected patients. 52 Thus, the decision to proceed with CABG and mitral repair/replacement versus durable LVAD or heart transplant should be made in the context of the patient's overall disease phenotype and projected survival based on available indices of myocardial recoverability.…”