Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

Abstract

Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1-51.5], 65.3 (95 % CI 61.4-69.2), and 42.3 % (95 % CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.

Graft Strategy for Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction

“…However, the benefit of bilateral ITA (BITA) grafting has not been well demonstrated in patients with severe LV dysfunction. Most previous studies included patients with moderate LV systolic dysfunction (30%< ejection fraction [EF] ≤40%), whose prognostic characteristics might be quite different from those of patients with an EF of 30% or less [6,10]. In this study, we report 15 years of institutional experience with isolated CABG in patients with severe LV dysfunction (EF ≤30%) and present recommendations on the optimal strategy by analyzing the effects of graft selection and use of the off-pump technique on long-term survival outcomes.…”

The Fate of a Composite Arterial Graft in a 58-Year-Old Man with Strong Comorbidities and Atherosclerotic Burden

“…Besides, no sternal complications occurred after surgery and there were no symptoms of coronary steal despite the presence of a dialysis fistula ipsilateral to the composite in situ ITA graft (albeit it would always be preferable to avoid the use of an in situ ITA graft in the case of an ipsilateral arterovenous fistula due to the risk of myocardial ischemia during hemodialysis) (7). Nevertheless, although there is increasing evidence of long-term survival benefits (1,(3)(4)(5)(6), many surgeons consider the use of both ITAs for myocardial revascularization as a too risky strategy that has to be adopted only for young and low-risk patients (8). Obviously, there are many factors that may affect the graft patency (primarily the coronary run-off), it is not a single (maybe) fortunate clinical case that may change the surgical practice, and the approach that is tailored to the baseline characteristics of each individual patient should always be preferred.…”

“…To perform a left-sided myocardial revascularization, the right ITA was dissected and used as a free graft from the in situ left ITA. Both ITAs were harvested as skeletonized conduits using low-intensity bipolar coagulation forceps (3,4). nally, a saphenous vein graft with the proximal end from the ascending aorta, was adopted to bypass the right posterior descending coronary artery.…”

Predictors and Clinical Impacts of Aggravated Left Ventricular Diastolic Dysfunction After Off-Pump Coronary Artery Bypass Grafting

“…Preoperative PAOD and renal failure were related to a high risk for severe atherosclerotic disease and high rates of comorbidities. 25 These factors might have contributed to aggravated LVDD. Interestingly, the mitral valve A′ velocity in the preoperative echocardiography data was the only parameter to predict aggravation of LVDD.…”