Early Results After Coronary Artery Bypass Grafting in Patients With Severe Ischemic Left Ventricular Dysfunction

Introduction. The number of patients with severe ischemic left ventricular dysfunction (ILVD), who undergo coronary artery bypass, increasing each year. ILVD is an established risk factor for mortality in patients after myocardial revascularization during the early and late postoperative periods.

Aim of study. To evaluate the early results of surgical myocardial revascularization in patients with coronary artery disease (CAD) and severe ILVD.

Material and methods. The study included 149 patients with coronary artery disease with severe left ventricular dysfunction (ejection fraction (EF) ≤39%), operated from January 2002 to December 2018. different variables were assessed (pre- and postoperative), including LV ejection fraction and end systolic volume index (ESVI).

Results. The average age of the patients was 59.36±8.97 years (from 30 to 78 years), 93% of the patients were men. In 28 patients (19%), ILVD developed against the background of myocardial infarction (MI) and in 121 (81%) due to ischemic cardiomyopathy (ICMP) with a history of myocardial infarction. The mean EF before surgery was 36.64±3.17 (from 21 to 39%). In the postoperative period, there was an increase in EF, which averaged 44.92±4.92 (from 36 to 59%) (p value <0.001). The mean LV ESVI before surgery was 60.23±11.52 ml/m². In the immediate postoperative period ESVI decreased to 46.26±12.40 ml/m² (the value of p<0.001). The average number of bypass coronary arteries in one patient was 3.9±0.87. There was also a decrease in the degree of mitral regurgitation in most patients after coronary artery bypass grafting (CABG) (p value <0.001). Hospital mortality was 2% (3 patients).

Conclusion. Coronary artery bypass grafting in patients with severe ischemic left ventricular dysfunction can be performed with low mortality. Surgical myocardial revascularization can be considered a safe and effective operation for patients with coronary artery disease with a satisfactory condition of the distal coronary arteries, low ejection fraction, and with a predominance of viable myocardium.

1. Trachiotis GD, Weintraub WS, Johnston TS, Jones EL, Guyton RA, Craver JM. Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg. 1998;66(5):1632–1639. PMID: 9875763 https://doi.org/10.1016/s0003-4975(98)00773-5

2. Alderman EL, Fisher LD, Litwin P, Kaiser GC, Myers WO, Maynard C, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation. 1983;68(4):785–795. PMID: 6352078 https://doi.org/10.1161/01.cir.68.4.785

3. Bounous EP, Mark DB, Pollock BG, Hlatky MA, Harrell FE, Jr Lee KL, et al. Surgical survival benefits for coronary disease patients with left ventricular dysfunction. Circulation. 1988;78(3Pt 2):1151–1157. PMID: 3261652

4. Dreyfus GD, Duboc D, Blasco A, Vigoni F, Dubois C, Brodaty D, et al. Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization. Ann Thorac Surg. 1994;57(6):1402–1407. PMID:8010780 https://doi.org/10.1016/0003-4975(94)90091-4

5. Hillis GS, Zehr KJ, Williams AW, Schaff HV, Orzulak TA, Daly RC, et al. Outcome of patients with low ejection fraction undergoing coronary artery bypass grafting: renal function and mortality after 3.8 years. Circulation. 2006;114(1Suppl):I414-441. PMID: 16820610 https://doi.org/10.1161/circulationaha.105.000661

6. Shapira OM, Hunter CT, Anter E, Bao Y, DeAndrade K, Lazar HL, et al. Coronary artery bypass grafting in patients with severe left ventricular dysfunction early and mid-term outcomes. J Card Surg. 2006;21(3):225–232. PMID: 16684046 https://doi.org/10.1111/j.1540-8191.2006.00221.x

7. Topkara V, Cheema FH, Kesavaramanujam S, Mercando ML,Cheema AF, Namerow PB, et al. Coronary artery bypass grafting in patients with low ejection fraction. Circulation. 2005;112(9 Suppl):I344–350. PMID: 16159844 https://doi.org/10.1161/CIRCULATIONAHA.104.526277

8. Carr JA, Haithcock BE, Paone G, Bernabei AF, Silverman NA. Long-term outcome after coronary artery bypass grafting in patients with severe left ventricular dysfunction. Ann Thorac Surg. 2002;74(5):1531–1536. PMID:12440604 https://doi.org/10.1016/s0003-4975(02)03944-9

9. O’Connor CM, Velazquez EJ, Gardner LH, Smith PK, Newman MF, Landolfo KP, et al. Comparison of coronary artery bypass grafting versus medical therapy on long term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol. 2002;90(2):101–107. PMID: 12106836 https://doi.org/10.1016/s0002-9149(02)02429-3

10. Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364(17):1607–1616. PMID: 21463150 https://doi.org/10.1056/nejmoa1100356

11. Elefteriades JA, Tolis GJr, Levi E, Mills LK, Zaret BL. Coronaryartery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol. 1993;22(5):1411–1417. PMID: 8227799 https://doi.org/10.1016/07351097(93)90551-b

12. Haxhibeqiri-Karabdic I, Hasanovic A, Kabil E, Straus S. Improvement of ejection fraction after coronary artery bypass grafting surgery in patients with impaired left ventricular function. Med Arch. 2014;68(5):332–334. PMID: 25568566 https://doi.org/10.5455/medarh.2014.68.332-334

13. Lozonschi L, Kohmoto T, Osaki S, De Oliveira NC, Dhingra R, Akhter SA, et al. Coronary bypass in left ventricular dysfunction and differential cardiac recovery. Asian Cardiovasc Thorac Ann. 2017;25(9):586–593. PMID: 29153000 https://doi.org/10.1177/0218492317744472

14. Wang J, Xiao F, Ren J, Li Y, Zhang ML. Risk factors for mortality after coronary artery bypass grafting in patients with low left ventricular ejection fraction. Chin Med J (Engl). 2007;120(4):317–322. PMID: 17374284 https://doi.org/10.1097/00029330-200702020-00012