Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state

Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut.

OBJECTIVES. The present study evaluated our experience with coronary artery bypass grafting in patients with severe left ventricular dysfunction. BACKGROUND. Despite the ominous prognosis of advanced ischemic cardiomyopathy, coronary artery bypass grafting in this setting remains controversial because of concerns over operative risk and lack of functional or survival benefit. METHODS. We analyzed the data of 83 consecutive patients (69 men, 14 women, aged 42 to 83 years [mean 66.8]) with a left ventricular ejection fraction < or = 30% who underwent isolated coronary artery bypass grafting (without aneurysmectomy, valve replacement or other open heart procedures) performed by one surgeon during a 6-year period. The ejection fraction ranged from 10% to 30% (mean 24.6%). Preoperatively, 49% of patients had angina, 52% had congestive heart failure (17% with pulmonary edema) and 30% manifested significant ventricular arrhythmia. The mean number of grafts was 2.7/patient. The internal mammary artery was used in 82% of grafts to the left anterior descending coronary artery. The intraaortic balloon pump was required therapeutically (for angina or pump failure) in 19% of patients and was prophylactically placed preoperatively in another 43% of patients. RESULTS. The hospital mortality rate was 8.4% (7 of 83). The mortality rate was 3.3% (2 of 61) in those patients who did not require admission to an intensive care unit immediately before operation. Canadian Cardiovascular Society angina class improved postoperatively by 1.9 categories and New York Heart Association congestive heart failure class by 1 category. Left ventricular ejection fraction (assessed postoperatively in 68 of 76 hospital survivors) improved from 24.6% preoperatively to 33.2% postoperatively (36% increase) (p < 0.001). At 1 and 3 years, respectively, all-cause survival was 87% and 80% and freedom from cardiac death was 89.8% and 84.5%. CONCLUSIONS. In patients with coronary artery disease and advanced ventricular dysfunction: 1) coronary artery bypass grafting can be performed relatively safely, 2) good medium-term survival is attained, 3) improvement in left ventricular function can be documented objectively after bypass grafting, 4) quality of life is improved (as reflected by improvement in anginal and congestive heart failure status), and 5) the internal mammary artery can safely be used as a conduit. The use of coronary artery bypass grafting is encouraged for this group of patients and may provide a viable alternative to transplantation in selected patients.

This article has been cited by other articles:

				D. D. Potter, P. A. Araoz, K. P. McGee, W. S. Harmsen, J. N. Mandrekar, and T. M. Sundt III Low-dose dobutamine cardiac magnetic resonance imaging with myocardial strain analysis predicts myocardial recoverability after coronary artery bypass grafting. J. Thorac. Cardiovasc. Surg., June 1, 2008; 135(6): 1342 - 1347. [Abstract] [Full Text] [PDF]

				M. A. Soliman Hamad, M. E. S.H. Tan, A. H.M. van Straten, A. A.J. van Zundert, and J. P.A.M. Schonberger Long-Term Results of Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction Ann. Thorac. Surg., February 1, 2008; 85(2): 488 - 493. [Abstract] [Full Text] [PDF]

				M. T. Spoor and S. F. Bolling Nontransplant Surgical Options for Heart Failure Card. Surg. Adult, January 1, 2008; 3(2008): 1639 - 1648. [Full Text]

				D. Kumbasar, O. Akyurek, I. Dincer, Y. Atmaca, M. Kilickap, C. Erol, and D. Oral Good Collaterals Predict Viable Myocardium Angiology, November 1, 2007; 58(5): 550 - 555. [Abstract] [PDF]

				M. Pocar, A. Moneta, A. Grossi, and F. Donatelli Coronary Artery Bypass for Heart Failure in Ischemic Cardiomyopathy: 17-Year Follow-Up Ann. Thorac. Surg., February 1, 2007; 83(2): 468 - 474. [Abstract] [Full Text] [PDF]

				N. Dib, R. E. Michler, F. D. Pagani, S. Wright, D. J. Kereiakes, R. Lengerich, P. Binkley, D. Buchele, I. Anand, C. Swingen, et al. Safety and Feasibility of Autologous Myoblast Transplantation in Patients With Ischemic Cardiomyopathy: Four-Year Follow-Up Circulation, September 20, 2005; 112(12): 1748 - 1755. [Abstract] [Full Text] [PDF]

				Y. J. Woo, T. J. Grand, M. F. Berry, P. Atluri, M. A. Moise, V. M. Hsu, J. Cohen, O. Fisher, J. Burdick, M. Taylor, et al. Stromal cell-derived factor and granulocyte-monocyte colony-stimulating factor form a combined neovasculogenic therapy for ischemic cardiomyopathy J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 321 - 329. [Abstract] [Full Text] [PDF]

				E. E. McCarron, M. J. Shackcloth, A. D. Grayson, and W. C. Dihmis Left internal mammary artery use in patients with poor left ventricular ejection fraction: a propensity-matched analysis of mid-term survival Interactive CardioVascular and Thoracic Surgery, June 1, 2005; 4(3): 184 - 188. [Abstract] [Full Text] [PDF]

				R. Atak, M. Ileri, O. Yetkin, E. Yetkin, H. Turhan, K. Senen, O. Sahin, C. Ozbakir, and D. Demikan The Role of Valvular and Thoracic Aortic Calcifications in Distinction Between Ischemic and Nonischemic Cardiomyopathy Angiology, November 1, 2004; 55(6): 661 - 667. [Abstract] [PDF]

				R. Atak, M. Ileri, O. Yetkin, E. Yetkin, H. Turhan, K. Senen, O. Sahin, C. Ozbakir, and D. Demikan The Role of Valvular and Thoracic Aortic Calcifications in Distinction Between Ischemic and Nonischemic Cardiomyopathy Angiology, November 1, 2004; 55(6): 661 - 667. [Abstract] [PDF]

				J. Appoo, C. Norris, S. Merali, M. M. Graham, A. Koshal, M. L. Knudtson, and W. A. Ghali Long-Term Outcome of Isolated Coronary Artery Bypass Surgery in Patients With Severe Left Ventricular Dysfunction Circulation, September 14, 2004; 110(11_suppl_1): II-13 - II-17. [Abstract] [Full Text] [PDF]

				J J Bax, E E van der Wall, and M Harbinson Radionuclide techniques for the assessment of myocardial viability and hibernation Heart, August 1, 2004; 90(suppl_5): v26 - v33. [Full Text] [PDF]

				A. F. L. Schinkel, D. Poldermans, V. Rizzello, J.-L. J. Vanoverschelde, A. Elhendy, E. Boersma, J. R.T.C. Roelandt, and J. J. Bax Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization? J. Thorac. Cardiovasc. Surg., February 1, 2004; 127(2): 385 - 390. [Abstract] [Full Text] [PDF]

				B. P. Griffith Surgical treatment of congestive heart failure: evolving options Ann. Thorac. Surg., December 1, 2003; 76(6): S2254 - 2259. [Full Text] [PDF]

				P. J. Shah, D. L. Hare, J. S. Raman, I. Gordon, R. K. Chan, J. D. Horowitz, A. Rosalion, and B. F. Buxton Survival after myocardial revascularization for ischemic cardiomyopathy: A prospective ten-year follow-up study J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1320 - 1327. [Abstract] [Full Text] [PDF]

				N. H. Bunce, C. H. Lorenz, A. S. John, J. R. Lesser, R. H. Mohiaddin, and D. J. Pennell Coronary Artery Bypass Graft Patency: Assessment with True Fast Imaging with Steady-State Precession versus Gadolinium-enhanced MR Angiography Radiology, May 1, 2003; 227(2): 440 - 446. [Abstract] [Full Text] [PDF]

				V. Badhwar and S. F. Bolling Nontransplant Surgical Options for Heart Failure Card. Surg. Adult, January 1, 2003; 2(2003): 1515 - 1526. [Full Text]

				G. A. Tolis Jr, D. P. Korkolis, G. S. Kopf, and J. A. Elefteriades Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation Ann. Thorac. Surg., November 1, 2002; 74(5): 1476 - 1481. [Abstract] [Full Text] [PDF]

				A F L Schinkel, J J Bax, F B Sozzi, E Boersma, R Valkema, A Elhendy, J R T C Roelandt, and D Poldermans Prevalence of myocardial viability assessed by single photon emission computed tomography in patients with chronic ischaemic left ventricular dysfunction Heart, August 1, 2002; 88(2): 125 - 130. [Abstract] [Full Text] [PDF]

				R. O. Bonow Myocardial viability and prognosis in patients with ischemic left ventricular dysfunction J. Am. Coll. Cardiol., April 3, 2002; 39(7): 1159 - 1162. [Full Text] [PDF]

				M.C Deng, D.D Ascheim, N.M Edwards, and Y Naka End-stage heart failure: which options? Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D122 - D130. [Abstract] [PDF]

				F. Bouchart, A. Tabley, P.Y. Litzler, C. Haas-Hubscher, J.P. Bessou, and R. Soyer Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients Eur. J. Cardiothorac. Surg., December 1, 2001; 20(6): 1157 - 1162. [Abstract] [Full Text] [PDF]

				B.L Gerber, F.F Ordoubadi, W Wijns, J.-L.J Vanoverschelde, M.J Knuuti, M Janier, P Melon, P.K Blanksma, A Bol, J.J Bax, et al. Positron emission tomography using18F-fluoro-deoxyglucose and euglycaemic hyperinsulinaemic glucose clamp: optimal criteria for the prediction of recovery of post-ischaemic left ventricular dysfunction. Results from the European Community Concerted Action Multicenter study on use of18F-fluoro-deoxyglucose Positron Emission Tomography for the Detection of Myocardial Viability Eur. Heart J., September 2, 2001; 22(18): 1691 - 1701. [Abstract] [PDF]

				J. Narula, M. S. Dawson, B. K. Singh, A. Amanullah, E. R. Acio, F. A. Chaudhry, R. B. Arani, and A. E. Iskandrian Noninvasive characterization of stunned, hibernating, remodeled and nonviable myocardium in ischemic cardiomyopathy J. Am. Coll. Cardiol., November 15, 2000; 36(6): 1913 - 1919. [Abstract] [Full Text] [PDF]

				G. B. Luciani, G. Montalbano, G. Casali, and A. Mazzucco Predicting long-term functional results after myocardial revascularization in ischemic cardiomyopathy J. Thorac. Cardiovasc. Surg., September 1, 2000; 120(3): 478 - 489. [Abstract] [Full Text] [PDF]

				G LaCanna, S.H Rahimtoola, O Visioli, R Giubbini, O Alfieri, M Zognio, E Milan, C Ceconi, M Gargano, R LoRusso, et al. Sensitivity, specificity, and predictive accuracies of non-invasive tests, singly and in combination, for diagnosis of hibernating myocardium Eur. Heart J., August 2, 2000; 21(16): 1358 - 1367. [Abstract] [PDF]

				F.J. Pinto Myocardial viability: the search for a perfect method is not over yet Eur. Heart J., July 1, 2000; 21(13): 1039 - 1040. [PDF]

				A.E Androulakis, G.K Andrikopoulos, D.J Richter, C.A Tentolouris, C.C Avgeropoulou, D.A Adamopoulos, P.K Toutouzas, A.G Trikas, C.I Stefanadis, and J.E Gialafos The role of carotid atherosclerosis in the distinction between ischaemic and non-ischaemic cardiomyopathy Eur. Heart J., June 1, 2000; 21(11): 919 - 926. [Abstract] [PDF]

				A. S. Shah, R. E. Lilly, A. P. Kypson, O. Tai, J. A. Hata, A. Pippen, S. C. Silvestry, R. J. Lefkowitz, D. D. Glower, and W. J. Koch Intracoronary Adenovirus-Mediated Delivery and Overexpression of the {beta}2-Adrenergic Receptor in the Heart : Prospects for Molecular Ventricular Assistance Circulation, February 1, 2000; 101(4): 408 - 414. [Abstract] [Full Text] [PDF]

				I. L. Kron Protection in the failing heart Ann. Thorac. Surg., November 1, 1999; 68(5): 1971 - 1973. [Abstract] [Full Text] [PDF]

				O. Jegaden, L. Bontemps, G. de Gevigney, A. Eker, P. Montagna, C. Chatel, R. Itti, and P. Mikaeloff Does the extended used of arterial grafts compromise the myocardial recovery after coronary artery bypass grafting in left ventricular dysfunction? Eur. J. Cardiothorac. Surg., October 1, 1999; 14(4): 353 - 359. [Abstract] [Full Text] [PDF]

				K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]

				F. A. Chaudhry, J. T. Tauke, R. S. Alessandrini, G. Vardi, M. A. Parker, and R. O. Bonow Prognostic implications of myocardial contractile reserve in patients with coronary artery disease and left ventricular dysfunction J. Am. Coll. Cardiol., September 1, 1999; 34(3): 730 - 738. [Abstract] [Full Text] [PDF]

				I. Afridi, P. A. Grayburn, J. A. Panza, J. K. Oh, W. A. Zoghbi, and T. H. Marwick Myocardial viability during dobutamine echocardiography predicts survival in patients with coronary artery disease and severe left ventricular systolic dysfunction J. Am. Coll. Cardiol., October 1, 1998; 32(4): 921 - 926. [Abstract] [Full Text] [PDF]

				W. T. Abraham Pharmacologic Management of Chronic Heart Failure: A Review Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 1998; 2(3): 168 - 190. [Abstract] [PDF]

				S R Redwood, R Ferrari, and M S Marber Myocardial hibernation and stunning: from physiological principles to clinical practice Heart, September 1, 1998; 80(3): 218 - 222. [Full Text]

				A. N. Kitsiou, G. Srinivasan, A. A. Quyyumi, R. M. Summers, S. L. Bacharach, and V. Dilsizian Stress-Induced Reversible and Mild-to-Moderate Irreversible Thallium Defects : Are They Equally Accurate for Predicting Recovery of Regional Left Ventricular Function After Revascularization? Circulation, August 11, 1998; 98(6): 501 - 508. [Abstract] [Full Text] [PDF]

				A. Yamaguchi, T. Ino, H. Adachi, S. Murata, H. Kamio, M. Okada, and J.-i. Tsuboi Left Ventricular Volume Predicts Postoperative Course in Patients With Ischemic Cardiomyopathy Ann. Thorac. Surg., February 1, 1998; 65(2): 434 - 438. [Abstract] [Full Text] [PDF]

				M. Gheorghiade and R. O. Bonow Chronic Heart Failure in the United States : A Manifestation of Coronary Artery Disease Circulation, January 27, 1998; 97(3): 282 - 289. [Full Text] [PDF]

				H. A. Dakik, J. F. Howell, G. M. Lawrie, R. Espada, D. G. Weilbaecher, Z.-X. He, J. J. Mahmarian, and M. S. Verani Assessment of Myocardial Viability With 99mTc-Sestamibi Tomography Before Coronary Bypass Graft Surgery : Correlation With Histopathology and Postoperative Improvement in Cardiac Function Circulation, November 4, 1997; 96(9): 2892 - 2898. [Abstract] [Full Text]

				G. E. Cimochowski, M. D. Harostock, and P. J. Foldes MINIMAL OPERATIVE MORTALITY IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS WITH SIGNIFICANT LEFT VENTRICULAR DYSFUNCTION BY MAXIMIZATION OF METABOLIC AND MECHANICAL SUPPORT J. Thorac. Cardiovasc. Surg., April 1, 1997; 113(4): 655 - 666. [Abstract] [Full Text]

				R. O. Bonow Identification of Viable Myocardium Circulation, December 1, 1996; 94(11): 2674 - 2680. [Full Text]

				R. W. Emery, N. L. Mills, F. J. Teijeira, K. V. Arom, P. Baldwin, R. J. Petersen, L. D. Joyce, G. L. B. Grinnan, M. S. Sussman, J. G. Copeland III, et al. North American Experience With the Perma-Flow Prosthetic Coronary Graft Ann. Thorac. Surg., September 1, 1996; 62(3): 691 - 695. [Abstract] [Full Text]

				A. S. Wechsler Editorial on "Coronary Artery Bypass Grafting in Patients With an Ejection Fraction of Twenty Percent or Less" J. Thorac. Cardiovasc. Surg., May 1, 1996; 111(5): 998 - 1000. [Full Text]

				R. K. M. Chan, J. Raman, K. J. Lee, A. Rosalion, R. J. Hicks, S. Pornvilawan, B. S. T. Sia, J. D. Horowitz, A. M. Tonkin, and B. F. Buxton Prediction of Outcome After Revascularization in Patients With Poor Left Ventricular Function Ann. Thorac. Surg., May 1, 1996; 61(5): 1428 - 1434. [Abstract] [Full Text]

				H. C. Alhan, H. Karabulut, R. Tosun, F. Karakoc, I. Okar, E. Demiray, S. Tarcan, and B. Yigiter Intermittent Aortic Cross-Clamping and Cold Crystalloid Cardioplegia for Low-Risk Coronary Patients Ann. Thorac. Surg., March 1, 1996; 61(3): 834 - 839. [Abstract] [Full Text]

				S. E. Langenburg, S. A. Buchanan, L. H. Blackbourne, R. P. Scheri, K. N. Sinclair, J. Martinez, W. D. Spotnitz, C. G. Tribble, and I. L. Kron Predicting Survival After Coronary Revascularization for Ischemic Cardiomyopathy Ann. Thorac. Surg., November 1, 1995; 60(5): 1193 - 1196. [Abstract] [Full Text]

				L. L. Mickleborough, H. Maruyama, Y. Takagi, S. Mohamed, Z. Sun, and L. Ebisuzaki Results of Revascularization in Patients With Severe Left Ventricular Dysfunction Circulation, November 1, 1995; 92(9): 73 - 79. [Abstract] [Full Text]

				COMMITTEE MEMBERS, J. F. WILLIAMS Jr, M. R. BRISTOW, M. B. FOWLER, G. S. FRANCIS, A. GARSON Jr, B. J. GERSH, D. F. HAMMER, M. A. HLATKY, C. V. LEIER, et al. Guidelines for the Evaluation and Management of Heart Failure : Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure) Circulation, November 1, 1995; 92(9): 2764 - 2784. [Full Text]

				A. Yamaguchi, T. Ino, H. Adachi, A. Mizuhara, S. Murata, and H. Kamio Left Ventricular End-Systolic Volume Index in Patients With Ischemic Cardiomyopathy Predicts Postoperative Ventricular Function Ann. Thorac. Surg., October 1, 1995; 60(4): 1059 - 1062. [Abstract] [Full Text]

				M. Arnese, J. H. Cornel, A. Salustri, A. P.W.M. Maat, A. Elhendy, A. E.M. Reijs, F. J. Ten Cate, D. Keane, A. H.M.M. Balk, J. R.T.C. Roelandt, et al. Prediction of Improvement of Regional Left Ventricular Function After Surgical Revascularization : A Comparison of Low-Dose Dobutamine Echocardiography With 201Tl Single-Photon Emission Computed Tomography Circulation, June 1, 1995; 91(11): 2748 - 2752. [Abstract] [Full Text]

				G. W. Dec and V. Fuster Idiopathic Dilated Cardiomyopathy N. Engl. J. Med., December 8, 1994; 331(23): 1564 - 1575. [Full Text]