Transplantation versus coronary artery bypass in patients with severe ventricular dysfunction. Surgical outcome and quality of life

BACKGROUND: The purpose of this study is to evaluate the quality of life, functional status and survival rate of patients with left ventricular ejection fraction (LVEF) < or = 20% following coronary bypass (CABG) versus heart transplantation. METHODS: Experimental design: comparative study, mean follow-up of 20 months. Setting: division of cardiac surgery at a McGill University-based hospital in Montreal, Canada. Patients: the charts of 65 consecutive patients with angiographic LVEF < or = 20% were reviewed. Among these patients, 14/65 were referred for transplantation but instead underwent CABG (Group I) after consultation with the transplant committee. The charts of 14 matched transplant patients (Group II) were reviewed. The SF-36 and Duke's questionnaire forms were mailed to both groups in order to evaluate their quality of life and functional capacity, respectively. Interventions: comparison between coronary bypass and heart transplantation. Measures: main outcome measures were mortality, quality of life, and functional capacity. RESULTS: Results are expressed as mean+/-SEM. The in-hospital mortality rate of CABG among all patients with LVEF < or = 20% was 4.6% (3/65). Among the 14 CABG patients initially referred for transplantation, perioperative mortality was 1/14 (7.1%), same as in the matched transplant group. Three additional group I patients were reported by family to have died of cardiac events at follow-up period. Postoperative death identified at follow-up was assigned the lowest life quality score. The transformed quality of life scores were as follows: physical functioning: I=42.5+/-10.6, II=73.2+/-7.2, p=0.029; physical role: I=35.0+/-13.5, I=61.4+/-13.2, p=0.180; bodily pain: I=54.0+/-14.0, II=69.8+/-8.5, p=0.349; general health: I=34.7+/-9.2, II=84.6+/-5.2, p=0.0003; vitality: I=36.5+/-9.3, II=60.0+/-5.2, p=0.045; social functioning: I=55.0+/-4.0, II=87.5+/-5.1, p=0.050; emotional role: I=36.7+/-15.3, II=87.9+/-6.8, p=0.009; mental health: I=52.8+/-12.4, II=81.5+/-4.2, p=0.054. Duke's activity status index: I=16.8+/-4.2, II=31.8+/-4.2, p=0.021. CONCLUSIONS: Heart transplant is associated with a significantly superior postoperative quality of life and functional capacity than bypass surgery. However, in patients with LVEF < or = 20%, CABG can be performed with an acceptable perioperative mortality of 4.6%-7.1%, similar to the rate for transplantation.     

Coronary artery bypass surgery in patients with impaired left ventricular function. Predictors of hospital outcome

This prospective study evaluates the surgical outcome of 75 consecutive patients with impaired left ventricular function, including an analysis of predictors of the short-term outcome following coronary artery bypass grafting (CABG). Seventy-five patients (mean age 64 +/- 13 years) with coronary artery disease and impaired left ventricular function (left ventricular ejection fraction [EF] < or = 40%) who underwent a coronary artery bypass surgery were prospectively studied. Echocardiography and thallium-201 myocardial scintigraphy were preoperatively performed to measure the left ventricular function and to assess myocardial viability. Postoperative echocardiography was done before discharge and six months later to evaluate recovery of left ventricular function. Five patients (6.7%) died in total: three deaths were cardiac related (4%) and two patients (2.7%) died due to other causes. The left ventricular ejection fraction improved immediately after the operation (from 32.2 +/- 6% to 39.5 +/- 8%, p = 0.01) and showed a sustained improvement at later follow-up (mean = 16.3 +/- 4.5 months) (44.0 +/- 4.0%, p = 0.01). The left ventricular wall motion score improved significantly only at later follow-up (from 12.2 +/- 1.8 to 9.4 +/- 2.0, p = 0.03). In 43 patients of whom a preoperative thallium-201 scintigraphy was available, the presence of extensive reversible defects was correlated with significant improvement in EF. On the other hand, a poor outcome was correlated with the presence of pathological Q waves in the preoperative ECG and with an increased left ventricular end-systolic volume index (> 100 ml/m2). Patients with marked left ventricular dysfunction can safely undergo CABG with a low mortality and morbidity. The presence of extensive reversible defects on preoperative thallium-201 scintigraphy is a strong predictor of postoperative recovery of myocardial function. A poor outcome of surgery can be expected in the presence of pathological Q waves on the preoperative ECG or when the left ventricular endsystolic volume index exceeds 100 ml/m2.     

Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function

OBJECTIVE: The aim of this study is to evaluate in a cohort of patients with impaired left ventricular (LV) function and ischemic mitral valve regurgitation (MVR), the effects of on-pump/beating heart versus conventional surgery in terms of postoperative mortality and morbidity and LV function improvement. MATERIALS AND METHODS: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III-IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 +/- 7 years and in Group II, 65 +/- 6 years (p = 0.69). RESULTS: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 +/- 1 and 2.7 +/- 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 +/- 6 (%) versus 16 +/- 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. CONCLUSION: We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients.     

Right ventricular dysfunction after coronary artery bypass grafting is a reality of unknown cause and significance

Objective: To evaluate the impact of coronary bypass surgery on the function of the right ventricle (RV) in patients with a pre-operative ejection fraction ≥ 35% who did not have any perioperative myocardial infarction.Method: We performed a prospective study of 30 patients who underwent uneventful isolated coronary artery bypass grafting (CABG). All patients had echocardiography prior to surgery and 3 months postoperatively. Myocardial tissue Doppler velocities were used to measure left and right ventricular function. The right ventricular myocardial performance index (Tei) and the ratio between the velocities of the RV and left ventricle (LV) were also calculated.Results: There was a significant improvement in left ventricular ejection fraction before and after CABG (P = .046). The tissue Doppler imaging (TDI) velocities from the LV remained unchanged, but highly significant reductions in right ventricular TDI velocities were observed (P <.001). The TDI peak systolic (S), early diastolic (E), and late diastolic (A) velocities had a reduction of 30%, 34.5%, and 20%, respectively. Similarly, a fall in RV to LV ratios of various TDI velocities was also observed. This was also accompanied by a significant rise in the RV Tei index. All of these findings are suggestive of significant RV dysfunction.Conclusion: There is a marked impairment of RV function after CABG.     

Efficacy of additional Dor approach to coronary bypass grafting in severe left ventricular dysfunction with large akinetic area

Between January 1994 and August 1999, we experienced 16 cases of coronary artery bypass grafting (CABG) in severe left ventricular dysfunction with left ventricular ejection fraction (LVEF) < or = 40%. Four had additional endoventricular patch plasty in large postinfarction akinetic scars, the so-called Dor approach, to CABG (group D). Eleven had only CABG, or CABG and mitral annuloplasty (group C). One had linear repair after the resection of the left ventricular aneurysm. One died of sustained low output syndrome 5 months after the operation in group C. Fractioning shortening and left ventricular diastolic diameter were not changed after the operation in group C. On the other hand, in group D, there were no complications after the operation, LVEF was significantly improved from 31.5 +/- 4.9% to 62.5 +/- 5.9% (p < 0.01) and the left ventricular end-diastolic volume index was reduced from 118 +/- 23 ml/m2 to 74 +/- 12 ml/m2 (p < 0.01). The Dor approach is considered to be a safe and effective additional procedure to CABG in severe patients with a large akinetic antero-septal segment.     

Late Results with Concomitant Coronary Artery Bypass Grafting and ICD Implantation

A bstract Background : To determine the influence of left ventricular function on the long-term survival of patients with coronary artery disease and lethal ventricular arrhythmias, who undergo concomitant coronary artery bypass grafting (CABG) and implantable cardiovertor defibrillator (ICD) implantation, we studied survival in 54 consecutive patients who underwent CABG and ICD implantation. Methods : Group I consisted of 35 patients with left ventricular ejection fraction (LVEF) ± 35% (mean 25.3 ± 5.6) and Group II consisted of 19 patients with LVEF > 35% (mean 47.5 ± 6.6). The two groups were similar with regards to age, gender, clinical presentation, induced arrhythmias, and the number of grafts placed at the time of surgery. Results: Two in-hospital deaths (3.7%) occurred, both in Group I. During follow-up (42.5 ± 21.8 months), there were 10 deaths in Group I (1 noncardiac, 1 sudden, and 8 heart failure), and 1 death in Group II (heart failure) (p < 0.04). Conclusions : Concomitant CABG and ICD implantation can be performed with an acceptable in-hospital mortality, even in patients with poor left ventricular function. Although freedom from sudden cardiac death remains excellent, overall long-term survival is limited by refractory heart failure, especially in those patients with left ventricular dysfunction at the time of surgery.     

Late outcomes after isolated coronary artery bypass grafting for ischemic mitral regurgitation.

OBJECTIVES: Although ischemic mitral regurgitation (IMR) is one of the most important issues to determine therapeutic strategy for ischemic heart disease, long-term outcome after coronary artery bypass grafting (CABG) for IMR is still unclear. It is also controversial how patients who would benefit from mitral valve (MV) surgery in combination with CABG should be identified. The purpose of this study is to elucidate late outcomes after isolated CABG for moderate IMR and to assess the indication of combined MV surgery. METHODS: Two hundred and seventy-nine patients who had grade 2 or 3 IMR preoperatively and underwent isolated CABG between 1980 and 2002 in our institute were enrolled. Mitral regurgitation was assessed by 2-dimensional Doppler echocardiography and left ventriculography. Among them, 84 patients (30.1%) had left ventricular ejection fraction (LVEF) less than 30% and 186 patients (66.7%) had prior inferior myocardial infarction (MI). RESULTS: One hundred and twenty-nine patients (46.2%) remained grade 2 or greater MR early postoperatively. Actuarial survival and freedom from cardiac events, analyzed by the Kaplan-Meier method, were 90.9% and 87.7% at 1 year, 79.2% and 68.8% at 5 years, 54.9% and 49.1% at 10 years and 48.8% and 18.9% at 15 years. Independent predictive risk factors for cardiac events, analyzed by multivariate analysis using the Cox proportional hazard model, were grade 2 or greater MR which remained early postoperatively (p = 0.0002), LVEF < 30% preoperatively (p = 0.0006), no inferior MI preoperatively (p = 0.007) and no internal thoracic artery-left anterior descending artery graft (p = 0.049). More than a 15% decrease in LVEF at more than 3 years after the operation was seen despite patent bypass grafts in 17.2% of patients who received a late follow-up catheterization, although 41.4% of patients showed an increase or less than 5% decrease in LVEF during this period. CONCLUSION: Combined MV surgery with CABG for IMR should be considered in patients with poor LVEF or without prior inferior MI.     

Improvement in resting ventricular performance following coronary bypass surgery

To assess the changes in resting left ventricular (LV) function following coronary bypass surgery, technetium 99m-labeled multiple equilibrated blood pool gated scans were performed in 53 consecutive patients at rest, before operation, and at 24 hours and 1 week after operation. Left ventricular ejection fraction (LVEF) and end-diastolic volume (EDV) were measured. The LVEF increased significantly from a preoperative value of 49 +/- 2% to 56 +/- 2% at 24 hours after operation (p less than 0.05) and 56 +/- 2% at 1 week following operation (p less than 0.05 compared with the preoperative value). The EDV also exhibited significant changes, decreasing from a preoperative value of 148 +/- 8 ml to 91 +/- 11 ml at 24 hours (p less than 0.001) and 114 +/- 9 ml at 1 week (p less than 0.01 compared with the preoperative value). When the patients were divided into two groups according to the preoperative LVEF (Group 1, LVEF of greater than or equal to 50%; Group 2, LVEF of less than 50%), the observed changes were similar. This study demonstrates significant improvement in resting LV function 24 hours following coronary bypass surgery. This improvement persists at 1 week and is not related to the degree of preoperative impairment. We conclude that the combination of successful revascularization and optimal myocardial protection can result in significant improvement of LV function at rest.     

Off-pump coronary artery bypass grafting/beating coronary artery bypass grafting for a patient with low left ventricular ejection fraction

Beating coronary artery bypass grafting could be performed for a 47-year-old man with left ventricular ejection fraction (LVEF) of 9.3%. Post-operative LVEF was improved to 51.6%. Conventional coronary artery bypass grafting (CABG) used to be contraindicative for patients with LVEF below 20%. Recently, such patients are involved to indication of off-pump CABG (OPCAB) or beating CABG, because we consider OPCAB are lower complications than conventional CABG. We were able to bypass the circumflex for the patient while we had been used percutaneous cardio-pulmonary support (PCPS). We could perform beating coronary artery bypass grafting for a patient of the low LVEF.     

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

INTRODUCTION: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function. MaTERIALS AND METHOD: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. RESULTS: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.     

Coronary artery bypass surgery in patients with severely impaired left ventricular function]

The efficacy and problem of coronary artery bypass grafting (CABG) in patients with severely impaired left ventricular function (left ventricular ejection fraction < or = 30%) were assessed in 27 patients of whom 17 (group 1) underwent emergent CABG and 10 (group 2) elective between Jan 1984 to Aug 1990. As a whole, history of myocardial infarction (24/27, 88.9%), large left ventricular volume with reduced ejection fraction (LVEDVI 126.08 +/- 25.91 ml/m2, LVESVI 93.04 +/- 21.02 ml/m2, LVEF 25.04 +/- 4.75%) and multiple vessel disease with at least one vessel total occlusion (20/27, 74.1%) were characteristically seen in these patients. The patients of group 1 were significantly older (mean 66.12 +/- 5.68 vs 57.10 +/- 8.08, p < 0.01) and needed more frequent preoperative support with IABP (17/17 vs 4/10, p < 0.01). Using Thallium-201 scintigraphy, in 10 patients of group 1 and 9 of group 2, myocardial viability in the proposed bypass area was evaluated before operations. Average 2.37 +/- 0.79 grafts were placed and continuous retrograde cold blood cardioplegia via the coronary sinus was employed for myocardial protection. Two mitral annuloplasty (MAP) for ischemic mitral regurgitation and 2 cryoablation for the treatment of ventricular tachycardia were performed concomitantly. Operative mortality was 47.1% in group 1 and none in group 2 (p < 0.05). Two cases of MAP died, but two cases of cryoablation survived. Postoperative LVEF was improved significantly only in group 2 (p < 0.05), but during the follow-up period of 7 months to 6 years, all 19 survivors expect one remains with NYHA class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aspartate and glutamate-enriched cardioplegia in left ventricular dysfunction

BACKGROUND: The effects of exogenous L-aspartate and L-glutamate-enriched cardioplegia on postoperative left ventricular functions after coronary artery bypass surgery in patients with moderate left ventricular dysfunction (left ventricular ejection fraction [LVEF]= 30-40%) were studied. METHODS: In this prospective randomized study, 22 patients with moderate left ventricular dysfunction (mean LVEF = 37.27%+/- 3.43%), who underwent elective coronary artery bypass surgery, were examined. Isothermic substrate-enriched [L-aspartate and L-glutamate (13 mmol/L)] blood cardioplegia was used in 11 patients (Group AG), and cardioplegia including only potassium and sodium bicarbonate was used in 11 patients (Group C). All hemodynamic parameters for left and right heart were studied in both groups. Total perfusion time was 126.63 +/- 44.91 minutes versus 114.81 +/- 43.66 minutes (p = 0.54). The aortic cross-clamp time was 77.09 +/- 28.02 minutes versus 67.81 +/- 22.77 minutes (p = 0.4), respectively. The amount of cardioplegic solutions were 7218.2 +/- 3043.6 mL versus 5454.5 +/- 3048.1 mL (p = 0.167). Mean number of distal anastomosis were 3 +/- 0.89 versus 2.9 +/- 0.7 (p = 0.793). RESULTS: There was no difference between both groups in intra- and postoperative periods. In coronary sinus blood gas measures, myocardial acidosis caused by the aortic cross-clamp was found to be more severe in the Group C, but delta pH (0.12 +/- 0.14 vs. 0.092 +/- 0.058; p = 0.613) and delta lactate (1.39 +/- 1.03 vs. 1.62 +/- 0.85; p = 0.579) were similar in both groups. Free oxygen radical production caused by aortic cross-clamp was significant in the Group C. Not all myocardial enzymes, but Troponin-T levels were found higher in control group than the study group (0.6 +/- 0.36 vs. 0.36 +/- 0.25; p = 0.1). CONCLUSIONS: Although L-aspartate and L-glutamate favor myocardial metabolic functions, they do not have any affect on myocardial functional recovery in patients with moderate left ventricular dysfunction.     

Late outcomes after isolated coronary artery bypass grafting for ischemic mitral regurgitation

Objectives: Although ischemic mitral regurgitation (IMR) is one of the most important issues to determine therapeutic strategy for ischemic heart disease, long-term outcome after coronary artery bypass grafting (CABG) for IMR is still unclear. It is also controversial how patients who would benefit from mitral valve (MV) surgery in combination with CABG should be identified. The purpose of this study is to elucidate late outcomes after isolated CABG for moderate IMR and to assess the indication of combined MV surgery. Methods: Two hundred and seventy-nine patients who had grade 2 or 3 IMR preoperatively and underwent isolated CABG between 1980 and 2002 in our institute were enrolled. Mitral regurgitation was assessed by 2-dimensional Doppler echocardiography and left ventriculography. Among them, 84 patients (30.1%) had left ventricular ejection fraction (LVEF) less than 30% and 186 patients (66.7%) had prior inferior myocardial infarction (MI). Results: One hundred and twenty-nine patients (46.2%) remained grade 2 or greater MR early postoperatively. Actuarial survival and freedom from cardiac events, analyzed by the Kaplan-Meier method, were 90.9% and 87.7% at 1 year, 79.2% and 68.8% at 5 years, 54.9% and 49.1% at 10 years and 48.8% and 18.9% at 15 years. Independent predictive risk factors for cardiac events, analyzed by multivariate analysis using the Cox proportional hazard model, were grade 2 or greater MR which remained early postoperatively (p=0.0002), LVEF<30% preoperatively (p=0.0006), no inferior MI preoperatively (p=0.007) and no internal thoracic artery-left anterior descending artery graft (p=0.049). More than a 15% decrease in LVEF at more than 3 years after the operation was seen despite patent bypass grafts in 17.2% of patients who received a late follow-up catheterization, although 41.4% of patients showed an increase or less than 5% decrease in LVEF during this period. Conclusion: Combined MV surgery with CABG for IMR should be considered in patients with poor LVEF or without prior inferior MI.     

Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium.

OBJECTIVE: Long-term left ventricular (LV) performance and patient outcome after coronary artery bypass grafting (CABG) procedure in the presence of depressed LV function and hibernating myocardium (HM) have been poorly determined. Therefore, we prospectively evaluated patients undergoing CABG with severe LV dysfunction and HM to elucidate postoperative prognosis. METHODS: We enrolled 120 consecutive patients undergoing CABG with severe LV dysfunction and HM as assessed by dobutamine echocardiography and by rest-redistribution radionuclide (Thallium-201) study. Mean patient age was 60+/-9 years (range 31-77 years). Mean preoperative LVEF was 28%+/-9 (range 10-40%). All patients underwent echocardiographic study to assess LV recovery of function intraoperatively, prior to hospital discharge, at 3 months, at 1 year, and yearly during the follow-up. Univariate and multivariate analysis were performed to to evaluate predictors of postoperative survival. RESULTS: There were 2 hospital (1.6%) and 15 late (12.5%) deaths, mainly for heart failure, leading to an actuarial survival of 80+/-6% and 60+/-9% at 5 and 8 years, respectively. LVEF significantly improved perioperatively (from 28+/-9% to 40+/-2%, P<0.01). Increase in LVEF, however, was gradually offset over the time (EF of 33+/-9%, 32+/-8%, and 30+/-9% at 3 months, and 12 months, and 8 years after surgery, respectively). Furthermore, patients who experienced limited LV functional recovery perioperatively had a more remarkable decline of LVEF thereafter, and suffered from recurrence of heart failure symptoms (freedom from heart failure 82+/-5% and 60+/-8% at 4 and 8 years respectively). Advanced preoperative NYHA Class, and age were independent risks factors for reduced postoperative survival. Preoperative angina and use of arterial conduits apparently did not influence patient morbidity and mortality at long term. CONCLUSION: CABG procedure in the presence of HM enhances LV recovery of function and has a favourable prognosis. Functional benefit of the left ventricle, however, appears to be time-limited, despite remarkable improvement in patient functional capacity. Advanced preoperative heart failure, minimal perioperative improvement of LVEF, and age account for a poor long-term prognosis.     

Does On‐Pump/Beating‐Heart Coronary Artery Bypass Grafting Offer Better Outcome in End‐Stage Coronary Artery Disease Patients?

OBJECTIVES: The purpose of our study was to evaluate in a cohort of end-stage coronary artery disease (ESCAD) patients the effects of on-pump/beating-heart versus conventional coronary artery bypass grafting (CABG) requiring cardioplegic arrest. We report early and midterm survival, morbidity, and improvement of left ventricular (LV) function. METHODS: Between January 1992 and October 1999, 107 (Group I) ESCAD patients underwent on-pump/beating-heart surgery and 191 (Group II) ESCAD patients underwent conventional CABG requiring cardioplegic arrest. Mean age in Group I was 65.8 +/- 6.5 years (58-79 years); New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications were 3.2 +/- 0.4 and 3.3 +/- 0.5, respectively. LV ejection fraction (LVEF) was 24.8% +/- 4%, LV end diastolic pressure (LVEDP) was 28.2 +/- 3.8 mmHg, and LV end diastolic diameter (LVEDD) was 69.6 +/- 4.6 mm. Mean age in Group II was 64.1 +/- 5 years (57-76 years), NYHA class was 3 +/- 0.6, CCS class was 3.4 +/- 0.4, LVEF was 26.2% +/- 4.3%, LVEDP was 27.2 +/- 3.4 mmHg, and LVED was 68 +/- 4.2 mm. RESULTS: Preoperatively, Group I patients versus Group II patients had a markedly depressed LV function (LVEF, p = 0.006; LVEDP, p = 0.02; LVEDD, p = 0.003; and NYHA class, p = 0.002), older age (p = 0.012), and higher incidences of multiple acute myocardial infarction (AMI; p = 0.004), cardiovascular disease (CVD; p = 0.008), and chronic renal failure (CRH, p = 0.002). Cardiopulmonary bypass (CPB) time was longer in Group II patients (p = 0.028). The mean distal anastomosis per patient was similar between groups (p = NS). Operative mortality between Groups I and II was 7 (6.5%) and 19 (10%), respectively (p = NS). Perioperative AMI (p = 0.034), low cardiac output syndrome (LCOS; p = 0.011), necessity for ultrafiltration (p = 0.017), and bleeding (p = 0.012) were higher in Group II. Improvement of LV function within 3 months after the surgical procedure was markedly higher in Group I, demonstrated by increased LVEF (p = 0.035), lower LVEDP (p = 0.027), and LVEDD (p = 0.001) versus the preoperative data in Group II. The actuarial survivals at 1, 3, and 5 years were 95%, 86%, and 73% in Group I and 95%, 84%, and 72% in Group II (p = NS). CONCLUSIONS: ESCAD patients with bypassable vessels to two or more regions of reversible ischemia can undergo safe CABG with acceptable hospital survival and mortality and morbidity. In higher risk ESCAD patients, who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers better myocardial and renal protection associated with lower postoperative complications.     

Beating heart versus conventional single-vessel reoperative coronary artery bypass

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG. METHODS: We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 +/- 9 for on-pump versus 24 +/- 8 for off-pump patients (p = nonsignificant). RESULTS: On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 +/- 4 days on-pump versus 5 +/- 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03). CONCLUSIONS: Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.     

Benefit to quality of life after off-pump versus on-pump coronary bypass surgery

BACKGROUND: Whether the clinical outcome of off-pump coronary artery bypass graft (OPCABG) surgery is superior to on-pump coronary artery bypass graft (CABG) surgery is still a matter of debate. However with the considerable reduction of mortality associated with CABG surgery in recent years, more subtle outcome indicators such as quality of life (QOL) become more important. The aim of this study was to compare midterm QOL after OPCABG with that after CABG procedures and with an age- and sex-matched standard population. METHODS: Quality of life was assessed using the Short-Form 36 Health Survey Questionnaire for 504 consecutive patients after CABG (n = 438) and OPCABG (n = 66) operated on between June 1999 and November 2000 at our institution. RESULTS: Except for single-vessel disease, which was more frequent in OPCABG compared with CABG procedures (13.6% versus 6.8%; p <0.01), the preoperative variables were similar. Median EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 3.2 +/- 1.3 in the CABG group compared with 3.0 +/- 0.8 in the OPCABG group (p = not significant). After a mean follow-up of 10.8 +/- 0.5 months physical role function (73.5 +/- 38.3 versus 45.3 +/- 41.6; p <0.01) and emotional role function (75.3 +/- 40.3 versus 61.0 +/- 43.9; p <0.01) were significantly better in OPCABG than in CABG patients. Compared with a standard population, OPCABG patients were significantly impaired in emotional role function and CABG patients in physical and emotional role function. CONCLUSIONS: Midterm QOL after myocardial revascularization is fairly well preserved compared with an age- and sex-matched standard population and is superior after OPCABG compared with CABG. Whether this is only due to avoidance of cardiopulmonary bypass remains to be elucidated.     

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older.

OBJECTIVES: Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older. METHODS: To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65-74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early. RESULTS: The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8 +/- 0.5 versus 0.3 +/- 0.5; p < 0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p = 0.0009), delirium in 36.7% versus 11.4%, (p = 0.0004), pneumonia in 6.1% versus 0%, (p = 0.0439), and intubation duration of 88.3 +/- 212.5 hours versus 37.2 +/- 92 hours (p = 0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p = 0.1867). CONCLUSION: These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.     

室壁瘤切除左心室几何重建连续42例经验

目的总结42例室壁瘤切除左心室成形加冠状动脉搭桥无死亡的经验. 方法 42例左心室室壁瘤患者,男41例、女1例,平均年龄(55.5±2.4)岁(40～68岁).38例有不稳定性心绞痛,术前合并严重室性心律失常10例,其中有心室颤动病史2例,反复发作室性心动过速8例,合并高血压病26例,糖尿病3例,重症慢性阻塞性肺疾病1例;心功能(NYHA)Ⅲ级32例,Ⅳ级10例;合并二尖瓣轻至中度关闭不全6例.42例经左心室造影和手术证实为解剖性室壁瘤,位于前间壁41例、下壁1例.左心室射血分数(LVEF)平均41%(17%～63%),其中LVEF<40%29例.33例采用Jatene术式,8例Dor术式, 1例Cooley术式,其中10例在心脏跳动下完成左心室成形术.左主干病变7例,3支病变30例,2支病变6例,单纯左前降支病变5例.全部患者同期行冠状动脉搭桥术,乳内动脉使用率100%.术中证实左心室内附壁血栓21例.平均体外循环时间(135±11)min,阻断升主动脉(78±10)min. 结果术后平均住院天数(13.1±1.2)d,住ICU(2.8±0.6)d.使用主动脉内气囊反搏7例(17%),术后发生顽固性室性心动过速1例,胸骨哆开1例,术后早期渗血、二次开胸止血1例.术后左心室前后径、舒张末期和收缩末期容量较术前明显缩小(P<0.05),LVEF有增加趋势(P>0.05).围手术期无死亡,均痊愈出院.术后随访10个月至4年,无死亡. 结论室壁瘤切除左心室几何重建术同期行冠状动脉旁路术,除改善心功能外,可消除室性心动过速,手术安全、可靠,效果良好.     

Coronary artery bypass grafting in patients with severe left ventricular dysfunction--early and mid-term outcomes

BACKGROUND: The prevalence of patients with severe left ventricular dysfunction (LVD) referred for coronary artery bypass grafting (CABG) is increasing. The aim of the present study was to assess the outcomes of patients with severe LVD undergoing CABG. METHODS: Outcomes of 115 consecutive patients with severe LVD (left ventricular ejection fraction [LVEF]30% (HEF). To further evaluate the LVD patients, they were divided into three subgroups base on LVEF: 0% to 10%, 11% to 20%, and 21% to 30%. Data were collected prospectively and entered into the departmental database of the Society of Thoracic Surgeons. RESULTS: Patients in the LVD group had increased incidence of diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, prior myocardial infarction (MI), congestive heart failure, and less elective procedures compared to the HEF group. Despite this greater risk profile, operative mortality (LVD 2.6% vs. HEF 1.2%, p = 0.19), the incidence of stroke (2.6% vs. 1.0%, p = 0.13), and perioperative MI (0.9% vs. 0.7%) were not statistically different between the groups. The incidence of respiratory (14.8% vs. 1.9%, p < 0.001), renal (5.2% vs. 1.0%, p < 0.001), and vascular (5.2% vs. 0.5%, p < 0.001) complications was significantly higher in the LVD group, resulting in a longer hospital length of stay (8 +/- 8 vs. 6 +/- 4 days, p < 0.0001). In a multivariate analysis, advanced age was as an independent predictor of hospital mortality. Average follow-up in 108 (94%) LVD patients was 36 +/- 22 months (range 2 to 78 months). Twenty-one patients expired during the follow-up, for nine the causes were cardiac-related. Three- and 5-year survival rates were 91 +/- 3% and 76 +/- 6%, respectively. Independent predictors of mid-term mortality in the LVD group by a multivariate analysis included female gender, renal failure, respiratory complications, and grade I/II mitral regurgitation (MR). At the time of follow-up, 72% of LVD patients were in functional class I/II. There were no statistically significant differences in short- and mid-term outcomes among the LVD subgroups. CONCLUSION: CABG in patients with severe LVD can be performed with a low mortality, albeit with higher morbidity and longer length of hospital stay, than patients with LVEF >30%. Low ejection fraction per se was not a predictor of hospital mortality. CABG should be considered a safe and effective therapy for low ejection fraction patients with ischemic heart disease. Mitral valve repair/replacement in the presence of moderate degree of MR should be considered at the time of the initial operation.