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Ann Thorac Surg 1995;60:1193-1196
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Predicting Survival After Coronary Revascularization for Ischemic Cardiomyopathy

Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The success of coronary revascularization for ischemic cardiomyopathy (left ventricular ejection fraction of 0.25 or less) has been unpredictable. We and others have demonstrated that the hospital operative mortality rate for these operations has been surprisingly low, particularly if evidence of ischemia is present. We subsequently liberalized our selection criteria based on our hypothesis that coronary artery bypass grafting is safe in this subset of patients regardless of the status of their distal coronary vasculature.

Methods. To examine this hypothesis, we studied retrospectively our patients undergoing coronary artery bypass grafting from 1983 to 1993. Ninety-six patients with ejection fractions of 0.25 or lower underwent this operation, with 88 hospital survivors (mortality 8%). All of the patients had clinical symptoms of heart failure. The male to female ratio was 4.6:1. The average age was 63.1 ± 0.9 years (mean ± standard error of the mean). Patients were excluded if they had valvular heart disease other than mild to moderate mitral regurgitation, required resection of a ventricular aneurysm, or required an emergency operation for acute coronary occlusion. Possible predictors of death were examined retrospectively. The catheterization films were reviewed retrospectively by a cardiovascular surgeon who was blinded to patient outcome and was never involved in the clinical management of any of the patients. Vessel quality was described as good, fair, or poor.

Results. Increased age and poor vessel quality were the only significant predictors of poor outcome. Sex, presence or absence of angina, preoperative angina, preoperative ejection fraction, preoperative arrhythmia disorder, aortic cross-clamp time, and the number of bypass grafts had no significant effect on outcome in the perioperative period.

Conclusion. These results demonstrate that poor vessel quality and older age are predictors of poor outcome in patients with low ejection fractions undergoing myocardial revascularization. We conclude that poor distal coronary vasculature is a contraindication to coronary artery bypass grafting in patients with an ejection fraction of 0.25 or less, even if angina is present.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1196.

Coronary artery bypass grafting (CABG) for ischemic cardiomyopathy has been shown to be a reasonable alternative to transplantation and medical treatment of patients with advanced ventricular dysfunction [1–3]. This is an important finding given the shortage of organs available for transplantation and the ever-increasing demand for organs. Although patients with ischemic cardiomyopathy have coronary revascularization as an option, it is still difficult to predict who will do well perioperatively. Luciani and associates [3] have suggested that perioperative angina may be a predictor of a good result. Our experience has shown that although this may be true, the lack of angina did not predict a poor result [2]. Because of the large size of our heart transplant waiting list, we liberalized our use of CABG for the treatment of ischemic cardiomyopathy (ejection fraction less than 0.25). We operated on patients regardless of age, sex, the presence or absence of angina, and status of the distal vasculature, with the hypothesis that these factors did not appear to be predictors of outcome.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
To examine our hypothesis, we performed a retrospective analysis of all patients undergoing CABG from 1983 to 1993 at our institution. All patients who underwent CABG and had a preoperative left ventricular ejection fraction less than 0.25 were available in the CABG Patch Trial database at our institution [4]. Patients were included in this series if they were free of valvular disease other than mild to moderate mitral regurgitation, they had no ventricular aneurysm requiring resection, and they had not been operated on emergently. These other surgical lesions, when corrected, could result in a marked improvement of cardiac function. Preoperative and postoperative patient information was obtained from the patients' medical records. Information concerning the operative procedures was obtained from operative notes and the anesthesia record. Information concerning the status of the distal coronary vasculature was obtained from catheterization films performed in our institution or in referring hospitals, when available. Ninety-six patients met our selection criteria. Fifty-seven catheterization films were available from our film archives. Cardiac catheterization films were reviewed by a cardiothoracic surgeon who was blinded to the patients' outcome and who had not participated in the preoperative, operative, or postoperative care of the patients. Vessel quality was described as good, fair, or poor. Figures 1, 2, and 3 are angiographic examples of vessel quality.

View larger version (112K): [in this window] [in a new window]   Fig 1. . Coronary artery angiogram classified as having good distal coronary vasculature.

View larger version (119K): [in this window] [in a new window]   Fig 2. . Coronary artery angiogram classified as having fair distal coronary vasculature.

View larger version (174K): [in this window] [in a new window]   Fig 3. . Coronary artery angiogram classified as having poor distal coronary vasculature.

Statistical Analysis
Statistical analysis between hospital survivors and hospital deaths was performed by using a two-sample t test for age, cross-clamp time, ejection fraction, and number of bypass grafts. Fisher's exact test was used to evaluate vessel-quality data and their relation to survival. All numbers are reported as mean ± standard error of the mean.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Ninety-six patients met our selection criteria. Their mean age was 63.1 ± 0.9 years. There were 79 men and 17 women (male to female ratio 4.6:1). Mean left ventricular ejection fraction was 0.20 ± 0.00%. Hospital survival, defined as discharge from the hospital alive, was 92% (eight deaths). One woman of the 17 in this series died (5.9%); 7 men of 79 died (8.9%). Five of the deaths were the result of arrhythmias refractory to medical therapy. Two deaths were secondary to heart failure and one was the result of a large cerebral vascular accident and a fatal arrhythmia.

Table 1 summarizes the hospital survivors versus hospital deaths with reference to several possible predictors of outcome. Contrary to our hypothesis, age was shown to be significantly higher in the group of patients who died during the postoperative period. Ejection fraction, aortic cross-clamp time, and the number of bypass grafts exhibited no predictive value.

Arrhythmias were present in 6 of the 96 patients preoperatively. None of the patients with preoperative arrhythmias died of arrhythmias postoperatively. In 12 patients, pronounced arrhythmias developed postoperatively. Five of these patients died of these arrhythmias refractory to medical management.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Coronary revascularization for ischemic cardiomyopathy rather than cardiac transplantation or medical therapy alone can be a viable option for patients with ejection fractions less than or equal to 0.25 who either do not meet the criteria for cardiac transplantation or are waiting on the transplant list for scarce organs. Revascularization in patients with low ejection fractions has an acceptable operative survival rate as well as late survival [5]. Patients who have undergone CABG for ischemic cardiomyopathy generally exhibit improvements in both ventricular function and quality of life [3, 6, 7]. Although the benefits of revascularization are well documented for patients with ischemic cardiomyopathy, the predictors of operative risk are less clear. The goal of this study was to evaluate possible predictors of operative risk in survivors and nonsurvivors. Older age has been shown to cause an increase in operative mortality in patients undergoing CABG regardless of preoperative ejection fraction [8]. Our series exhibits this finding in the cohort of patients with low ejection fractions. Low ejection fraction (less than 0.20) alone has been shown to be associated with a higher operative mortality rate compared with a higher ejection fraction [8]. However, in our series as well as others, the ejection fractions of the operative survivors were not significantly different from those in patients who did not survive the operations [9]. Thus, within the cohort of patients with low ejection fractions, a low ejection fraction alone cannot be used to predict outcome. Preoperative angina has been shown to be associated with a good result because its presence connotes reversible ischemia [3]. This study and previous reports have shown that although angina was a predictor of a good result, the lack of angina did not necessarily predict a poor result [2]. We have also examined preoperative thallium imaging to help predict outcome in this subset of patients undergoing CABG and have found that thallium scanning is not predictive of a poor outcome [2].

We did not find that the presence of arrhythmias preoperatively was a predictor of poor outcome. This is in agreement with the findings of Milano and associates [5]. Milano and associates also found that female sex was predictive of increased mortality. We had a similar number of women in our series, and did not find that women did worse in outcome. Fisher and associates [10] hypothesized that women, regardless of ejection fraction, have a higher mortality rate after CABG because overall, they have smaller stature and a smaller diameter of the coronary arteries. Our evaluation of catheterization films clearly showed that patients with poor vessels had significantly worse outcomes than those with good or fair vessels. Although the interpretation of films can be very subjective, the reproducibility of interpretation of coronary arteriograms increases as the severity of the disease increases [11].

In conclusion, we believe that myocardial revascularization remains a viable alternative to cardiac transplantation in patients with ischemic cardiomyopathy. Our results demonstrate that poor vessel quality and older age are predictors of poor outcome in patients with low ejection fractions undergoing myocardial revascularization. Poor distal coronary vasculature on arteriogram is a relative contraindication to CABG in patients with an ejection fraction less than 0.25.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

Address reprint requests to Dr Kron, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health Sciences Center, Box 181, Charlottesville, VA 22908.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Elefteriades JA, Tolis G Jr, Levi E, Mills LK, Zaret BL. Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol 1993;22:1411–7.[Abstract]
2. Kron IL, Flanagan TL, Blackbourne LH, Schroeder RA, Nolan SP. Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy. Ann Surg 1989;210:348–54.[Medline]
3. Luciani GB, Faggian G, Razzolini R, Livi U, Bortolotti U, Mazzucco A. Severe ischemic left ventricular failure: coronary operation or heart transplantation. Ann Thorac Surg 1993;55:719–23.[Abstract]
4. CABG Trial Group. Prog Cardiovasc Dis 1993;36:97–114.[Medline]
5. Milano CA, White WD, Smith LR, et al. Coronary artery bypass in patients with severely depressed ventricular function. Ann Thorac Surg 1993;56:487–93.[Abstract]
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7. Johnson MR, Nordin MR, Heroux AL, et al. High-risk cardiac operation: a viable alternative to heart transplantation. Ann Thorac Surg 1993;55:876–82.[Abstract]
8. Kennedy JW, Kaiser GC, Fisher LD, et al. Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation 1981;63:793–802.[Abstract/Free Full Text]
9. Louie HW, Laks H, Milgalter E, et al. Ischemic cardiomyopathy: criteria for coronary revascularization and cardiac transplantation. Circulation 1991;84(Suppl 3):290–5.
10. Fisher LD, Kennedy JW, Davis KB, et al. Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS). J Thorac Cardiovasc Surg 1982;84:334–41.[Abstract]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Scott A. Buchanan William D. Spotnitz Curtis G. Tribble Irving L. Kron Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Langenburg, S. E. Articles by Kron, I. L. Search for Related Content PubMed PubMed Citation Articles by Langenburg, S. E. Articles by Kron, I. L. Related Collections Related Article