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Ann Thorac Surg 2002;74:1531-1536
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Long-term outcome after coronary artery bypass grafting in patients with severe left ventricular dysfunction

^a Department of Cardiothoracic Surgery, Henry Ford Health Sciences Center, Detroit, Michigan, USA

Accepted for publication June 20, 2002.

* Address reprint requests to Dr Carr, Department of Cardiothoracic Surgery, Rush-Presbyterian-St. Luke’s Medical Center, 1653 West Congress Pkwy, Chicago, IL 60612, USA.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: The aim of this study was to define the potential for long-term survival with severe left ventricular dysfunction after coronary bypass and to quantify any improvement in overall functional status.

METHODS: Left ventricular dysfunction was confirmed preoperatively and the long-term survival and functional outcome after bypass was determined by follow-up studies obtained during the span of a decade.

RESULTS: From 1/1990 to 12/1999, 86 patients with severe left ventricular dysfunction (mean ejection fraction, 0.18 ± 0.03; range, 0.10 to 0.20) underwent coronary artery bypass grafting. There were 10 perioperative deaths (11% mortality). The mean survival was 55 months (standard deviation ± 34 months; range, 2 to 141 months) with an actual 5-year survival rate of 59% (actuarial 5-year 65%, 10-year 33%). Echocardiography obtained between 1 and 6 months, 6 months and 1 year, 1 and 2 years, 2 and 4 years, 4 and 6 years, and 6 and 11 years showed the ejection fraction improved to 0.29 ± 0.08 (p < 0.001), 0.31 ± 0.14 (p < 0.002), 0.35 ± 0.08 (p < 0.001), 0.27 ± 0.10 (p = 0.002), 0.36 ± 0.14 (p = 0.004), and 0.30 ± 0.11 (p = 0.004), respectively. At 1 to 6 months, 6 months to 1 year, and 1 to 2 years, the diastolic left ventricular dimension was unchanged, but the systolic left ventricular dimension decreased significantly from 5.02 ± 0.77 cm to 4.26 ± 0.91 cm (p = 0.046), 3.98 ± 1.43 cm (p = 0.08), and 4.10 ± 1.14 cm (p = 0.07). The preoperative New York Heart Association classification for all patients improved from 2.8 ± 0.8 to 1.6 ± 0.7 (p < 0.001) after a mean of 53 months (standard deviation ± 34 months).

CONCLUSIONS: Patients with severe left ventricular dysfunction can derive long-term benefit from coronary bypass through improved left ventricular contractility as documented by a significantly decreased systolic left ventricular dimension and increased ejection fraction. Successful bypass is associated with a 59% actual 5-year survival rate and significantly improved New York Heart Association functional class.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The life expectancy for patients with severely depressed left ventricular (LV) function (ejection fraction [EF] 0.20) is very short. Data from the Framingham Heart Study demonstrate that the median survival after development of congestive heart failure is 1.7 years in men and 3.2 years in women [1]. Cardiac surgeons have generally been hesitant to operate on this group of patients due to an excessive postbypass mortality of 13% to 33% and a morbidity of 40% to 67% [2]. Often these patients are referred directly for cardiac transplantation, before definitive evaluation for revascularization [3]. Several large centers have shown comparable short-term morbidity, mortality, and functional recovery with coronary artery bypass grafting (CABG) rather than transplantation in this challenging group of patients [4–6]. In addition, revascularization has been shown to be much less expensive with similar survival when compared to transplantation [7].

Recent research has demonstrated that a substantial percentage of these patients may have "hibernating" or "stunned" myocardium that does not contribute to the overall contractility of the heart, but may be recruited into functionality with revascularization [8, 9]. Thus patients with severe LV dysfunction may have a significant amount of rejuvenated myocardium and a prolonged survival benefit, enhanced LV function, and improved New York Heart Association (NYHA) functional class after coronary bypass [10].

However, any long-term survival benefit after CABG in the face of severely depressed LV function is unknown. Furthermore, any increase in functional status or the degree of quantitative improvement in LV function has yet to be defined. Due to an ever-increasing elderly population with significant medical comorbidities and severe LV dysfunction referred for bypass, we sought to determine the long-term functional outcome of this population at our medical center. In this study, we reviewed a single center’s experience with CABG in patients with LV EF of 0.20 during the past 10 years. It is the goal of this study to define the potential for long-term survival in this patient population after CABG and to quantify any improvement in their overall functional status.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From January 1990 to December 1999, we identified 86 patients with severe LV dysfunction (EF 0.20) who underwent coronary artery bypass grafting at Henry Ford Health Sciences Center. The data on these patients were prospectively collected into our own institution’s satellite database that contributes to the national database of the Society of Thoracic Surgeons, but was retrospectively reviewed for the purpose of this study.

All patients had extremely poor LV function confirmed by echocardiography (ECHO), cardiac catheterization, or nuclear scintigraphy at the time of operation before being included in the study. Improvement in ventricular function was assessed by follow-up studies obtained at our institution throughout the remainder of the patients’ lives.

The patients were divided into two groups: elective and emergency CABG. Patients were considered emergent if they were hemodynamically unstable (in shock). All emergent cases had suffered an acute myocardial infarction within 24 hours of operation causing hemodynamic instability, with an acute drop in their EF to less than 20%. None of the elective patients were hemodynamically unstable. Eighteen of the elective patients (25%) had an acute myocardial infarction within 14 days of operation; however, none of them developed hemodynamic instability from it and most of these were only documented by enzyme elevations.

The indication for operation on the emergency cases was acute myocardial infarction with instability. In the majority of patients, the instability was due to the acute myocardial infarction itself and in others, the coronary catheterization (after the myocardial infarction) led to dissection or failed angioplasty causing instability. Regardless, all emergent patients were in shock before being rushed to the operating room. The indications for operation in the elective cases were unstable angina, chronic stable angina, postinfarction angina, or evidence of reversible ischemia on stress ECHO or nuclear scintigraphy. The long-term outcome and survival benefit after bypass was analyzed both separately and together for these two groups.

The medical records were reviewed in detail and any absent follow-up information was obtained by telephone contact with the patient’s family, physician, or the patient directly. Patients who had died had the date of death confirmed by the medical record or by reviewing the online Social Security Death Index. Follow-up was complete in 92% of the patients. Only 7 patients could not be contacted for recent follow-up information.

The statistical analysis was performed using the protocols incorporated into the SigmaPlot statistical software package (RockWare Inc., Golden, CO). The survival curve was plotted using a Kaplan-Meier analysis to obtain actuarial survival using the StatView software package (Abacus Concepts, Cary, NC). The Student’s t test for paired data was used to analyze the significance of differences between preoperative and postoperative ECHO and NYHA classification data.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
From January 1990 to December 1999, 86 patients with severely reduced LV function (mean EF, 0.18 ± 0.03; range, 0.10 to 0.20) underwent CABG. Sixty-four were men and 22 were women with an average age of 65 years (standard deviation ± 10 years). Sixty-one patients were white and 25 were African-American. The prevalence of risk factors was as follows: hypertension 67%, smoking 60%, diabetes 46%, hypercholesterolemia 38%, positive family history 19%, and obesity 7%. Triple vessel disease was found in 63 (73%), double vessel disease in 18 (21%), and single in 5 patients (6%) in which the left anterior descending artery was a dominant vessel and the circumflex system was more diminutive. Overall, 30 patients had significant (>50%) left main stenoses. Thirty-three patients (38%) had an acute myocardial infarction within 2 weeks before operation. Of these 33, 15 were massive infarctions leading to hemodynamic instability before or after cardiac catheterization requiring emergent bypass and 18 were small infarcts without hemodynamic sequelae. This led to 15 patients (17%) being performed emergently and 71 (83%) patients having elective operations.

Surgical intervention
An intraaortic balloon pump was required in 46% of the patients: preoperatively in 88% (including all hemodynamically unstable patients and prophylactically by cardiology in several others during catheterization) and intraoperatively or postoperatively in 12%. The indications for intraaortic balloon pump counterpulsation included prophylaxis, shock, low cardiac output, unstable angina, and failure to wean off cardiopulmonary bypass.

Eighty patients (93%) underwent CABG alone, and 6 (7%) had concomitant CABG and valve operation (mitral repair in 4, mitral replacement in 2). Thirty-four (40%) patients underwent triple bypass, 36 (42%) underwent double bypass, and 10 (12%) underwent single vessel bypass, all of these being to the left anterior descending artery. Five patients had a quadruple bypass and one received five bypass grafts (mean 2.4 grafts/patient ±0.8).

The left internal mammary artery was used in 42%, the left radial artery in 8%, the right internal mammary artery in none, and saphenous vein grafts accounted for the remainder. The left internal mammary artery or radial artery grafts were only used in the elective cases. Because the saphenous vein could be harvested and ready for use by the time the patient was on bypass, vein grafts were used exclusively in the emergent cases to reduce operative time. The left anterior descending artery was not grafted in 6 patients. Incomplete revascularization was secondary to heavily diseased target vessels or inadequate size in all patients.

All procedures were done using cardiopulmonary bypass with antegrade or retrograde blood cardioplegia. The average time on bypass was 83 minutes (standard deviation ±41 minutes) with a mean cross-clamp time of 46 minutes (standard deviation ± 28 minutes).

Postoperative care
The mean duration in the intensive care unit was 4.1 days (standard deviation ± 7.1 days). Inotropic support was required by 14 patients (16%) for 6 to 24 hours, 31 (36%) for 1 to 3 days, 30 (35%) for 4 to 6 days, but no patient required more than 6 days. Eleven patients (13%) required no inotropic support after operation.

Complications
There were 10 perioperative deaths (six within 24 hours after operation, and 4 patients died at 2, 5, 6, and 7 days after operation) for an 11% (10 of 86 patients) overall operative mortality rate. All of these deaths were due to low output cardiac failure. The next death in the series occurred at 2 months after operation and is considered a late mortality. The mortality rate for the elective procedures was 5% (4 of 71 patients). The mortality rate for the emergency cases was 40% (6 of 15 patients).

No patient received a left ventricular assist device. Of the 10 patients who died in the immediate perioperative period, 7 were too old for transplant consideration and 2, who were significantly younger, died intraoperatively. The final patient may have benefited from an left ventricular assist device; however, he appeared to be making slow improvement before suddenly dropping his cardiac output and rapidly deteriorating on postoperative day 7.

Data were available to accurately determine the complications from only 86% (74 of 86) of the patients. There was a 65% (48 of 74 patients) complication rate. Several patients had more than one complication. The breakdown of complications is listed in Table 1.

View larger version (69K): [in this window] [in a new window]   Fig 1. Kaplan-Meier curve showing the long-term survival after coronary artery bypass grafting. The brackets show 95% confidence limits.

Despite extensive review of the medical record and phone contact with patient’s family members, the cause of death could only be determined in 77% of all patients in the study. The causes of death are listed in Table 2. Cardiac causes were most common.

View larger version (84K): [in this window] [in a new window]   Fig 2. Upper graph shows the improvement in the ejection fraction after coronary artery bypass grafting. Lower graph documents the change in the ventricular dimensions over time (n = 64 patients). (DLVD = diastolic left ventricular dimension; EF = ejection fraction; SLVD = systolic left ventricular dimension.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
During the past 10 years, patients with severely reduced LV function successfully underwent CABG at our institution with an overall 11% perioperative mortality rate. Excluding the emergency cases, the mortality rate for the elective procedures was 5%. This is slightly better than that previously reported in the literature for this patient population (11% to 33%), with a similar complication rate of 65% (30% to 67%) [2, 11]. Patients with this degree of congestive heart failure had been previously shown to have four times the mortality rate after bypass compared to patients with better ventricular performance [12]. Of the 15 emergency cases, 6 patients died for a 40% mortality rate. The long-term survival for those discharged after the emergent operations was statistically worse than the elective population with a mean survival of 33 months versus 58 months. This may be due to the fact that all 15 emergency cases were performed on patients who sustained a hemodynamically significant acute myocardial infarction within 24 hours before bypass, a scenario known to have an increased mortality rate.

With a mean survival of 55 months after bypass for all patients and an overall improvement in NYHA classification from 2.8 to 1.6, the benefits would seem to support operative intervention in this group of patients, despite a slightly higher mortality rate. The unacceptably high mortality rate for emergency intervention would also mandate an earlier intervention that favors revascularization before severe deterioration in contractile function. However, our current results show that CABG can be performed on the severely dyskinetic ventricle with long-term improvement in EF and functional status. The actual 5-year survival rate was 59%, with an actuarial 5-year survival of 65% and an actuarial 10-year survival of 33%. Other investigators have shown similar results in patients with an EF less than 0.25 with a 60% to 72% 5-year survival after bypass [11, 13].

The reason for this improvement appears to be a decreased SLVD, which demonstrated a statistically significant improvement over preoperative values in the first 6 months after operation with a stable and improved trend out to 2 years. This correlates with prior work showing that chronic ischemia causes the left ventricle’s end-systolic diameter to dilate along the short axis, giving the left ventricle a more spherical shape with decreased contractility [14]. Likewise, the end-systolic dimension has been shown to reversibly decrease with improved contractility as the coronary perfusion pressure increases [15]. The improved SLVD documents the increase in contractile function and remained much lower up to 24 months after operation, although this did not reach statistical significance. A favorable change in LV end-systolic dimension has been shown to be the only reliable discriminator of mortality in long-term follow-up studies [16]. The DLVD remained basically the same after revascularization. Between 24 and 48 months, the SLVD began to increase again which correlates with an overall decrease in the group’s ejection fraction (Fig 2). After 48 months, the number of patients in each time bracket was reduced and affects the quality of any possible interpretation after this point. The preoperative LV dimension did not have an affect on the long-term postoperative outcome.

Patients with a significant amount of hibernating myocardium or reversible ventricular dysfunction have been shown to have immediate improvement in LV function as soon as 6 to 48 hours after revascularization [17]. This is likely why the most dramatic change in EF occurred in the first 6 months after operation, with an overall increase in the EF by 11%. This gradually peaked at 17% improvement by 24 months. In a similar group of patients with severe ventricular dysfunction, other researchers have shown an average improvement of 11% to 18% [18, 19].

Despite the improved cardiac function, cardiac disease was still the most common cause of death (55%). Progressive deterioration in contractility years after bypass lead to recurrent congestive heart failure or heart and renal failure in 39%. The common comorbidities of obstructive pulmonary disease and vascular occlusive disease accounted for most of the remaining causes. Patients who initially showed dramatic improvement in LV function also had a tendency for longer survival, whereas patients who experienced limited LV functional recovery had a tendency to display later recurrence of heart failure symptoms and ultimately died from heart failure. Thus, despite remarkable improvements in functional capacity, the benefit from bypass is somewhat time limited, with a large percentage of patients eventually developing recurrent symptoms years later [20].

In patients with such severe ventricular dysfunction, it is difficult to predict which patients will show a dramatic response after revascularization and which will not. Several attempts to determine which patients have viable but hibernating myocardium using stress dobutamine echocardiography, positron emission tomography, or thallium scintigraphy have been met with mixed results [21–23]. Reversible defects seen by these imaging modalities do not always awaken into contractile segments after bypass. Some investigators have even stated that these preoperative tests have no predictive benefit and therefore, should not be routinely used to determine which patients should be offered bypass [11]. Only 4 patients in our study underwent preoperative thallium scintigraphy to determine the presence of reversible defects or hibernating myocardium. This information was not available routinely for all patients. Rather, most patients had chronic stable, unstable, or postinfarction angina with reasonable distal targets and went directly to operation for these indications. The vast majority had substantially improved LV function after bypass. Whether or not this same majority would have displayed reversibility on scintigraphic scans remains unknown. After reviewing these results, it would seem that the indication for operation in patients with a dilated left ventricle and true ischemic cardiomyopathy is evidence of reversibility (by nuclear scintigraphy), inducible ischemia (by stress ECHO), or ongoing ischemia (by symptoms of angina).

One patient in this series did have a left ventricular aneurysm that was repaired at the same time as her CABG using a pericardial patch. But in general, we have not adopted the method described by Dor and colleagues [24] and have not routinely excised the akinetic scar to reconstruct the left ventricle in our patients undergoing CABG. It is interesting to contrast our results with theirs, as we also showed a dramatic improvement in LV function, without the LV reconstruction. Because Dor and associates [25] routinely revascularize their patients, in addition to the LV myoplasty, it is unclear whether the revascularization alone is enough to account for the improved LV function. However, because our average preoperative end-diastolic LV dimension was 6.02 ± 0.85 cm, most patients in this series did not have severely dilated left ventricles in the 7 to 8-cm range, for which endoventricular myoplasty may have been more prudent.

In conclusion, patients with severe LV dysfunction can derive long-term benefit from CABG through improved LV contractility as documented by a significantly decreased SLVD and increased EF. Successful bypass is associated with a 59% actual 5-year survival rate and significantly improved NYHA functional class. The immediate and long-term mortality rates are better for elective rather than emergency cases. Although the mortality rate in this population is slightly higher than that in patients with better LV contractility, the global improvements in their overall function make bypass worthwhile.

	References

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This Article Abstract Full Text (PDF) 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): Gaetano Paone Alvise F. Bernabei Norman A. Silverman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carr, J. A. Articles by Silverman, N. A. Search for Related Content PubMed PubMed Citation Articles by Carr, J. A. Articles by Silverman, N. A. Related Collections Coronary disease