PREDICTING SURVIVAL AFTER CORONARY REVASCULARIZATION FOR ISCHEMIC CARDIOMYOPATHY

Background. The success of coronary revascularization for ischemic car diomyopathy (left ventricular ejection fraction of 0.25 or less) has b een unpredictable. We and others have demonstrated that the hospital o perative mortality rate for these operations has been surprisingly low , particularly if evidence of ischemia is present. We subsequently lib eralized our selection criteria based on our hypothesis that coronary artery bypass grafting is safe in this subset of patients regardless o f the status of their distal coronary vasculature. Methods. To examine this hypothesis, we studied retrospectively our patients undergoing c oronary artery bypass grafting from 1983 to 1993. Ninety-six patients with ejection fractions of 0.25 or lower underwent this operation, wit h 88 hospital survivors (mortality 8%). All of the patients had clinic al 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 mea n). Patients were excluded if they had valvular heart disease other th an mild to moderate mitral regurgitation, required resection of a vent ricular aneurysm, or required an emergency operation for acute coronar y occlusion. Possible predictors of death were examined retrospectivel y. The catheterization films were reviewed retrospectively by a cardio vascular surgeon who was blinded to patient outcome and was never invo lved 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-clam p time, and the number of bypass grafts had no significant effect on o utcome in the perioperative period. Conclusion. These results demonstr ate that poor vessel quality and older age are predictors of poor outc ome in patients with low ejection fractions undergoing myocardial reva scularization. We conclude that poor distal coronary vasculature is a contraindication to coronary artery bypass grafting in patients with a n ejection fraction of 0.25 or less, even if angina is present.