EFFECT OF LOW LEFT-VENTRICULAR EJECTION FRACTIONS ON THE OUTCOME OF PRIMARY CORONARY-BYPASS GRAFTING IN END-STAGE CORONARY-ARTERY DISEASE

Advanced ischemic heart disease (HID) with very low left ventricular e jection fraction (LVEF), pulmonary hypertension (PHT) with or/without left ventricular aneurysm (LVA) are criteria for defining end-stage co ronary artery disease (ESCAD). Coronary artery by-pass grafting is oft en denied to these patients. Between January 1990 and December 1993, 9 1 patients with ESCAD, significant 2 or 3-vessel disease (stenosis gre ater than or equal to 70%) and LVEF less than or equal to 25% underwen t primary CABG at our institutions. The mean age was 62.5 +/- 8.0 year s (41-81), 89% were men. Eighty-one patients were in preoperative NYHA (New York Heart Association) functional class 3 and 4. Mean LVEF was 21.3 +/- 3.8% (10-25). Mitral regurgitation (MR) was present in 39/91 (43%). The systolic pulmonary artery pressure (PAP) was 33.2 +/- 17.1 mmHg (11-75) and the wedge pressure was 19.0 +/- 10.8 mmHg (5-47). Twe nty-two patients had significant PHT with a systolic PAP greater than or equal to 40 mmHg. The overall perioperative mortality was 14.3% (13 /91). Low postoperative cardiac output occurred in 33 patients, requir ing intraaortic ballon support in 13. Gastrointestinal complications o ccurred in 6 patients and neurological events in one. Fifteen patients had additional left ventricular aneurysm repair. There was a good cor relation between LVEF and PAP (r = 0.782). Surprisingly, in a subset o f patients with preoperative PHT and LVEF less than or equal to 25% th e mortality rate was only 4.6% (1/22). Other perioperative complicatio ns did not differ. At an average 3 months follow up of 20 patients, al l improved their NYHA class by 1.5 +/- 0.8, mean ergometry tolerance w as 83 +/- 32 W and an improved LVEF was achieved, 40.9 +/- 9.9, p < 0. 001, without any mortality. Seven patients improved their MR with at l east one grade compared to preoperatively. A combination of LVEF less than or equal to 25%, pulmonary artery hypertension, mitral regurgitat ion with or without left ventricular aneurysm is not a contra-indicati on for primary CABG provided that the patient presents with significan t ischemia.