RESULTS OF REVASCULARIZATION IN PATIENTS WITH SEVERE LEFT-VENTRICULARDYSFUNCTION

Background In patients with coronary artery disease and poor ventricul ar function (ejection fraction, <20%), bypass grafting remains a surgi cal challenge. This study evaluates experience with isolated revascula rization in such patients. Methods and Results In 79 consecutive patie nts (69 men, 10 women; average age, 59+/-9 years), preoperative ejecti on fraction was 18+/-5%. Indications for surgery were congestive heart failure (CHF) in 5 of 79 patients (6%), CHF and angina in 19 (24%), a ngina in 41 (52%), ventricular arrhythmias (VAs) in 8 (10%), and criti cal anatomy in 6 (8%). Some patients had prior VAs (23 of 79; 29%) or mitral regurgitation (18; 23%) and required emergent surgery (25; 32%) . At surgery, temperature mapping ensured adequate distribution of ant egrade cold cardioplegia, with 3.6+/-0.7 grafts per patient, including left internal mammary artery graft in 60 of 79 (76%) and endarterecto my in 14 (18%). Hospital mortality was 3.8%. Perioperative support inc luded intra-aortic balloon pump in 18 of 79 (23%) and drugs; for VAs i n 28 (35%). Morbidity included myocardial infarction in 2 of 79 (2.5%) and stroke in 2 (2.5%). During follow-up, there were 19 late deaths. Actuarial survival was 94%, 82%; and 65% at 1, 2, acid 5 years, respec tively, and was similar in patients with severe angina, CHF, mitral re gurgitation, or VAs. Freedom from sudden death was 100%, 98%: and 91% at 1, 2, and 5 years, respectively. Among survivors, angina improved i n 84% and heart failure improved in 26%. Conclusions These data suppor t bypass graft surgery in patients with severe LV dysfunction. With ca reful cardioplegic techniques, hospital mortality was low (3.8%). Long -term survival is encouraging, with good relief of symptoms in most pa tients. Perioperative VAs are frequent but respond to medical treatmen t, with only 23% of patients discharged on anti-arrhythmic drugs. Five -year freedom from sudden death is 91%, with only 3 late sudden deaths in this series.