Predicting long-term functional results after myocardial revascularizationin ischemic cardiomyopathy

Objective: The goal of the present study was to define the early and late f unctional results after revascularization in ischemic cardiomyopathy and to identify variables predictive of a favorable outcome. Methods: A retrospective review of all consecutive patients with ischemic c ardiomyopathy undergoing myocardial revascularization between January 1991 and June 1998 was undertaken. One hundred sixty-seven patients (140 men) ag ed 60 +/- 8 years (range, 39-77 years) with angina (n = 107), congestive he art failure (n = 54), or silent ischemia (n = 6) were identified. One hundr ed six (63%) patients with angina were in Canadian Cardiovascular Society c lass III or IV, and 40 (24%) patients with congestive failure were in New Y ork Heart Association class III or IV. The preoperative left ventricular ej ection fraction averaged 0.28 +/- 0.05 (range, 0.16-0.30). Thirteen (8%) pa tients required preoperative mechanical life support. A mean of 2.9 +/- 0.9 grafts per patient were performed, with an average myocardial ischemia tim e of 53 +/- 23 minutes and bypass time of 104 +/- 31 minutes. Results: There were 3 (1.7%) early deaths and 21 (13%) deaths during follow -up (2.7 +/- 2.1 years; range, 0.3-7.8 years), producing a survival of 94% +/- 2% and 75% +/- 10% at 1 and 5 years, respectively. Despite a significan t increase in left ventricular ejection fraction (0.28 +/- 0.05 vs 0.38 +/- 0.09, P = .0001), only 89 (54%) patients were symptom-free at follow-up. F reedom from recurrent angina was 98% +/- 1% and 81% +/- 8%, whereas freedom from congestive failure was 78% +/- 11% and 37% +/- 20% at 1 and 5 years, respectively. Follow-up New York Heart Association class in patients with c ongestive failure was improved (40/54 class III-IV vs 11/54 class III-IV, P = .0001). Multivariate analysis showed a lower ejection fraction (P = .01) , preoperative congestive failure (P = .03), and a need for preoperative in tra-aortic balloon pumping (P = .03) to be associated with a greater preval ence of recurrent congestive failure, whereas male sex (P = .01), preoperat ive angina (P = .04), use of the internal thoracic artery (P = .03), and hi gher number of grafts (P = .01) were associated with lower prevalence. Male sex (P = .06), higher number of grafts (P = .04), and shorter duration of myocardial ischemia (P = .04) were also predictive of improvement in New Yo rk Heart Association class at follow-up. Conclusions: Despite satisfactory early and late survival, late functional outcome after myocardial revascularization in ischemic cardiomyopathy remai ns suboptimal because of recurrence or persistence of congestive failure. S election of appropriate surgical candidates and extensive use of complete r evascularization with the internal thoracic artery may substantially improv e functional results.