Functional outcome after myocardial revascularization in ischemic left ventricular failure

BACKGROUND: Myocardial revascularization in patients with left ventricular failure (ejection fraction <30%) offers survival comparable to heart transplantation. The functional outcome, however, has yet to be determined. In order to assess the clinical results in patients with LVEF <30% undergoing coronary artery bypass grafts (CABG), 101 consecutive patients operated between 1/91 and 1/97 were reviewed retrospectively. METHODS: The patients were stratified according to presentation: 65 pts had angina (Group 1) and 36 congestive failure (Group 2). Mean age (62 ± 7 vs 60 ± 8 yrs), sex (90 vs 88% male), LVEF (0.28 ± 0.04 vs 0.29 ± 0.04), prior myocardial infarction (1.2 ± 0.4 vs 1.2 ± 0.5 episodes/pt), presence of vital myocardium at scintiscan or low-dose dobutamine echocardiography (92 vs 93%), need for preoperative IABP (3.1 vs 8.3%), aortic cross-clamp (53 ± 21 vs 60 ± 21 min) and cardiopulmonary bypass (104 ± 31 vs 114 ± 36 min) times were comparable. RESULTS: There was only 1 (1%) perioperative death due to low- output syndrome. Eleven pts (6 vs 5, Group 1 vs Group 2) had postoperative low-output syndrome, requiring IABP in 7 pts (4 vs 3). There were 14 (10 vs 4, Group 1 vs Group 2) deaths during follow-up (29 ± 19 months, range 2- 67), with an overall actuarial survival of 91 ± 4 vs 100% at 1 yr and 74 ± 9 vs 78 ± 10% at 5 yrs in Group 1 vs Group 2, respectively (p = ns). Actuarial symptom-free survival was 89 ± 4 vs 84 ± 6% at 1 yr and 49 ± 9 vs 28 ± 11% at 5 yrs, respectively (p = 0.05). Despite the high recurrence of congestive failure (22 vs 66% in Group 1 vs Group 2, p = 0.004), improvement in functional class (3.1 ± 0.8 vs 1.5 ± 0.7 in Group 1 and 2.7 ± 0.7 vs 1.8 ± 0.5 in Group 2) and LVEF (0.28 ± 0.04 vs 0.38 ± 0.04 in Group 1 and 0.29 ± 0.04 vs 0.40 ± 0.06 in Group 2) was found in both groups at follow-up. CONCLUSIONS: In spite of improving early and late survival after revascularization for ischemic left ventricular failure, patients presenting with congestive failure have an unsatisfactory symptom-free survival. Further studies are necessary to ascertain the relative indications to revascularization or transplantation in this specific patient subgroup.