Outcomes of Coronary Artery Disease Patients with Severe Left Ventricular Dysfunction Undergoing Surgical Management
Surgical Outcomes of Ischaemic Cardiomyopathy
DOI:
https://doi.org/10.1532/hsf.4353Keywords:
severe left ventricular dysfunction, ischaemic cardiomyopathy, coronary artery bypass surgery, ischaemic mitral regurgitationAbstract
Background: Surgical revascularization by coronary artery bypass grafting (CABG) is the gold standard treatment for coronary artery disease. But, in patients with severe left ventricular dysfunction (ischemic cardiomyopathy), the result of CABG is different from those with normal left ventricular function. The coronary artery disease pattern in the Indian subconti-nent is different from the western world, due to the diffuse nature of coronary involvement, the smaller size of native vessels, increased prevalence of diabetes mellitus and other risk factors, and more prevalence of severe left ventricular dysfunction. Most of the studies regarding the surgical outcomes in ischemic cardiomyopathy come from western countries. This study attempts to assess the outcomes of surgical management of ischemic cardiomyopathy in the Indian subcontinent.
Methods: A single-center retrospective cohort study was conducted at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. The data of CAD pa-tients, who underwent surgical coronary revascularization for severe LV dysfunction from January 2010 to December 2014, were collected from the hospital records and through tele-phonic interviews in a structured study proforma. A total of 146 patients satisfied the criteria and were followed up for a period of 5 years.
Results: The mean age of the study population was 55.6 (8.8) years. Male preponderance was observed (94.52%; N = 138). CABG alone was done in 62.3% (N = 91) of the study partici-pants. CABG with linear plication was done in 23.3% (N = 34), CABG with MV repair in 7.5% (N = 11), and CABG with DORS in 6.8% (N = 10). The majority of patients (N = 54, 37%) received 4 grafts. Thirty-day mortality observed in the study population was 11 (7.5%). The causes documented were cardiac causes in 9 (82%), cerebrovascular events in one (9%), and septicemia in one (9%). The mean of 5-year survival of the study population was 94.2 (3.5) months with 95% CI 87.32, 101.13. There was a substantial improvement in the degree of mitral regurgitation. Ejection fraction (EF) also showed improvement. The mean preoperative EF was 29.51 (4.84%) and that of post-op was 39.92 (9.0%).
Conclusion: Despite the challenges of diffusely diseased coronary arteries, severe LV dysfunction, addressing associated significant MR and ventricular aneurysms, the outcome of surgical management of CAD with severe LV dysfunction, in the Indian population can be done with acceptable results. Randomized control studies in this subset can provide more solid evidence in this regard.
References
Ajay VS, Prabhakaran D. 2010. Coronary heart disease in Indians: implications of the INTERHEART study. Indian J Med Res. 132:561–566.
Campwala SZ, Bansal RC, Wang N, Razzouk A, Pai RG. 2005. Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery. Eur J Cardiothorac Surg. Nov;28(5):783-7.
Davoodi S, Sheikhvatan M, Karimi A, Ahmadi SH, Goodarzynejad H, Fathollahi MS. 2012. Outcomes and long-term quality of life of patients with severe left ventricular dysfunction who underwent coronary artery bypass surgery. Gen Thorac Cardiovasc Surg. Apr;60(4):202-12.
Elefteriades JA, Morales DL, Gradel C, Tollis G, Levi E, Zaret BL. 1997. Results of coronary artery bypass grafting by a single surgeon in patients with left ventricular ejection fractions ≤ 30%. Am J Cardiol. 79:1573–1578.
Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. 2008. Epidemiology and causation of coronary heart disease and stroke in India. Heart. 94:16–26.
Ji Q, Xia LM, Shi YQ, et al. 2017. Impact of severe left ventricular dysfunction on inhospital and mid-term outcomes of Chinese patients undergoing first isolated off-pump coronary artery bypass grafting. J Cardiothorac Surg. 12(1):87. Published 2017 Oct 10.
Jose R, Shetty A, Krishna N, Chathoth V, Bhaskaran R, Jayant A, Varma PK. 2019. Early and Mid-Term Outcomes of Patients Undergoing Coronary Artery Bypass Grafting in Ischemic Cardiomyopathy. J Am Heart Assoc. May 21;8(10):e010225.
Khaled S, Kasem E, Fadel A, Alzahrani Y, Banjar K, Al-Zahrani W, Alsulami H, Allhyani MA. 2019. Left ventricular function outcome after coronary artery bypass grafting, King Abdullah Medical City (KAMC)- single-center experience. Egypt Heart J. Aug 5;71(1):2.
Khan MS, Islam MY, Ahmed MU, Bawany FI, Khan A, Arshad MH. 2014. On pump coronary artery bypass graft surgery versus off pump coronary artery bypass graft surgery: a review. Glob J Health Sci. 6(3):186-193.
Kumar S, Agarwala S, Talbot C, Nair RU. 2008. Long term survival after coronary endarterectomy in patients undergoing combined coronary and valvular surgery--a fifteen year experience. J Cardiothorac Surg. Mar 26;3:15.
Ngu JMC, Ruel M, Sun LY. 2018. Left ventricular function recovery after revascularization: comparative effects of percutaneous coronary intervention and coronary artery bypass grafting. Curr Opin Cardiol. Nov;33(6):633-637.
Popovic B, Maureira P, Juilliere Y, Danchin N, Voilliot D, Vanhuyse F, Villemot JP. 2017. Bilateral vs unilateral internal mammary revascularization in patients with left ventricular dysfunction. World J Cardiol. Apr 26;9(4):339-346.
Shapira OM, Hunter CT, Anter E, Bao Y, DeAndrade K, Lazar HL, Shemin RJ. 2006. Coronary artery bypass grafting in patients with severe left ventricular dysfunction-early and mid-term outcomes. J Card Surg. May-Jun;21(3):225-32.
Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, Lucke JC, Baltz JH, Novitzky D. 2009. Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. Nov 5;361(19):1827-37.
Shroyer AL, Hattler B, Grover FL. 2017. Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass. N Engl J Med. Nov 9;377(19):1898-1899.
Varma PK, Krishna N, Jose RL, Madkaiker AN. 2017. Ischemic mitral regurgitation. Ann Card Anaesth. 20:432-9.
Varma P, Kundan S, Ananthanarayanan C, Panicker VT, Pillai VV, Sarma PS, Karunakaran J. 2014. Demographic profile, clinical characteristics and outcomes of patients undergoing coronary artery bypass grafting–retrospective analysis of 4,024 patients. Indian J Thorac Cardiovasc Surg. 30:272–277.
Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, Ali IS, Pohost G, Gradi-nac S, Abraham WT, Yii M, Prabhakaran D, Szwed H, Ferrazzi P, Petrie MC, O'Connor CM, Panchavinnin P, She L, Bonow RO, Rankin GR, Jones RH, Rouleau JL; STICH Investigators. 2011. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. Apr 28;364(17):1607-16.
Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, et al.; STICHES Investigators. 2016. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 374:1511–1520.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, Gupta R, Joshi P, Kerkar P, Thanikachalam S, Haridas KK, Jaison TM, Naik S, Maity AK, Yusuf S. 2008. CREATE registry investigators. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. Apr 26;371(9622):1435-42.
