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J Thorac Cardiovasc Surg 2000;119:550-557
© 2000 Mosby, Inc.
SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE |
From the University of Toronto, Toronto, Ontario, Canada.
Address for reprints: Lynda L. Mickleborough, MD, EN 13-217, The Toronto Hospital, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada (E-mail: lmickleborough{at}torhosp.toronto.on.ca ).
Objective: In patients with coronary disease and poor left ventricular function, bypass grafting remains a surgical challenge. This study evaluates experience in 125 consecutive patients with ejection fraction less than 20% (study group).
Methods: Preoperative viability studies were not used for patient selection. Clinical data were prospectively collected. The average age of the study subjects was 59 ± 9 years, and 112 (90%) were male. Most patients (108 [86%]) were in symptom class III or IV. Main indications for surgery included angina in 62 (50%), heart failure and angina in 36 (29%), heart failure in 9 (7%), ventricular arrhythmia in 2 (2%), and critical anatomy in 16 (13%). Significant mitral regurgitation was present in 48 (38%), and distal vessels were poorly visualized in 67 (54%). At surgery, temperature mapping guided an integrated approach to cold cardioplegia. Results in this group were compared with those obtained in case-matched control subjects receiving cardioplegia without temperature mapping (matched for age, sex, functional class, and urgency of operation).
Results: Hospital morbidity (intra-aortic balloon pump support) and mortality rates were significantly lower in the study group versus those of control subjects (15% vs 30%, P = .004; and 4% vs 11%, P = .03, respectively). In study patients the 5-year actuarial survival was 72%. Among survivors, both anginal class and heart failure class improved significantly. By means of multivariate analysis, survival was adversely affected by older age, class IV symptoms, and poorly visualized distal vessels.
Conclusions: These results support the use of coronary artery bypass grafting in patients with severe left ventricular dysfunction without case selection on the basis of viability studies or visibility of distal vessels. Low hospital morbidity and mortality rates have been achieved when temperature mapping guides cardioplegia. Symptoms are improved in most patients, and long-term survival is encouraging.
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