CABG in patients with left ventricular dysfunction: indications, techniques and outcomes

Abstract

Ischemic chronic heart failure (CHF) represents one of the cardiovascular diseases with the worst degree of morbidity and mortality in the western world, and with the highest health care costs. Despite several studies demonstrated that surgical revascularization (CABG), especially in the presence of viable myocardium, improve heart function, and therefore, survival, the matter remains unclear and controversial. In the late 1970s, the Coronary Artery Surgery Study showed that a subgroup of patients with coronary artery disease, angina, and reduce LV function had a significant survival benefit after CABG compared to those treated medically. The key concept behind this observation was the presence of viable myocardium, which can resume function following revascularization. In contrary, the surgical treatment for ischemic heart failure (STICH) trial, which randomized patients with CAD and LV dysfunction to evidence-based medical therapy or CABG plus medical therapy, failed to demonstrate at a median follow-up of 56 months a significant difference between the CABG group and the medical therapy group in the rate of death from any cause. However, the results of the STICH extension study (STICHES) at 10 years follow-up demonstrated that CABG is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and readmission for heart compared to optimal medical therapy (OMT) in patients with severe ischemic LV dysfunction. Therefore, this review discusses the available evidences in literature, from observational studies to randomized trials, including operative techniques and controversial issues, in order to better clarify the role of CABG in the current management of ischemic patients with LVD.

Keywords: CABG; Heart failure; Left ventricular dysfunction.

Conflict of interest statement

Conflict of interestThe authors declare that they have no conflict of interest.

© Indian Association of Cardiovascular-Thoracic Surgeons 2018.

Figures

Fig. 1

The LV is opened parallel to the LAD, the scar tissue is identified as well as the border-zone and the remote myocardium

Fig. 2

A mannequin is filled and inserted in the LV cavity, in order to avoid excessive reduction and amputation of the LV

Fig. 3

The remaining cavity is closed with an ovalar patch trying to respect the longitudinal dimension of the LV

Fig. 4

The overall experience of surgical ventricular reconstruction at IRCCS Policlinico San Donato