Circulation, Vol 68, 785-795, Copyright © 1983 by American Heart Association
EL Alderman, LD Fisher, P Litwin, GC Kaiser, WO Myers, C Maynard, F Levine and M Schloss
We identified 420 medically treated and 231 surgically treated patients
(coronary graft plus myocardial surgery in 30%) who had severe left
ventricular dysfunction manifest by an ejection fraction below 0.36 and
markedly abnormal wall motion. Compared with medically treated patients,
those treated surgically had more severe angina (56.7% vs 29.0% class III
or IV; p less than .001), less heart failure as predominant symptom (11.1%
vs 18.8%; p less than .003), more severe coronary disease (66.7% vs 50.2%
three-vessel disease; p less than .001), a greater concentration of left
main coronary artery lesions greater than 70% (12.6% vs 3.8%: p less than
.001), and a greater estimated extent of jeopardized myocardium (p less
than .001). Multivariate regression analysis of survival, which adjusts for
the above covariates, showed that surgical treatment prolonged survival (p
less than .05), although it ranked below severity of heart failure
symptoms, age, ejection fraction, and left main stenosis greater than 70%
in determining prognosis. Surgical benefit was most apparent for patients
with ejection fractions below 0.26 who had a 43% 5 year survival with
medical treatment vs 63% with surgery. Surgically treated patients
experienced substantial symptomatic benefit compared with medically treated
patients if their presenting symptoms were predominantly angina; however,
there was no relief of symptoms caused primarily by heart failure. We
conclude that patients with predominantly ischemic pain symptoms, despite
poor left ventricular function, benefit from surgery; however, operative
mortality in this high-risk subset must equal or better the 6.9% obtained
in this study.
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Results of coronary artery surgery in patients with poor left ventricular function (CASS)
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