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COMMENTARY
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 166-167  

Importance of coronary artery bypass grafting in patients with left ventricular dysfunction


1 Department of Cardiovascular Surgery, Bozok University School of Medicine, Yozgat, Turkey
2 Department of Nutrition and Dietetics, Bozok University School of Health, Yozgat, Turkey

Date of Web Publication14-Mar-2017

Correspondence Address:
Hasan Ekim
Department of Cardiovascular Surgery, Bozok University School of Medicine, Adnan Menderes Bulvarı, Adliye Karşısı, Yozgat
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.202114

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How to cite this article:
Ekim H, Ekim M. Importance of coronary artery bypass grafting in patients with left ventricular dysfunction. Med J DY Patil Univ 2017;10:166-7

How to cite this URL:
Ekim H, Ekim M. Importance of coronary artery bypass grafting in patients with left ventricular dysfunction. Med J DY Patil Univ [serial online] 2017 [cited 2017 May 23];10:166-7. Available from: http://www.mjdrdypu.org/text.asp?2017/10/2/166/202114

Coronary artery disease is a major cause of morbidity and mortality worldwide. Patients with coronary artery disease present with either acute or chronic clinical manifestations. Medical therapy decreases myocardial oxygen requirements to relieve myocardial ischemia in these patients. By contrast, revascularization procedures can effectively restore impaired myocardial blood supply.[1] The long-term benefits of coronary artery bypass grafting (CABG) have been found to be superior to medical therapy even in patients with advanced left ventricular dysfunction.[2] The outcomes of alternative surgical interventions (cardiac transplantation, myocardial laser revascularization) to CABG are not always satisfactory.[2]

Considering the development of interventional cardiology in the recent decade, most patients requiring revascularization have been treated with percutaneous transluminal coronary angioplasty procedures instead of CABG. Therefore, CABG is performed in more complicated patients.

Off-pump CABG can be performed adequately and safely on a beating heart without cardiopulmonary bypass (CPB) even in patients with ventricular dysfunction. Thus, patients can avoid the ischemia-reperfusion injury and the harmful effects of CPB with satisfactory short-term and long-term outcomes.[3]

Off-pump CABG is a viable alternative to on-pump CABG for patients with severely impaired left ventricular function or those with acute myocardial infarction (MI) and cardiogenic shock.[4] The adverse effects of CPB may be poorly tolerated by the myocardial tissue in these circumstances. Off-pump CABG may be performed with acceptable morbidity and mortality in patients with ejection fraction (EF) ≤35%.[4] However, in some circumstances, conversion to on-pump CABG may be required due to severe hemodynamic instability. Patients who suffered from hemodynamic deterioration during cardiac manipulation should be converted to on-pump CABG after full-dose heparinization, as reported in an article (outcome of coronary artery bypass graft surgery in patients with low EF) published in this issue of the journal. In patients requiring CPB, adequate myocardial protection should be maintained by antegrade and retrograde combined use of blood cardioplegia during aortic cross-clamping time.

In patients with ventricular dysfunction and in acute phase of MI, cardiac manipulations during off-pump surgery may lead to hypotension and arrhythmias. Therefore, these patients should be operated on in stable condition after 30 days of MI, if possible.[3]

During operation, the sites of proximal anastomoses should be controlled to avoid plaque-related complications by ascending aortic palpation or epiaortic ultrasonography.[5] If the ascending aorta found severely calcified, using off-pump CABG and sequential internal mammary artery grafts should be preferred to avoid severe complications even in patients with good ventricular function.

Off-pump CABG can be safely performed with acceptable mortality and morbidity even in patients with ventricular dysfunction. Therefore, patients with poor ventricular function should not be regarded as inoperable.

 
  References Top

1.
Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation 2005;111:3481-8.  Back to cited text no. 1
    
2.
Selim Isbir C, Yildirim T, Akgun S, Civelek A, Aksoy N, Oz M, et al. Coronary artery bypass surgery in patients with severe left ventricular dysfunction. Int J Cardiol 2003;90:309-16.  Back to cited text no. 2
    
3.
Ling Y, Liu X, Chen Y, Chen S, Jin X, Dong S, et al. One center experience in China. Int J Clin Exp Med 2015;8:21477-81.  Back to cited text no. 3
    
4.
Moshkovitz Y, Sternik L, Paz Y, Gurevitch J, Feinberg MS, Smolinsky AK, et al. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 1997;63:S44-7.  Back to cited text no. 4
    
5.
Caputti GM, Palma JH, Gaia DF, Buffolo E. Off-pump coronary artery bypass surgery in selected patients is superior to the conventional approach for patients with severely depressed left ventricular function. Clinics 2011;66:2049-953.  Back to cited text no. 5
    




 

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