Surgical Management of Ischemic Heart Disease Patients With Left Ventricular Dysfunction in Lower-Middle-Income Countries: Our Strategies and Experience at the Medical Teaching Institute-Hayatabad Medical Complex (MTI-HMC) Peshawar, Pakistan

Overview

Journal Cureus

Date 2025 Feb 7

PMID 39917095

Authors

Muhammad Aasim

Raheel Khan

Atta Ul Mohsin

Jibran Ikram

Raheela Aziz

Ayesha Zahid

Affiliations

Soon will be listed here.

Abstract

Introduction and objectives Severe left ventricular dysfunction (LVD) in coronary artery disease (CAD) is linked to high risks and limited outcomes. Coronary artery bypass grafting (CABG) remains a key surgical intervention for these patients. This study aimed to assess hospital and short-term outcomes in patients with severe LVD undergoing isolated CABG and identify predictors of adverse outcomes. Methodology We conducted a retrospective study of 454 patients who underwent CABG for CAD with significant LVD at Hayatabad Medical Complex between 2018 and 2024. Data were extracted from clinical records and analyzed statistically to evaluate outcomes and predictors. Results The study included 454 patients with a mean age of 58.14 ± 9.576 years and a mean ejection fraction of 35.59 ± 3.996%. There were 396 (87.2%) male patients with common comorbidities, including hypertension (122, 26.9%), diabetes mellitus (88, 19.4%), and smoking (39, 8.6%). Intraoperative findings showed a mean cardiopulmonary bypass (CPB) time of 155.94 ± 38.120 minutes, with 451 (99.3%) achieving LIMA (left internal mammary artery) to LAD (left anterior descending artery) revascularization. Postoperative in-hospital mortality was 21 (4.6%), re-intubation occurred in 18 (4.0%), and arrhythmias were observed in 26 (5.7%). Wound infections were minimal (444 (97.8%) without infection), and 406 (89.4%) underwent elective CABG, while nine (2.0%) had emergent CABG, mostly due to ventricular septal rupture. Conclusion CABG remains a vital surgical intervention for patients with severe LVD, offering favorable short-term outcomes despite the inherent risks. Key factors contributing to these results include comprehensive myocardial revascularization, effective use of internal mammary artery grafting, and advanced myocardial protection strategies. This study highlights the potential of CABG to improve survival and functional outcomes in this high-risk population.

References

Scott S, DEUPREE R, Sharma G, LUCHI R . VA Study of Unstable Angina. 10-year results show duration of surgical advantage for patients with impaired ejection fraction. Circulation. 1994; 90(5 Pt 2):II120-3. View

Aasim M, Aziz R, Mohsin A, Khan R, Zahid A, Awais M . Outcomes of Coronary Artery Bypass Grafting in Patients With Impaired Left Ventricular Function and the Role of Preoperative Myocardial Viability. Cureus. 2025; 16(12):e76198. PMC: 11750051. DOI: 10.7759/cureus.76198. View

Hillis G, Zehr K, Williams A, Schaff H, Orzulak T, Daly R . Outcome of patients with low ejection fraction undergoing coronary artery bypass grafting: renal function and mortality after 3.8 years. Circulation. 2006; 114(1 Suppl):I414-9. DOI: 10.1161/CIRCULATIONAHA.105.000661. View

Carney R, Freedland K . Depression and coronary heart disease: more pieces of the puzzle. Am J Psychiatry. 2007; 164(9):1307-9. DOI: 10.1176/appi.ajp.2007.07071053. View

Velazquez E, Lee K, Deja M, Jain A, Sopko G, Marchenko A . Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011; 364(17):1607-16. PMC: 3415273. DOI: 10.1056/NEJMoa1100356. View

Lam C, Donal E, Kraigher-Krainer E, Vasan R . Epidemiology and clinical course of heart failure with preserved ejection fraction. Eur J Heart Fail. 2010; 13(1):18-28. PMC: 3003453. DOI: 10.1093/eurjhf/hfq121. View

Gheorghiade M, Sopko G, De Luca L, Velazquez E, Parker J, Binkley P . Navigating the crossroads of coronary artery disease and heart failure. Circulation. 2006; 114(11):1202-13. DOI: 10.1161/CIRCULATIONAHA.106.623199. View

Borlaug B, Paulus W . Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J. 2010; 32(6):670-9. PMC: 3056204. DOI: 10.1093/eurheartj/ehq426. View

Topkara V, Cheema F, Kesavaramanujam S, Mercando M, Cheema A, Namerow P . Coronary artery bypass grafting in patients with low ejection fraction. Circulation. 2005; 112(9 Suppl):I344-50. DOI: 10.1161/CIRCULATIONAHA.104.526277. View

10.

Hattler B, Messenger J, Shroyer A, Collins J, Haugen S, Garcia J . Off-Pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: Results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial. Circulation. 2012; 125(23):2827-35. DOI: 10.1161/CIRCULATIONAHA.111.069260. View

11.

OConnor C, Velazquez E, Gardner L, Smith P, Newman M, Landolfo K . Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol. 2002; 90(2):101-7. DOI: 10.1016/s0002-9149(02)02429-3. View

12.

Paterson D, OMeara E, Chow B, Ukkonen H, Beanlands R . Recent advances in cardiac imaging for patients with heart failure. Curr Opin Cardiol. 2011; 26(2):132-43. DOI: 10.1097/HCO.0b013e32834380e7. View

13.

Attaran S, Shaw M, Bond L, Pullan M, Fabri B . Does off-pump coronary artery revascularization improve the long-term survival in patients with ventricular dysfunction?. Interact Cardiovasc Thorac Surg. 2010; 11(4):442-6. DOI: 10.1510/icvts.2010.237040. View

14.

Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T . Guidelines on myocardial revascularization. Eur Heart J. 2010; 31(20):2501-55. DOI: 10.1093/eurheartj/ehq277. View

15.

Spadaccio C, Benedetto U . Coronary artery bypass grafting (CABG) percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? -a review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018; 7(4):506-515. PMC: 6082779. DOI: 10.21037/acs.2018.05.17. View

16.

Pocock S, Henderson R, Clayton T, Lyman G, Chamberlain D . Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina. J Am Coll Cardiol. 2000; 35(4):907-14. DOI: 10.1016/s0735-1097(99)00637-3. View

17.

Shapira O, Hunter C, Anter E, Bao Y, DeAndrade K, Lazar H . Coronary artery bypass grafting in patients with severe left ventricular dysfunction--early and mid-term outcomes. J Card Surg. 2006; 21(3):225-32. DOI: 10.1111/j.1540-8191.2006.00221.x. View

18.

Carr J, Haithcock B, Paone G, Bernabei A, Silverman N . Long-term outcome after coronary artery bypass grafting in patients with severe left ventricular dysfunction. Ann Thorac Surg. 2002; 74(5):1531-6. DOI: 10.1016/s0003-4975(02)03944-9. View

19.

Hamad M, van Straten A, Van Zundert A, Ter Woorst J, Martens E, Penn O . Preoperative prediction of early mortality in patients with low ejection fraction undergoing coronary artery bypass grafting. J Card Surg. 2010; 26(1):9-15. DOI: 10.1111/j.1540-8191.2010.01161.x. View

20.

Cleland J, Freemantle N . Revascularization for patients with heart failure. Inconsistencies between theory and practice. Eur J Heart Fail. 2011; 13(7):694-7. DOI: 10.1093/eurjhf/hfr075. View