Eighty consecutive patients receiving maximum inotropic and intraaortic balloon support underwent emergency coronary artery bypass grafting 3.4 ± 1 days (mean ± standard error) after infarction for severe left ventricular power failure (stroke work index < 25 gm-m, left atrial pressure > 20 mm Hg). All underwent induction of cardioplegia with a 37°C glutamate/aspartate blood cardioplegic solution, multidose cold (4°C) replenishment, and warm reperfusate. Viable areas were grafted first to ensure cardioplegic distribution. Left ventricular power failure was reversed in 94% of patients; 75 of 80 patients had discontinuation of inotropic drugs and intraaortic balloon support. The early mortality rate (< 30 days) was only 7% (3/45) with early operation (< 18 hours) and rose to 31% (11/35, p < 0.05) if operation was delayed more than 18 hours. Six of 14 early deaths were due to progression of preoperative organ failure despite reversal of shock. Eighteen of 66 early survivors died of end-stage heart failure (21/80), a 26% late mortality rate. Nonsurvivors (early and late) had a higher incidence of extending versus evolving infarction (33/64 versus 2/16, p < 0.05), a longer delay from shock to operation (11/45 versus 24/35, p < 0.05), more preoperative organ failure (9/9 versus 26/71, p < 0.05), and a greater incidence of previous infarction (22/43 versus 13/37, p > 0.05). Thirty of 45 late survivors (67%) remain physically active. We conclude that left ventricular power failure should be considered a medical/surgical emergency that necessitates prompt angiography and can be reversed in selected patients. Postoperative mortality (early and late) is due principally to delay of operation leading to progression of preoperative organ failure of progression of underlying cardiac disease if infarction becomes established.
ASJC Scopus subject areas
- Pulmonary and Respiratory Medicine
- Cardiology and Cardiovascular Medicine