Coronary artery bypass grafting in patients with low ejection fraction.

BACKGROUND: Patients with low ejection fraction (EF) are at a higher risk for postoperative complications and mortality. Our objective was to assess the effect of low EF on clinical outcomes after coronary artery bypass grafting (CABG). METHODS AND RESULTS: We analyzed 55,515 patients from New York State database who underwent CABG between 1997 and 1999. Patients were stratified into 1 of the 4 EF groups: Group I (EF< or =20%), Group II (EF 21% to 30%), Group III (EF 31% to 40%), and Group IV (EF>40%). History of previous myocardial infarction, renal failure, and congestive heart failure were higher in patients with low EF (all P<0.001). Group I experienced a higher incidence of postoperative respiratory failure (10.1% versus 2.9%), renal failure (2.5% versus 0.6%), and sepsis (2.5% versus 0.6%) compared with Group IV. In-hospital mortality was significantly higher in Group I (6.5% versus 1.4%; P<0.001). Multivariate analysis showed hepatic failure [odds ratio (OR), 11.2], renal failure (OR, 4.1), previous myocardial infarction (OR, 3.4), reoperation (OR, 3.4), emergent procedures (OR, 3.2), female gender (OR, 1.7), congestive heart failure (OR, 1.6), and age (OR, 1.04) as independent predictors of in-hospital mortality in the low EF group. The discharges to home rate were significantly lower in Group I versus Group IV (73.1% and 87.7%, respectively; P<0.001). CONCLUSIONS: Patients with low EF are sicker at baseline and have >4 times higher mortality than patients with high EF. However, outcomes are improving over time and are superior to historical data. Therefore, CABG remains a viable option in selected patients with low EF.

Predictors of quality of life among women with coronary heart disease.

BACKGROUND: Health-related quality of life (HRQOL) is an increasingly relevant outcome as the population ages and associated morbidities increase. The purpose of this study was to evaluate predictors of HRQOL among ethnically diverse women hospitalized for coronary heart disease (CHD) and determine the impact of a brief, educational intervention on HRQOL 6 months post-hospitalization. METHODS: Women (n = 160; mean age 63 years, 53% minority) admitted for CHD at three academic hospitals who completed a 6 month secondary prevention trial were studied. The SF-36 was administered at admission and 6 months. Multiple linear regressions were used to identify significant independent predictors of 6 month HRQOL. RESULTS: Significant improvements in HRQOL were noted from admission to 6 months post-hospitalization. Subjects reporting better HRQOL at 6 months included those who were employed, married, physically active, enrolled in cardiac rehabilitation, and not depressed. Women who received an educational intervention had significantly less bodily pain at 6 months compared with usual care in a model adjusted for baseline HRQOL and physical activity goal adherence (p = 0.04). CONCLUSIONS: Baseline HRQOL (8 SF-36 subscales), physical activity (3 SF-36 subscales) and marital status (1 SF-36 subscale) were the major determinants of HRQOL at 6 months post-hospitalization. Future interventions and preventive efforts should be targeted to women with CHD who have impaired HRQOL and may be at increased risk of poor clinical outcomes.

Effect of diabetes on short- and long-term outcomes after left ventricular assist device implantation.

BACKGROUND: Diabetes mellitus (DM) is a frequent co-morbidity in patients with congestive heart failure (CHF). Implantation of LVADs is an acceptable option for diabetic patients with end-stage heart failure, yet no previous study has specifically examined the clinical outcomes of this patient population. METHODS: A retrospective analysis was performed on all patients who underwent LVAD insertion at a single institution from June 17, 1996 to April 14, 2004. Patients were divided into 2 groups: diabetics (DM) and non-diabetics (NDM). The groups were compared with regard to demographics, etiology of heart failure, body mass index (BMI), intensive care unit (ICU) stay, early mortality (< or =30 days), bridge-to-transplantation rate and post-LVAD and post-transplant survival. RESULTS: Two hundred one patients were identified. Of these, 49 (24.4%) had DM. Compared with the NDM group, DM patients had a higher mean body mass index (30.1 +/- 6.0 vs 26.1 +/- 4.8, p < 0.001) and a higher proportion of hypertension (57.4% vs 19.7%, p < 0.001). Although post-LVAD survival was similar, post-transplant survival in DM patients was significantly lower compared with NDM patients, with 1-, 3-, 5- and 7-year actuarial survival rates of 86.9%, 71.0%, 56.5% and 56.5% vs 90.5%, 88.4%, 83.0% and 80.7% (p = 0.020), respectively. CONCLUSIONS: Carefully selected diabetic patients can be successfully bridged to transplantation using LVADs with comparable outcomes to non-diabetic patients. Reasons for diminished post-transplant survival in this cohort are unclear and necessitate the conductance of multi-institutional studies to evaluate outcomes.