Clinical implication of coronary artery bypass grafting with surgical ventricular reconstruction in clinical practice

“In a large randomized control trial, CABG + SVR was not associated with a greater reduction in the rate of death or cardiac hospitalization than I-CABG. How do the authors explain this discrepancy?” (1). In Jones et al.’s study, patients had dominant anterior left ventricular dysfunction (2). However, there’s no information about the percentage of patients who had large, dyskinetic aneurysms. Patients with such aneurysms have poor hemodynamics and decreased cardiac function. Therefore, the conclusions of this trial may not be consistent in patients with akinesia, as compared with dyskinesia.

Patients with large aneurysms are very rare in developed countries nowadays, mostly because of the application of excellent revascularization techniques. However, in developing nations, many patients still suffer from the disease. In our center, 7% of patients undergoing coronary artery bypass graft (CABG) had dyskinetic aneurysms, and 1/5 of the aneurysms were large.

Optimal patient selection may be a key to successful CABG + surgical ventricular reconstruction (SVR) surgery. The indication of SVR in our center is the presence of anterior/anteroseptal myocardial infarction (MI) and dominant anterior/anteroseptal akinesia or dyskinesia of left ventricle (LV) (3). In other words, we perform ventricular aneurysmectomy when the ventricular wall is thin or lack of viability for the purpose of rupture prevention or non-functioning part exclusion.

Our surgical team was blinded to patient identification and reviewed the contrast-enhanced cardiovascular magnetic resonance imaging (CE-CMR) of all patients with left ventricular ejection fraction (LVEF) ≤35% to determine their eligibility for SVR. During surgery, the presence of anterior/anteroseptal scar tissue and dominant dyskinesia of LV made the team more inclined to perform SVR. Consequently, patients were divided into two groups: those who underwent isolated CABG (I-CABG) and those who underwent CABG + SVR. Therefore, the indication for I-CABG at our institution is more dependent on the surgeon’s own experience.

In our center, On-pump beating-heart CABGs are not performed, while Off-pump CABGs are excluded from the present study because CABG + SVR have to be performed on-pump.

After the surgery, patients also received aspirin, clopidogrel, Beta blockers, diuretics, angiotensin-converting enzyme inhibitor (ACEI), statins, and nitrates regularly as usual (4). Currently, several new anti-heart failure medications are clinically available, including SGLT2 inhibitors, sacubitril/varsaltan, and vericiguat. These patients were followed up regularly at the outpatient clinic; therefore, received the new anti-heart failure medications mentioned above.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2023-07/coif). The authors have no conflicts of interest to declare.

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References

1. Akao K, Imamura T. Clinical implication of coronary artery bypass graft with surgical ventricular reconstruction in patients with left ventricular dysfunction in the current clinical practice. J Thorac Dis 2023;15:4544-5.
2. Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009;360:1705-17. [Crossref] [PubMed]
3. Yang T, Yuan X, Li B, et al. Long-term outcomes after coronary artery bypass graft with or without surgical ventricular reconstruction in patients with severe left ventricular dysfunction. J Thorac Dis 2023;15:1627-39. [Crossref] [PubMed]
4. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022;145:e895-1032. Erratum in: Circulation 2022;145:e1033 Erratum in: Circulation 2022;146:e185. Erratum in: Circulation 2023;147:e674. [Crossref] [PubMed]