Commentary: Coronary artery bypass grafting surgery alone is not the only way!

Central MessageLong-term optimal medical treatment for patients with heart failure and moderate left ventricular dysfunction who underwent coronary artery bypass grafting is mandatory.See Article page 149. Long-term optimal medical treatment for patients with heart failure and moderate left ventricular dysfunction who underwent coronary artery bypass grafting is mandatory. See Article page 149. Nearly 70% of all heart failure cases can be attributed to underlying ischemic heart disease, and one-third of patients with coronary artery disease suffer from heart failure.1Elgendy I.Y. Mahtta D. Pepine C.J. Medical therapy for heart failure caused by ischemic heart disease.Circ Res. 2019; 124: 1520-1535Crossref PubMed Scopus (83) Google Scholar The prognosis of these patients is intimately related to many factors, including age, left ventricular ejection fraction (LVEF), number of diseased vessels, myocardial viability, associated mitral disease, quality and completeness of revascularization, and the quality and observance of medical treatment, among others. A few years ago, the STICH trial reported that patients with an LVEF <35% assigned to coronary artery bypass grafting (CABG) had lower rates of death from cardiovascular causes and rehospitalization for heart failure compared with those assigned to medical treatment.2Velazquez E.J. Lee K.L. Deja M.A. Jain A. Sopko G. Marchenko A. et al.Coronary-artery bypass surgery in patients with left ventricular dysfunction.N Engl J Med. 2011; 364: 1607-1616Crossref PubMed Scopus (896) Google Scholar The benefit of surgical revascularization was also demonstrated at 10 years, with lower rates of all-cause, cardiovascular, and heart failure hospitalizations.3Howlett J.G. Stebbins A. Petrie M.C. Jhund P.S. Castelvecchio S. Cherniavsky A. et al.CABG improves outcomes in patients with ischemic cardiomyopathy: 10-year follow-up of the STICH trial.JACC Heart Fail. 2019; 7: 878-887Crossref PubMed Scopus (39) Google Scholar In addition, CABG provides a survival benefit compared with percutaneous coronary intervention in patients with reduced LVEF.4Iribarne A. DiScipio A.W. Leavitt B.J. Baribeau Y.R. McCullough J.N. Weldner P.W. et al.Comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in a real-world surgical treatment for ischemic heart failure trial population.J Thorac Cardiovasc Surg. 2018; 156: 1410-1421.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar In this issue of the Journal, Deo and colleagues5Deo S.V. Sundaram V. Sahadevan J. Selvaganesan P. Mohan S.M. Rubelowsky J. et al.Outcomes of coronary artery bypass grafting in heart failure with a mid-range ejection fraction.J Thorac Cardiovasc Surg. 2023; 165: 149-158.e4Abstract Full Text Full Text PDF Scopus (4) Google Scholar used the Veterans Health Affairs database to analyze the outcomes of patients with heart failure and midrange ejection fraction (HFmrEF) (LVEF 40%-55%) secondary to stable coronary disease and who underwent isolated CABG surgery between 2010 and 2019. This subgroup of CABG patients constitutes 26% of the total CABG population, with 52% also treated for diabetes. As suggested by the authors and others, this proportion of patients likely will increase as the burden of heart failure grows worldwide.1Elgendy I.Y. Mahtta D. Pepine C.J. Medical therapy for heart failure caused by ischemic heart disease.Circ Res. 2019; 124: 1520-1535Crossref PubMed Scopus (83) Google Scholar Although this interesting study has several limitations, it provides a good picture of our CABG patient population and raises some concerns in 3 major areas. First, patients with HFmrEF displayed a higher risk of myocardial infarction, heart failure–related hospitalization, and lower survival rate compared with CABG patients with normal LVEF. The 5-year survival averaged 74% in the HFmrEF group, compared with 82% in patients with normal LVEF and 65% in patients with LVEF <40%, which is lower than previously reported in randomized trials.2Velazquez E.J. Lee K.L. Deja M.A. Jain A. Sopko G. Marchenko A. et al.Coronary-artery bypass surgery in patients with left ventricular dysfunction.N Engl J Med. 2011; 364: 1607-1616Crossref PubMed Scopus (896) Google Scholar,3Howlett J.G. Stebbins A. Petrie M.C. Jhund P.S. Castelvecchio S. Cherniavsky A. et al.CABG improves outcomes in patients with ischemic cardiomyopathy: 10-year follow-up of the STICH trial.JACC Heart Fail. 2019; 7: 878-887Crossref PubMed Scopus (39) Google Scholar,6Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data.Circulation. 1983; 68: 939-950Crossref PubMed Scopus (998) Google Scholar,7Thuijs D.J. Kappetein A.P. Serruys P.W. Mohr F.W. Morice M.C. Mack M.J. et al.Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar This reminds us of the discrepancy between “real world” data and data from randomized trials. Second, 3 or more grafts were performed, and more than 1 arterial graft was used in only 6% of the patients. Third, and of great concern, only 30% of patients with reduced or midrange LVEF were discharged from the hospital with the appropriate medical treatment for heart failure. How to improve the clinical results of this newly recognized subset of patients with heart failure and ischemic cardiomyopathy? Intuitively, we should aim to optimize or normalize, if possible, the LVEF by ensuring complete myocardial revascularization using the best coronary bypass grafts for long-term outcomes: arterial grafts. Bilateral internal mammary artery grafts and radial artery grafts should account for 30%-40% in these young patients, averaging 67 years of age at the time of surgery. We also need to offer the optimal medical management for heart failure from the onset of postoperative care. Only one-third of patients with LVEF <40% and one-quarter of those with HFmrEF were treated with an ACE inhibitor or an angiotensin receptor blocker at the time of hospital discharge. Optimal medical management according to current clinical guidelines for the treatment of heart failure should be initiated or maintained throughout the long-term care of these patients.1Elgendy I.Y. Mahtta D. Pepine C.J. Medical therapy for heart failure caused by ischemic heart disease.Circ Res. 2019; 124: 1520-1535Crossref PubMed Scopus (83) Google Scholar,8Ezekowitz J.A. O'Meara E. McDonald M.A. Abrams H. Chan M. Ducharme A. et al.2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of heart failure.Can J Cardiol. 2017; 33: 1342-1433Abstract Full Text Full Text PDF PubMed Scopus (445) Google Scholar,9Yancy C.W. Jessup M. Bozkurt B. Butler J. Casey Jr., D.E. Drazner M.H. et al.2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.Circulation. 2013; 128: 1810-1852Crossref PubMed Scopus (1716) Google Scholar Patients with heart failure and ischemic heart disease undergoing CABG surgery with reduced LVEF deserve our best surgical techniques, as well as standardized and optimal medical long-term care. CABG surgery alone is not the only way here! Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fractionThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1PreviewCoronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%). Full-Text PDF