Prognosis in patients rejected for coronary revascularization surgery

Abstract

The clinical course, catheterization data, and coronary and left ventricular angiograms of 231 patients rejected for coronary revascularization surgery between 1971 and 1974 and treated conservatively were evaluated. Based upon analysis of available data, patients were classified into one of eight groups as follows: 66 patients with poor left ventricular function, 43 with atherosclerotic distal coronary vessels, one with advanced age, 13 with isolated stenosis of the left circumflex coronary artery, 14 with nonjeopardized collaterals to myocardium beyond the critical coronary stenosis, 25 with akinetic or dyskinetic myocardium beyond the critical coronary stenosis, and 19 with coronary lesions of 50 to 74 per cent of the luminal diameter were rejected; 50 patients were considered acceptable surgical candidates at the time of this review. At three years the actuarial survival rate for all patients was 77.6 per cent. However, those considered operable had a 36 month survival rate of 97.9 per cent. Ejection fraction was the only hemodynamic or clinical feature which had significant prognostic value. The probability of survival for three years was 89.7 per cent for those with ejection fractions greater than 34 per cent, whereas in others the survival rate was only 59.0 per cent (p < 0.001). Patients with poor distal vessels but adequate left ventricular function and those in the other five patient groups had three year survival rates exceeding 82 per cent. Patients with one, two and three vessel disease had three year survival rates of 88.3, 74.7 and 61.3 per cent, respectively. However, when subdivided according to left ventricular function, there was little difference in survival rates for patients with ejection fractions in excess of 34 per cent and one, two or three vessel disease. In patients with poor ventricular function survival rates were similarly low irrespective of the extent of coronary obstructive disease. Fifty-six per cent of patients returned to work, and 42 per cent had no or minimal symptoms. Only nine patients were housebound. Thus, (1) ejection fraction is confirmed as an important prognostic tool, (2) the extent and severity of coronary artery disease, and the condition of the myocardium are important chiefly as they affect the ejection fraction, (3) distal vessel disease does not affect survival adversely, and (4) extensive vascular and myocardial damage can be compatible with a long survival and productive life.