Coronary artery bypass grafting (CABG) is the standard of care for revascularization in patients with multi-vessel coronary artery disease (CAD) and is performed without cardiopulmonary bypass (off-pump). [1] One of the main reasons to offer cardiac surgery is to improve both survival and quality of life (QoL). [2] The assessment of QoL prior to cardiac surgery has thus garnered increasing interest among clinicians as a factor to be taken into consideration when estimating the potential benefit to be gained by the patient from the intervention. [3] Low preoperative left ventricular ejection fraction (LVEF) is common in patients undergoing cardiac surgery. Despite improvements in medical therapy and surgical techniques, management of patients with moderate or severe left ventricular dysfunction undergoing cardiac surgery remains challenging. [4]

Several perioperative variables have been purposed as predictors of mortality, and are currently applied in everyday clinical practice to identify patients at higher risk. Low EF per se is the strongest predictor of a poor outcome and is included in all scoring system currently available. [5] Indeed, low LVEF is associated to the postoperative low cardiac output syndrome (LCOS), need for inotropic support, acute renal failure, respiratory failure, atrial fibrillation, stroke, sepsis, deep sternal wound infection (DSWI), bleeding requiring reoperation and gastrointestinal bleeding. The frequency of patients presenting with severe left ventricular dysfunction is rising together with a growing profile of co-morbidities. [6,7]

The presence of viable myocardium as a target for revascularization has become the gold standard ever since the Allman et al. meta-analysis in 2002, where a benefit of revascularization only in patients with myocardial viability was found. [8] The reason for viability testing is to identify regions of hibernating myocardium. The currently available methods of myocardial viability testing are: 1. Transthoracic resting echocardiography 2. Echocardiographic stress testing 3. Magnetic resonance imaging (MRI), 4. Single photon emission computed tomography (SPECT), 5. 18F-fluorodeoxyglucose positron emission tomography (18-FDG-PPreviously, CABG in patients with severe LV dysfunction has been associated with high mortality. However, recent studies have shown encouraging early, mid- and long-term results due to advancement in surgical techniques and postoperative management. [9,10]

Aim: The aim of this study is to evaluate the Quality of Life in patients with severely depressed left ventricular function (EF of < 35%) who undergo

Objective: To evaluate the quality of life of patients undergoing coronary artery bypass graft (CABG) surgery using the 5-dimensional questionnaire (EQ-5D) after surgery. To assess the major adverse cardiac and cerebrovascular events in patients with low ejection fraction who undergo CAB.

The present study is prospective and observational study was conducted in the Department of Cardiothoracic and vascular surgery, Yashoda Hospital. We analyzed the data from 60 patients who were scheduled to undergo CABG. The institutional ethics committee approved the present study and patient consent was obtained from all the patients.

Inclusion criteria

·         Patient age >21-70 years old

·         Undergoing first isolated CABG surgery

·         LVEF <35%

Exclusion criteria

·         Emergency operation

·         Concomitant cardiac procedures with CABG

·         Operation which was carried out via an incision other than median sternotomy. (e.g., anterolateral left thoracotomy)

·         LVEF>35%

·         CVA (Recent CVA < 3 months) with or without residual neurological deficit.

Method of treatment:

1. Coronary Artery Bypass Graft (CABG).

2. We enrolled 120 consecutive patients with severe dysfunction of left ventricle in the study. Quality of Life was assessed after the mean time of 0, 1, 3, 6 months in all four groups. Taking reference from the study as 40% of improvement in quality of life in CABG group, for the current study assuming for a hypothesized difference of 60% improvement in quality of life after CABG in severe LV dysfunction patients at 5% significance level the sample size required to achieve a power of the test 0.90 is calculated using statistical software Minitab (version 19.0).

Statistical methods

Data will be presented as absolute numbers, mean, and standard deviation, or percentages. Values of continuous variables were expressed as a mean ± standard deviation (SD). Categorical variables are represented as frequency distributions and single percentages. Normally distributed continuous variables were compared using a student t-test.

The mean systemic arterial pressure was maintained around 65 to 70 mm Hg throughout the procedure. ONCAB Myocardial protection was achieved with intermittent antegrade hyperkalaemia cold blood cardioplegia. The proximal anastomoses were performed after completion of all distal anastomoses on partial aortic clamp while on cardiopulmonary bypass. The study cohort includes 60 patients with low ejection fraction (35%) who under CABG.

Table 1: Baseline characteristics of total cohort characteristics were evaluated (table 1)

The mean age of the patients was 55.83±9.77, (76.67%) percentage of male and (23.33%) of female were included. Diabetes mellitus was observed in (66.67%) of patients and COPD in 5% of patients. The means of severe LV dysfunction was 29.56±2.09.

Most of the study groups contains triple vessel disease (88.33%) followed by double vessel disease (8.33%) and single vessel disease (3.33%). Preoperative IABP was not used in any of the patients and preoperative inotropes were used in two patients (3.33%).

Table 2: Intraoperative and postoperative characteristics of total cohort

Intraoperative and postoperative characteristics of the patients was evaluated (table 2). Off-pump surgery was done in (95%) of patients whereas (5%) of the patients underwent On-pump surgery. Mean number of grafts used were 3.36±1.02. There were no conversions from off - pump to on- pump the mean of total chest tube drain was 685.8±138.4, intraoperative IABP support was used in 1 patient (1.67%) which was continued postoperatively, means of ventilation time and hospitals stay was 17.35±7.05, 7.50±2.56 respectively.

Table 3: Postoperative complications of total cohort

Postoperative complications were evaluated (table 3), low cardiac output was observed in 5 patients (8.33%). None of the patients had pulmonary complications, atrial fibrillation was observed in 14 patients (23.33%). None of the patients suffered renal dysfunction requiring renal replacement therapy and none had deep sternal wound infection.

Table 4: MACCE outcomes of total cohort

Table 5: Pre, post-operative and follow up data of hemodynamic and echocardiography parameters in total study cohort

Table 6: EQ-VAS score

Table 7: Pre, post-operative and follow up data of Ejection fraction between males and females

Table 8: Pre, post-operative and follow up data of EQ-VAS between males and females

Table 9: Pre, post-operative and follow up data of Ejection fraction between ≤50and >50 years of age

Table 10: Pre, post-operative and follow up data of EQ-VAS between ≤50and >50 years of age

Left ventricular dysfunction in patients with coronary artery disease is not always an irreversible process related to previous myocardial infarction since left ventricular function improves substantially in many patients and may even normalize after coronary artery bypass grafting. [11] In these patients with low EF, coronary artery bypass grafting has been shown to be superior to medical therapy alone, resulting in significant clinical improvement and improving long-term survival. [12] Advances in preoperative management, refinements in surgical techniques, use of off-pump coronary artery bypass grafting, and advances in cardiac anesthesia with improvement in intensive postoperative care all have resulted in a decrease in the mortality rate in patients with low EF operated by off-pump coronary artery bypass surgery.

Sadık Eryilmaz et al[13] reported their experience in off-pump coronary artery surgery in 48 patients who have left ventricular dysfunction less than 30%. There were three deaths. The clinical situations of 41 of 45 patients (91.1%) improved after the operation. Moursi, et al [14] Sajja et al [15]investigated the safety, feasibility and efficacy of off-pump coronary artery bypass grafting in 318 patients with significant left ventricular dysfunction. Operative mortality was 2.8% (6 deaths) following OPCAB and 3.93% (7 deaths) following ONCAB (p=0746). ). Di Carli et al. had operative mortality of 9.3% in patient with low EF. [16]  In concurrence with the published literature this study also observed 8.33% mortality in patients with an EF of <35%.

In the present study intraoperative IABP was used in 1(1.67%) patients and to postoperative period. The timing is very important either perioperatively or preoperatively to help the recovery of the myocardium from the low output state. Free use of IABP was reported by Elefteriades and Edwards [17]  as a perioperative support in patients with extremely impaired LV function and the left main disease.

In surgically treated patients, Chocron et al. [18] reported higher New York Heart Association functional classes to be predictive of less improvement of energy and physical mobility, and segmental left ventricular dysfunction to be predictive of less improvement of pain. Indeed, in that study, higher functional classes were associated with a greater likelihood of deterioration of QOL after surgery. In the context of these findings, it is reassuring that QOL in most patients with severe LV dysfunction but viable myocardium improved after bypass surgery. In concurrence with these results the present study also recorded viable myocardium improvement after CABG. This study found that in patients with low EF, CABG surgery was associated with significant reductions in MACCE outcomes and improvements in QOL.

In patients with coronary artery disease, CABG surgery is not only for prolonging the life of patients, it is important for improving the quality of life of CAD patients. Therefore, it is important to evaluate pre- operative conditions of cardiac surgery patients to obtain results that can be compared with post-operative quality of life outcomes.

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