Left Ventricular Size and Outcomes in Patients With Left Ventricular Ejection Fraction Less Than 20

Ann Thorac Surg. 2020 Feb 16;S0003-4975(20)30202-2. doi: 10.1016/j.athoracsur.2020.01.005. Online ahead of print.


Background: The interactive relationship between left ventricular (LV) ejection fraction (LVEF) and LV size in predicting perioperative outcomes after cardiac surgery has not been clarified.

Methods: This study reviewed all patients who underwent cardiac surgery between 2010 and 2016 with either preserved LVEF (>60%; n = 5685) or severely reduced LVEF (<20%; n = 143). LV size was categorized by using either LV end-diastolic or end-systolic diameter or a qualitative assessment, as follows: normal, smaller than 4 cm; mildly enlarged, 4.1 to 5.4 cm moderately enlarged, 5.5 to 6.5 cm; and severely enlarged, larger than 6.5 cm. Using propensity-score analysis, we matched patients with LVEF less than 20% (n = 143) in a 3:1 ratio with patients with LVEF greater than 60% (n = 429).

Results: There were significant differences in mortality, major morbidity, and operative mortality and prolonged length of stay between patients with LVEF less than 20% and LVEF greater than 60%. In patients with LVEF less than 20%, there were no significant differences in outcomes between those with an LV size of 5.4 cm or smaller and an LV size of 5.5 cm or larger. In patients undergoing isolated coronary artery bypass grafting (CABG), LV size predicted mortality, major morbidity, and operative mortality (odds ratio, 5.5 [95% confidence interval, 2.0 to 15.7]; P < .001) and prolonged length of stay (odds ratio, 3.4 [95% confidence interval, 1.2 to 10.3]; P = .026), respectively.

Conclusions: LVEF is more important than LV size in predicting outcomes after cardiac surgery. However, in patients undergoing isolated CABG, LV size has an interactive effect with LVEF and can potentially aid the decision-making process. Risk adjustment models using only LVEF may be inaccurate, particularly with respect to isolated CABG procedures.