Optimal surgical management of patients with severely reduced left ventricular ejection fraction undergoing coronary artery bypass grafting

Patients with severely reduced left ventricular ejection fraction (LVEF ≤ 30%) undergoing coronary artery bypass grafting (CABG) face heightened peri-operative risk. Prophylactic mechanical circulatory support with the surgical Impella 5.5 pump may enhance hemodynamic stability, yet its clinical value remains uncertain. Here, we report our institutional experience in managing patients with reduced LVEF undergoing CABG. We retrospectively reviewed adults who underwent isolated elective or urgent CABG at a single center between January 2020 and July 2024. Patients supported with preoperative Impella 5.5 were excluded. Included patients had a preoperative LVEF ≤ 30%, without evidence of cardiogenic shock or need for inotropes prior to CABG. The primary outcome was operative mortality. Overall, we included 74 patients with a mean age of 61 ± 10 years who were predominantly male (85.1%). Twenty patients (27%) received prophylactic intraoperative Impella 5.5 support via axillary or ascending aortic graft. Fifty-four patients did not receive intraoperative Impella 5.5 support. Operative mortality was 1.4% in the entire cohort. Median ICU stay and hospital stay were 5.0 days and 19 days, respectively. The most common postoperative complication was atrial fibrillation (36.5%), followed by renal failure (5.4%), and pneumonia (5.4%). Two patients who did not receive intraoperative Impella 5.5, required rescue Impella 5.5 or CP post-operatively. This study showed that with appropriate patient selection, mortality rates in patients with reduced LVEF undergoing CABG could be significantly reduced. Thus, selective, indication-driven deployment of Impella 5.5 rather than universal adoption appears warranted.