A 27-Year Comparative Analysis of Coronary Artery Surgery with Single and Multiple Arterial Grafting in Severe Left Ventricular Dysfunction

Abstract

Background: Patients with severely reduced left ventricular ejection fraction (EF <30%) undergoing coronary artery bypass grafting represent a high‑risk group. Although multiple arterial grafting has demonstrated survival advantages in broader populations, its effect in this subset remains insufficiently defined. Methods: A retrospective review of 489 patients with EF <30% undergoing surgery over 27 years was performed. Propensity matching (1:1 greedy technique) produced 121 pairs who received either single or multiple arterial conduits. Short‑term outcomes, 30‑day mortality, and long‑term survival were evaluated. Survival analyses and Cox models were used to identify factors associated with mortality. Results: Matched groups showed no significant differences in early outcomes, including 30‑day mortality (single 3.3% vs multiple 5.8%, P=0.36). In the unmatched cohort, multiple arterial grafting was linked to improved long‑term survival (P=0.008), but this advantage was not statistically significant after matching (P=0.35). Ten‑year survival was 71.9% for single versus 77.2% for multiple grafts; twenty‑year survival was 49.3% versus 57.2%. In single arterial grafting group, preoperative atrial fibrillation was the only independent predictor of mortality (HR 3.216, 95% CI 1.080–9.575, P=0.04). In multiple arterial grafting group, age (HR 1.104, 95% CI 1.061–1.150, P<0.001), two prior myocardial infarctions (HR 4.242, 95% CI 1.749–10.338, P<0.001), and ex‑smoking status (HR 3.069, 95% CI 1.401–6.721, P=0.01) were independently associated with higher mortality. Conclusion: These findings emphasise the need for careful patient selection and strategic conduit planning in severe ventricular dysfunction, and support further prospective work to determine which patients may derive durable benefit from more extensive arterial revascularisation.