As the severity of left ventricular dysfunction increases, so does the potential benefit of surgery to the patient. Unfortunately, the clarity of indications for coronary artery bypass grafting decreases. Following the results of the STICH trial, surgical revascularisation offers improved survival and quality of life, particularly in patients with more extensive three-vessel coronary disease and the greatest degree of left ventricle systolic dysfunction and remodelling. Unfortunately, these same patients are at the greatest short-term risk of death following coronary artery bypass surgery. SVR does not appear to add to the clinical benefit of coronary surgery in patients with more severely remodelled ventricles, but the STICH trial suffered from not having the most suitable patients enrolled. Concomitant mitral valve surgery is warranted in patients undergoing coronary bypass surgery with moderate or severe ischaemic mitral regurgitation. The discussion with patients has to focus on the balance between the short-term risks of an operation versus the potential for long-term benefit.
It is critical for the management of these complex patients that they are fully assessed by a heart team in a multi-disciplinary setting, which includes heart failure cardiologists, surgeons, intensivists, nurses and physiotherapists and possibly patients who have recovered from these procedures.