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Myocardial revascularisation after acute myocardial infarction
A Bana1, O P Yadava, R Ghadiok
1Department of Cardiac Surgery, Sir Ganga Ram Hospital Marg, Rajinder Nagar, New Delhi, India. gangaram@giasdl01.vsnl.net.in
Insights
Coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) is safe for stable patients with post-infarct angina. Urgent surgery, cardiogenic shock, and poor left ventricular function increase risks.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) is a critical intervention for patients experiencing acute myocardial infarction (AMI).
- Persistent or recurrent angina post-MI often necessitates surgical consideration.
- Timing and patient selection are crucial for optimizing outcomes after CABG in the context of AMI.
Purpose of the Study:
- To evaluate the safety and outcomes of CABG performed within 30 days of AMI.
- To identify predictors of morbidity, complications, and mortality in patients undergoing early CABG post-MI.
- To assess the long-term efficacy of CABG for managing post-infarct angina.
Main Methods:
- Retrospective analysis of 123 patients who underwent CABG within 30 days of AMI (May 1992 - November 1997).
- Data collection included infarct characteristics, surgical indications, pre-operative support (inotropes, IABP), and procedural details (complete revascularization).
- Multivariate analysis was used to identify independent predictors of post-operative morbidity, complications, and 30-day mortality.
Main Results:
- The most common infarct was anterior transmural (61.8%), and the primary indication for surgery was post-infarct angina (69.1%).
- Thirty-day mortality was 3.3%. Independent predictors of mortality included LVEF <30%, Q-wave MI, surgery <48 hours post-AMI, pre-operative cardiogenic shock, and age >60 years.
- Post-operative morbidity and complications were associated with factors such as prolonged ventilation, ICU stay, re-exploration, arrhythmias, pulmonary complications, CVA, and wound infection.
Conclusions:
- CABG can be performed with low risk in stable patients following AMI for post-infarct angina.
- Urgent/emergent surgery, pre-operative cardiogenic shock, IABP use, poor left ventricular function, advanced age, and Q-wave MI are associated with increased risk.
- Careful patient selection and risk stratification are essential for successful early CABG after AMI.
Abstract:
One hundred and twenty-three patients had coronary artery bypass grafting (CABG) within 30 days of acute myocardial infarction (AMI) from May 1992 to November 1997. Commonest infarct was anterior transmural (61.8%) and commonest indication of surgery was post-infarct persistent or recurrent angina (69.1%). Ten patients were operated within 48 h and 36 between 48 h to 2 weeks of having MI. Out of these, nine patients were having infarct extension and cardiogenic shock at the time of surgery. Pre-operatively fourteen patients were on inotropes of which six also had intra-aortic balloon pump (IABP) support. All patients had complete revascularisation with 3.8+/-1.2 distal anastomoses per patient. By multivariate analysis, we found that independent predictors of post-operative morbidity [inotropes >48 h, use of IABP, ventilation >24 h, ICU stay >5 days] and complications [re-exploration, arrhythmias, pulmonary complications, wound infection, cerebrovascular accident (CVA)] were left ventricular ejection fraction (LVEF) <30%, Q-wave MI, surgery <48 h after AMI, presence of pre-operative cardiogenic shock and age >60 years (P < or = 0.01). Mortality at 30 days was 3.3%. LVEF <30%, Q-wave MI, surgery <48 h after AMI, presence of pre-operative cardiogenic shock and age >60 years were found to be independent predictors of 30 days mortality (P < or = 0.01). Ninety patients were followed up for a mean duration of 33 months (1 to 65 months). There were three late deaths and five patients developed recurrence of angina. To conclude, CABG can be carried out with low risk following AMI in stable patients for post-infarct angina. Patients who undergo urgent or emergent surgery and who have pre-operative cardiogenic shock, IABP, poor left ventricular functions, age >60 years and Q-wave MI are at increased risk.
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