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Does coronary angiography before emergency aortic surgery affect in-hospital mortality?
1Department of Cardiology, Cleveland Clinic Foundation, Ohio, USA. pennm@ccf.org
Insights
Coronary angiography before emergency aortic surgery does not impact in-hospital mortality. Patients with a history of myocardial infarction also showed no survival benefit from angiography, supporting prompt surgical intervention.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Thoracic Surgery
Background:
- Acute ascending aortic dissection often necessitates emergency aortic repair.
- Coronary angiography is frequently considered essential for defining coronary anatomy before such procedures.
- The potential benefits of coronary angiography must be balanced against the risk of delaying life-saving surgery.
Purpose of the Study:
- To investigate the relationship between coronary angiography and in-hospital mortality in patients undergoing emergency aortic surgery.
- To determine if pre-operative coronary angiography influences outcomes in patients without prior coronary revascularization or angiography.
- To identify predictors of mortality in this high-risk surgical population.
Main Methods:
- Retrospective analysis of patient charts and the Cardiovascular Information Registry (CVIR).
- Inclusion of 122 patients who underwent emergency aortic surgery between 1982 and 1997.
- Comparison of mortality rates between patients who did and did not undergo coronary angiography on the day of surgery.
Main Results:
- Overall in-hospital mortality was 18.0% with no significant difference based on pre-operative coronary angiography (16% vs. 22%, p=0.46).
- Myocardial infarction history was the sole predictor of mortality (RR 4.98), but angiography did not alter this risk.
- Coronary angiography did not significantly affect the rate of coronary artery bypass grafting (CABG) during aortic surgery; most CABGs were for dissection, not coronary artery disease.
Conclusions:
- Coronary anatomy determination may not impact survival in patients undergoing emergency aortic surgery.
- These findings support proceeding rapidly to surgery once a diagnosis is made, without routine pre-operative angiography.
- Prioritizing timely surgical intervention is crucial in acute aortic dissection cases.
Objectives:
To study the relationship between coronary angiography and in-hospital mortality in patients undergoing emergency surgery of the aorta without a history of coronary revascularization or coronary angiography before the onset of symptoms.
Background:
In the setting of acute ascending aortic dissection warranting emergency aortic repair, coronary angiography has been considered to be desirable, if not essential. The benefits of defining coronary anatomy have to be weighed against the risks of additional delay before surgical intervention.
Methods:
Retrospective analysis of patient charts and the Cardiovascular Information Registry (CVIR) at the Cleveland Clinic Foundation.
Results:
We studied 122 patients who underwent emergency surgery of the aorta between January 1982 and December 1997. Overall, in-hospital mortality was 18.0%, and there was no significant difference between those who had coronary angiography on the day of surgery compared with those who had not (No: 16%, n = 81 vs. Yes: 22%, n = 41, p = 0.46). Multivariate analysis revealed that a history of myocardial infarction (MI) was the only predictor of in-hospital mortality (relative risk: 4.98 95% confidence interval: 1.48-16.75, p = 0.009); however, coronary angiography had no impact on in-hospital mortality in patients with a history of MI. Furthermore, coronary angiography did not significantly affect the incidence of coronary artery bypass grafting (CABG) during aortic surgery (17% vs. 25%, Yes vs. No). Operative reports revealed that 74% of all CABG procedures were performed because of coronary dissection, and not coronary artery disease.
Conclusions:
These data indicate that determination of coronary anatomy may not impact on survival in patients undergoing emergency surgery of the aorta and support the concept that once diagnosed, patients should proceed as quickly as possible to surgery.