Related Experiment Videos
Optimal timing of revascularization: transmural versus nontransmural acute myocardial infarction
D C Lee1, M C Oz, A D Weinberg
1Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA. dcl64@columbia.edu.
Insights
Emergency coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) carries higher mortality. Early CABG after transmural AMI poses significant risks, while waiting may be beneficial for some patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Public Health
Background:
- Emergency coronary artery bypass grafting (CABG) following acute myocardial infarction (AMI) is associated with increased mortality.
- The impact of CABG on mortality differs between transmural and nontransmural AMI, necessitating distinct therapeutic strategies.
Purpose of the Study:
- To investigate the relationship between the timing of CABG and mortality in patients with acute myocardial infarction (AMI).
- To compare outcomes for transmural versus nontransmural AMI patients undergoing CABG relative to the timing of the infarction.
Main Methods:
- A retrospective analysis of 44,365 patients undergoing CABG after myocardial infarction between 1993 and 1996.
- Data collected from 32 hospitals in New York State, involving 179 surgeons.
Main Results:
- Overall hospital mortality for CABG post-MI was 3.1%.
- Mortality decreased significantly with longer intervals between AMI and CABG (11.8% <6 hrs, 9.5% 6 hrs-1 day, 2.8% >1 day).
- While transmural and nontransmural AMI had similar overall mortality (3.1%), early CABG (<7 days) after transmural AMI showed higher risk. CABG within 1 day (transmural) and 6 hours (nontransmural) were independent risk factors for mortality.
Conclusions:
- Early CABG after transmural AMI presents a significantly higher risk.
- Surgeons should consider aggressive cardiac support, potentially including left ventricular assist devices, for high-risk transmural AMI patients.
- A waiting period may be warranted for certain patients to improve outcomes.
Background:
Higher mortality for emergency coronary artery bypass grafting (CABG) after an acute myocardial infarction (AMI) is well established. Whether it applies to both transmural and nontransmural AMI is unclear. This information may have different therapeutic implications for each cohort of patients.
Methods:
A retrospective multicenter analysis of 44,365 patients who underwent CABG after myocardial infarction between 1993 and 1996 by 179 surgeons at 32 hospitals in New York State was performed.
Results:
Overall hospital mortality for all patients with or without AMI was 2.5% versus 3.1% for patients who underwent CABG with history of myocardial infarction. Hospital mortality decreased with increasing time interval between CABG and AMI; 11.8%, 9.5%, and 2.8% (p < 0.001 for all values) for less than 6 hours, 6 hours to 1 day, and greater than 1 day, respectively. Patients with transmural and nontransmural AMI had identical mortality of 3.1%. However, different patterns emerged when comparing these two groups of patients with respect to time of operation. Mortality was higher in the transmural group if CABG was performed within 7 days after AMI. Multivariate analysis confirmed that CABG within 1 day and 6 hours of AMI are independent risk factors for mortality in the transmural and nontransmural groups, respectively.
Conclusions:
Early operation after transmural AMI has a significantly higher risk, and surgeons should be prepared to provide aggressive cardiac support including left ventricular assist devices in this ailing population. Waiting in some may be warranted.