Acute myocardial infarction: OPCAB is an alternative approach for treatment

Mortality in intensive care units among patients with acute myocardial infarction (AMI) may reach 10-20%, and with cardiogenic shock 50-100%. Moreover, the mortality rate at one year is about 15%, and 25-40% of survivors suffer from recurrent angina. In this report, we describe the surgical results of high-risk patients with AMI who were operated on within 96 hours of the infarction.

From January 1998 through July 2000, among 348 patients who underwent off-pump coronary surgery at the [institution removed for review], 26 consecutive patients (7.5%) were operated on for acute myocardial infarction. Patients with AMI secondary to failed percutaneous transluminal coronary angioplasty (PTCA) were not included in the study group. Four patients (15.3%) were admitted to surgery in cardiogenic shock, four (15.3%) with life-threatening ventricular arrhythmias, and one patient with a rupture of the posterior left ventricular wall. Repeated ventricular fibrillations were recorded in the operating room in three patients (11.5%). In 16 patients, conventional off-pump coronary artery bypass (OPCAB) surgery through median sternotomy was performed using 1-3 saphenous vein grafts, and 10 patients underwent minimally invasive coronary artery bypass (MICAB) with the endoscopic dissection of the left internal mammary artery (LIMA) for single- or double-vessel revascularization.

A mean time of 620 +/- 45 minutes (range 180 min. to 96 hours) was recorded between first symptoms and surgical reperfusion. The mortality rate was 7.7% (N = 2). Major complications, which included cerebrovascular accident (CVA), were observed in one patient and resulted in a morbidity rate of 3.8%. The mean number of grafts per patient was 1.8. Twenty-two patients (84.6%) underwent complete revascularization, but four patients (15.4%) with multivessel coronary disease and unstable hemodynamics received incomplete revascularization as a result of not grafting the obtuse marginal or posterior lateral branches of the circumflex coronary artery. In the early postoperative period, all patients were asymptomatic. Early angiographic study was undertaken from five to fifteen days postoperatively in 12 patients (46%); the angiography demonstrated the patency of all studied grafts and the recovery of left ventricular function.

Off-pump coronary surgery after AMI can be performed with an acceptable mortality rate and low risk of major complications, and offers prospects for early rehabilitation.