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[Coronary artery surgery in the first 24 hours after myocardial infarction]
Mauricio Villavicencio1, Bernardita Garayar, Manuel José Irarrázaval
1Departamento de Enfermedades Cardiovasculares. Facultad de Medicina. Pontificia Universidad Católica de Chile, manuelj@med.puc.cl.
Insights
Emergency coronary artery bypass grafting within 24 hours of myocardial infarction offers good outcomes for stable patients. However, shock or cardiac arrest significantly increases perioperative complications and mortality, highlighting them as key risk factors.
Area of Science:
- Cardiology
- Cardiac Surgery
- Emergency Medicine
Context:
- Thrombolysis and angioplasty are limited in severe myocardial infarction (MI) with three-vessel disease and cardiogenic shock.
- Emergency coronary surgery presents an alternative treatment in select MI cases.
- Early intervention post-MI aims to minimize myocardial necrosis and improve survival.
Purpose:
- To evaluate perioperative complications, mortality rates, and long-term survival.
- To assess outcomes of coronary surgery performed within 24 hours of MI onset.
- To identify risk factors influencing outcomes in emergency coronary surgery patients.
Summary:
- A retrospective study of 57 patients undergoing emergency coronary surgery within 24 hours of MI.
- Hemodynamically stable patients had 0% operative mortality, while those in shock/cardiac arrest had 44% mortality.
- Long-term survival was 89% at 5 years for stable patients versus 55% for unstable patients. Freedom from reintervention was high (>95% at 5 years).
Impact:
- Coronary artery bypass grafting is a viable option in the early hours post-MI for stable patients.
- Shock and cardiac arrest are critical risk factors for adverse outcomes and mortality.
- Early surgery improves long-term survival and reduces reintervention rates in hemodynamically stable MI patients.
Background:
Thrombolysis and angioplasty in the first hours after myocardial infarction minimize necrosis, leading to better early and late survival, but these therapies have limited effect in patients with three-vessel disease and cardiogenic shock. Emergency coronary surgery is an alternative treatment in some cases.
Aim:
To assess perioperative complications, mortality and long-term survival in patients undergoing coronary surgery within 24 h of myocardial infarction.
Patients And Methods:
We retrospectively studied 57 patients undergoing surgery within 24 h of the onset of symptoms of myocardial infarction between 1982 and 1998. Multiple vessel disease was present in 31 patients (54%), shock or cardiac arrest in 19 (33%) and coronary angiography complications in 7 (12%). The mean time between onset of symptoms and surgery was 6.32 h. At the beginning of surgery 32 patients (56%) were hemodynamically stable, 15 (26%) were in shock and 10 (17%) were in cardiac arrest.
Results:
The operative mortality was 0% for those who were hemodynamically stable at the start of surgery and 44% (11 of 25 patients) for those in shock or cardiac arrest. Shock or prior cardiac arrest were associated with higher rates of sternal infection and heart failure and longer hospital stays.Follow-up (mean 67 months) was possible for all remaining patients. The 5- and 10-year survival rates were 89 and 82%, respectively, for patients who were hemodynamically stable at the time of surgery. Five-year survival was 55%, however, for those who underwent surgery in shock or cardiac arrest. The overall rate of freedom from myocardial infarction, angioplasty or reoperation was over 95% at 5 years and over 85% at 10 years of follow-up. Age and shock or cardiac arrest were risk factors for a poor long-term outcome.
Conclusion:
The early and long-term outcome of coronary surgery within 24 h of myocardial infarction is good for patients who are hemodynamically stable when surgery begins. Shock and cardiac arrest are important risk factors for complication and death. Coronary artery bypass grafting is a good treatment option in the first hours after myocardial infarction.