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Myocardial revascularization for acute myocardial infarction: benefits and drawbacks of avoiding cardiopulmonary
Chaim Locker1, Rephael Mohr, Yosef Paz
1Department of Thoracic and Cardiovascular Surgery, The Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. raphmohr@tasmc.health.gov.il
Insights
Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) carries higher mortality. Avoiding cardiopulmonary bypass (CPB) in AMI patients, especially within 48 hours, significantly reduces operative mortality while maintaining long-term survival.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Myocardial Infarction Management
Background:
- Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is linked to increased operative mortality.
- Utilizing cardiopulmonary bypass (CPB) may contribute to higher mortality rates in AMI patients undergoing CABG.
Purpose of the Study:
- To compare the operative mortality and long-term survival rates of patients undergoing CABG with and without CPB within 7 days of AMI.
- To identify predictors of operative mortality in AMI patients undergoing CABG.
Main Methods:
- A retrospective study of 225 patients undergoing CABG within 7 days of AMI between 1992 and 1998.
- 119 patients underwent CABG with CPB, and 106 underwent CABG without CPB.
- Patient characteristics, perioperative data, and follow-up outcomes were analyzed.
Main Results:
- Operative mortality was significantly lower in the no-CPB group (3.8%) compared to the CPB group (12%) (p = 0.027).
- Avoiding CPB was particularly beneficial for patients operated on within 48 hours of AMI, showing reduced mortality (4.3% vs. 16.5%).
- Five-year survival rates were similar between groups (81%), but the no-CPB group had fewer reinterventions.
Conclusions:
- Cardiopulmonary bypass can be safely used for most patients undergoing CABG within a week of AMI.
- For emergency CABG within 48 hours of AMI symptom onset, avoiding CPB is recommended to lower operative mortality.
- The findings support a strategy of minimizing CPB use in high-risk AMI patients undergoing urgent CABG.
Background:
Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased mortality compared with CABG in non-AMI patients. Operating without cardiopulmonary bypass (CPB) might reduce this mortality.
Methods:
Between January 1992 and December 1998, 225 patients underwent CABG within 7 days of AMI, 119 with CPB and 106 without. The two groups were similar regarding age, gender, left ventricular dysfunction, and incidence of cardiogenic shock. Mean number of grafts per patient was 3.1 in the CPB group, and 1.7 in the no-CPB group (p < 0.0001).
Results:
Operative mortality in the CPB group was 12% compared with 3.8% without CPB (p = 0.027). Independent predictors of operative mortality were preoperative use of intraaortic balloon counterpulsation (IABP), nonuse of internal thoracic artery (ITA) to the left anerior descending artery, and the use of less than three grafts. Mortality of patients operated on with CPB within 48 hours of AMI was significantly higher (16.5% vs 4.3%, respectively; p = 0.044). However, patients operated on after 48 hours had similar mortality (5.8% vs 3.4%, respectively). Follow-up ranged from 6 to 84 months. Five-year survival (Kaplan-Meier) of both groups was similar (81%). Patients operated on with CPB had similar rates of recurrent angina; however, they had lower prevalence of reinterventions (0.8% vs 6.3%; p = 0.03).
Conclusions:
Our study suggests that CPB can be used safely for most patients referred for CABG within the first week of AMI. However, for emergency patients operated on within the first 48 hours of symptom onset, we advocate avoiding CPB because it is associated with lower operative mortality.
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