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Determinants and prognosis of myocardial damage after coronary artery bypass grafting
Francesco Onorati1, Marisa De Feo, Pasquale Mastroroberto
1Cardiac Surgery Unit, University Magna Graecia, Catanzaro, Italy. frankono@libero.it
Insights
Elevated troponin I after coronary artery bypass grafting indicates myocardial damage and predicts worse outcomes. Identifying predictors and protective strategies like combined cardioplegia is crucial for improving patient prognosis.
Area of Science:
- Cardiology
- Cardiac Surgery
- Biomarkers
Background:
- Myocardial infarction (MI) is a severe complication following coronary revascularization procedures.
- Electrocardiography (ECG) and echocardiography can suggest MI, but troponin I (TnI) levels are essential for quantifying myocardial damage (MD) and assessing myocardial protection quality after coronary artery bypass grafting (CABG).
- Understanding the factors influencing TnI elevation and its prognostic implications post-CABG is critical.
Purpose of the Study:
- To evaluate the determinants of troponin I elevation after CABG.
- To assess the prognostic significance of TnI elevation, both with and without accompanying ECG-echocardiographic criteria for acute MI.
- To identify predictors of perioperative myocardial damage and evaluate potential protective strategies.
Main Methods:
- Prospective analysis of 776 consecutive patients undergoing CABG between January 2002 and January 2004.
- Univariate and multivariate analyses were employed to identify determinants and predictors.
- Twelve-month follow-up assessed survival and freedom from cardiac events (FCE) for patients with and without TnI elevation.
Main Results:
- Elevated TnI (>3.1 µg/L at 12 hours) was observed in 6.9% of patients, correlating with reduced in-hospital and follow-up survival, and lower FCE.
- Patients with elevated TnI and ECG-echocardiographic criteria for MI exhibited higher TnI levels, prolonged ventilation, increased in-hospital mortality, and worse long-term outcomes.
- Independent predictors of MD included high EuroSCORE, unstable angina, prolonged aortic cross-clamp and cardiopulmonary bypass times, incomplete revascularization, and intraoperative intraaortic balloon pump use. Combined antegrade/retrograde cardioplegia and postoperative enoximone infusion were associated with reduced TnI elevation.
Conclusions:
- Troponin I elevation >3.1 µg/L at 12 hours post-CABG signifies perioperative myocardial damage.
- The presence of associated ECG-echocardiographic criteria for acute MI indicates a worse prognosis.
- Identifying MD predictors is vital for developing preventative strategies, with combined cardioplegia and enoximone showing promise.
Background:
Myocardial infarction remains a devastating complication after coronary revascularization. Although electrocardiography (ECG) and echocardiography suggest transmural infarction, myocardial damage and the quality of myocardial protection are not recognized unless troponin I (TnI) is assessed. Determinants and prognosis of TnI elevation after coronary artery bypass grafting (CABG) were evaluated.
Methods:
Data of 776 consecutive patients undergoing CABG between January 2002 and January 2004 were prospectively exposed to univariate and multivariate analysis. We evaluated the prognosis of patients with all the ECG, echocardiographic, and biochemical criteria for acute myocardial infarction and that of patients with only TnI elevation. Twelve-month follow-up survival and freedom from cardiac events (FCE) were accomplished.
Results:
Troponin I greater than 3.1 mug/L at 12 hours was detected in 6.9% of the population, and correlated with lower in-hospital (p < 0.001) and follow-up survival (p = 0.00001), and lower FCE (p = 0.0009). Twenty-one (38.8%) of these fulfilled ECG-echocardiographic criteria (p = 0.05), demonstrating higher TnI values at 12 (p = 0.001), 24 (p = 0.01), 48 (p = 0.01), and 72 (p = 0.04) hours, prolonged ventilation time (p = 0.001), higher in hospital mortality (p = 0.003), lower follow-up survival (p = 0.023), and lower FCE (p = 0.0084). A EuroSCORE greater than 6, ongoing unstable angina, aortic cross-clamp time greater than 90 minutes, cardiopulmonary bypass time greater than 180 minutes, incomplete revascularization, and intraoperative intraaortic balloon pump were independent predictors of myocardial damage (MD) at multivariate analysis. Combined antegrade and retrograde cardioplegia and postoperative enoximone infusion were associated with a lower TnI elevation.
Conclusions:
Troponin I greater than 3.1 mug/L at 12 hours defines perioperative MD. Associated ECG-echocardiographic criteria indicate acute myocardial infarction and anticipate a worse outcome. Identification of predictors for MD is important to develop preventative strategies, as antegrade plus retrograde cardioplegia and enoximone infusion.
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