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The impact of surgical and percutaneous coronary revascularization on the cardiac myocyte
Kamal R Khabbaz1, Sidney Levitsky
1Division of Cardiothoracic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, LMOB 2A, 110 Francis Street, Boston, Massachusetts 02215, USA.
Insights
Revascularization strategies like CABG and PCI can cause cardiac myocyte injury. Myocardial protection strategies are crucial to minimize necrosis during these procedures, though optimal methods remain debated.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Re-establishing coronary blood flow after cessation or diminution can injure the myocardium.
- Surgical revascularization (coronary artery bypass grafting - CABG) involves aortic cross-clamping, reducing oxygen transport and potentially causing myocyte injury and necrosis.
- Percutaneous coronary interventions (PCI) can also lead to myonecrosis via microcirculation issues and ischemia/reperfusion injury.
Purpose of the Study:
- To review the complications associated with myocardial injury during revascularization procedures.
- To discuss the role of ischemia/reperfusion injury in myocyte necrosis.
- To address the ongoing controversy regarding which revascularization strategy offers superior outcomes with less cardiac myocyte necrosis.
Main Methods:
- Review of existing literature on myocardial injury during CABG and PCI.
- Analysis of factors contributing to myocyte necrosis, including ischemia/reperfusion.
- Evaluation of the efficacy of intracoronary filtering devices.
Main Results:
- Both CABG and PCI are associated with myocardial injury and myonecrosis.
- Inadequate myocardial protection strategies and ischemia/reperfusion alterations exacerbate injury.
- Intracoronary filtering devices have not demonstrated improved outcomes.
Conclusions:
- Myocardial injury is a significant complication of coronary revascularization.
- Effective myocardial protection strategies are essential to mitigate myocyte necrosis.
- The comparative effectiveness of different revascularization strategies in minimizing cardiac necrosis is still under investigation.
Abstract:
Re-establishing coronary blood flow to a segment of myocardium suffering from cessation or diminution of flow, either with surgical or percutaneous approaches, may be complicated by injury to the myocardium. During surgical revascularization with coronary artery bypass grafting (CABG), aortic cross-clamping and subsequent reduction in oxygen transport to the myocardium may result in cardiac myocyte injury and myonecrosis. This injury can be compounded if protection of the myocardium using myocardial protective strategies is not adequate. Ischemia/reperfusion cellular alterations may contribute to this injury as well. Percutaneous coronary interventions (PCI) are also associated with myonecrosis resulting from side branch compromise, distal embolization of debris, and plugging of the microcirculation, as well as ischemia/reperfusion injury. Intracoronary filtering devices have not been shown to improve outcomes associated with such complications. Which revascularization strategy is associated with superior outcomes and less cardiac myocyte necrosis is an area of continuing controversy.
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