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[Current operative risk in emergency coronary surgery. Experience of the last 5 years]
A Leguerrier1, T Langanay, J L Fasquel
1Clinique Chirurgicale Cardiovasculaire et Thoracique, CHU Hôpital Pontchaillou, Rennes.
Insights
Emergency coronary artery bypass surgery shows higher mortality (12.5%) compared to elective procedures (2.4%). Factors influencing outcomes include patient condition, clinical context, and surgical completeness, highlighting limitations for emergency interventions.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Emergency Medicine
Background:
- Coronary artery surgery has evolved significantly with advancements in fibrinolysis and angioplasty.
- Between 1982 and 1986, 1,232 patients underwent isolated coronary artery revascularization at the University Hospital of Rennes.
Purpose of the Study:
- To analyze the outcomes of elective versus emergency coronary artery bypass surgery.
- To identify factors contributing to mortality in emergency coronary artery surgery.
Main Methods:
- Retrospective analysis of 1,232 patients undergoing coronary artery revascularization.
- Comparison of mortality rates between elective (1,040 patients) and emergency (192 patients) surgery groups.
- Analysis of mortality factors including surgical circumstances, patient clinical context, and surgical revascularization completeness.
Main Results:
- Emergency surgery had a significantly higher mortality rate (12.5%) compared to elective surgery (2.4%).
- Mortality was analyzed across four emergency subgroups: post-thrombolysis, post-angioplasty complication, threatened infarction, and threatened extension of infarction.
- Factors influencing mortality included emergency status, hemodynamic compromise, patient age, sex, prior infarction, myocardial function, and quality/completeness of revascularization.
Conclusions:
- Emergency coronary artery bypass surgery carries a substantially higher risk.
- Limitations exist for emergency surgery indications, particularly in patients with severe ventricular dysfunction or poor distal vessel quality.
- Careful consideration of patient condition and surgical feasibility is crucial for determining appropriate emergency revascularization strategies.
Abstract:
Technique of fibrinolysis and angioplasty have changed the face of emergency coronary artery surgery, which had developed considerably over recent years. Between 1982 and 1986, in the Department of Cardiovascular and Thoracic Surgery of the University Hospital of Rennes, 1,232 patients underwent isolated coronary artery revascularisation (with the exclusion of mechanical complications of infarction). 1,040 patients were operated electively and 192 patients underwent emergency surgery with very different results: mortality of 2.4% with elective surgery versus 12.5% with emergency surgery, divided into four subgroups: revascularisation after thrombolysis (gradually being replaced by angioplasty), by-pass surgery after a complication of angioplasty (or coronary angiography), by-pass surgery in threatened unresponsive infarction (now less common), by-pass surgery in the context of threatened extension of pre-existing myocardial infraction. The factors of mortality are analysed according to the circumstances (emergency, presence or absence of haemodynamic repercussions), clinical context (age, sex, previous infarction, myocardial function) and lastly the surgical possibilities (complete or incomplete revascularisation in vessels of variable quality ...). In relation to this last point, the authors stress the limitations of reasonable indications for emergency surgery, although surgery is readily proposed in deteriorating patients unresponsive to medical treatment, on vessels with a severely pathological disal bed and in myocardia with severely altered ventricular function.