Immediate surgical coronary revascularisation in patients presenting with acute myocardial infarction
Nawid Khaladj1, Dmitry Bobylev, Sven Peterss
1Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str, 1, 30625 Hannover, Germany.
Insights
Emergency coronary artery bypass grafting (CABG) is a viable option for acute myocardial infarction (AMI) patients unsuitable for intervention. While outcomes for NSTEMI are comparable to elective procedures, STEMI patients, especially with cardiogenic shock, face high mortality, necessitating alternative strategies.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Increasing number of acute myocardial infarction (AMI) patients are untreatable by interventional cardiologists.
- Previous experience with emergency coronary artery bypass grafting (CABG) prompted a more liberal surgical approach.
- A prospective protocol was implemented for surgical management and analysis of these patients.
Purpose of the Study:
- To evaluate the outcomes of emergency coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) who are not candidates for percutaneous coronary intervention.
- To assess the feasibility and safety of immediate surgical revascularization in a high-risk AMI population.
- To identify risk factors for mortality in this patient cohort.
Main Methods:
- A prospective study included 127 patients with AMI (86 NSTEMI, 41 STEMI) undergoing emergency CABG within six hours of cardiac catheterization.
- Patients had high rates of three-vessel disease (77%), left main stem stenosis (47%), and cardiogenic shock (11%).
- Preoperative intraaortic balloon pump (IABP) support was used in 21% of patients.
Main Results:
- The 30-day mortality rate was 6% overall, with significant differences between NSTEMI (2%) and STEMI (15%) groups (p=0.014).
- Complete revascularization was achieved in 80% of patients.
- Logistic regression identified EuroSCORE II (ES II) as an independent predictor of mortality (HR 1.216, p<0.001).
Conclusions:
- Emergency CABG offers comparable outcomes to elective revascularization for non-ST-elevation myocardial infarction (NSTEMI) patients.
- Complete revascularization is associated with clear patient benefit.
- High mortality in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock warrants consideration of alternative timing and bridging strategies for surgical revascularization.
Background:
The number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed.
Methods:
Within a two year interval, 127 patients (38 female, age 68±12 years, EuroScore (ES) II 6.7±7.2%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77% three-vessel-disease, 47% left main stem stenosis, 11% cardiogenic shock, 21% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48±15%).
Results:
30-day-mortality was 6% (8 patients, 2 NSTEMI (2%) 6 STEMI (15%), p=0.014). Complete revascularisation could be achieved in 80% of the patients using 2±1 grafts and 3±1 distal anastomoses. In total, 66% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p<0.001, HR 1.216, 95%-CI-Intervall 1.082-1.366).
Conclusions:
Quo ad vitam, results of emergency CABG for patients presenting with NSTEMI can be compared with those of elective revascularisation. Complete revascularisation obviously offers a clear benefit for the patients. Mortality in patients presenting with STEMI and cardiogenic shock is substantially high. For these patients, other concepts regarding timing of surgical revascularisation and bridging until surgery need to be taken into consideration.
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