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Surgical treatment of acute myocardial infarction
1Harvard Medical School, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass 02115.
Insights
Surgical treatment for acute myocardial infarction is indicated for evolving cases unresponsive to angioplasty or streptokinase, post-infarction angina, and specific complications like coronary occlusion or ventricular septal defects.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Acute myocardial infarction (AMI) management has evolved, necessitating clear guidelines for surgical intervention.
- Identifying optimal surgical candidates is crucial for improving outcomes in complex AMI cases.
Purpose of the Study:
- To delineate the established indications for surgical treatment of acute myocardial infarction as of 1989.
- To provide a comprehensive overview of surgical interventions for various AMI complications.
Main Methods:
- Review of clinical indications for surgical intervention in acute myocardial infarction.
- Categorization of surgical treatment scenarios based on timing, patient condition, and coronary anatomy.
Main Results:
- Specific indications include evolving AMI unresponsive to PTCA/SK, post-infarction angina, iatrogenic coronary occlusion, and cardiogenic shock.
- Surgical intervention is also recommended for ventricular septal defects, papillary muscle rupture, and as a bridge to transplantation in select cases.
Conclusions:
- The 1989 guidelines outline critical scenarios where surgical treatment is indicated for acute myocardial infarction and its complications.
- These indications cover a spectrum from acute evolving infarction to severe mechanical and electrical complications requiring surgical repair or transplantation.
Abstract:
In 1989 the following indications for surgical treatment of acute myocardial infarction are: (1) acute evolving myocardial infarction less than 6 h from onset, in patients in whom percutaneous transluminal coronary angioplasty (PTCA) or streptokinase (SK), depending on the coronary anatomy, has been unsuccessful; if single vessel disease, coronary artery bypass grafting (CABG) is unlikely; if multiple vessel disease, CABG is preferable to SK/PTCA unless a very major 'culprit' lesion can be identified with certainty; (2) postinfarction angina hours to days after a transmural myocardial infarction unyielding to maximal medical therapy and in patients with a coronary artery obstruction not amenable to PTCA; (3) occlusion of a coronary artery during cardiac catheterization that cannot be fixed by PTCA and/or SK; (4) occlusion of a coronary artery during PTCA causing hemodynamic obstruction and a threatened myocardium subtended by the obstructed coronary artery; (5) balloon-dependent patients in cardiogenic shock without mechanical defects who have adequate residual left ventricular function as determined by regional wall motion studies; (6) ventricular septal defect secondary to myocardial infarction unless there is terminal organ damage; (7) mitral valve replacement with coronary bypass for acute papillary muscle rupture; (8) semi-emergency cardiac transplantation, either with or without a mechanical bridge to transplant in young individuals (less than 50 years) who have suffered massive destruction of left ventricular myocardium by an acute coronary occlusion with or without recurring ventricular tachyarrhythmias. Ejection fraction in this clinical category is always under 0.20 and usually under 0.15.