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Early coronary artery bypass grafting for complicated acute myocardial infarction
M W Connolly1, J S Gelbfish, D M Rose
1Department of Surgery, Maimonides Medical Center, Brooklyn, NY.
Insights
Surgical revascularization after acute myocardial infarction (MI) is safe, with low operative mortality. Early intervention for unstable angina or cardiogenic shock post-MI improves long-term survival and functional status.
Area of Science:
- Cardiology
- Cardiac Surgery
- Critical Care Medicine
Background:
- Patients experiencing acute myocardial infarction (MI) with subsequent unstable angina or cardiogenic shock face high morbidity and mortality.
- Identifying optimal treatment strategies for this high-risk subgroup is crucial.
Purpose of the Study:
- To evaluate the efficacy and safety of surgical revascularization in patients who underwent coronary artery bypass grafting (CABG) within six weeks of an acute MI.
Main Methods:
- A comparative study involving 96 patients with recent MI undergoing CABG versus 485 patients without recent MI undergoing myocardial revascularization.
- Preoperative clinical characteristics, intraoperative support, and postoperative outcomes including operative mortality and long-term survival were analyzed.
Main Results:
- The acute MI group had higher rates of cardiogenic shock (15%) and unstable angina (85%) preoperatively, with increased comorbidities like congestive heart failure and lower ejection fractions.
- Overall operative mortality for the acute MI group was 7.3% (28% for cardiogenic shock, 3.7% for unstable angina), comparable to the 3.7% in the no-recent-MI group.
- Predictors of early mortality in the recent MI cohort included ejection fraction <45% and age >70.
- Actuarial survival was 97% at 3 years post-surgery with no late MIs, and 95% of survivors were in NYHA Class I or II.
Conclusions:
- Surgical revascularization within six weeks of acute MI is associated with acceptable operative mortality.
- Early surgical intervention in this high-risk population leads to favorable long-term survival and functional outcomes.
- Preoperative ejection fraction and age are key determinants of early mortality in patients undergoing revascularization post-MI.
Abstract:
The occurrence of unstable angina or cardiogenic shock after an acute myocardial infarction characterizes a subgroup of patients with increased morbidity and mortality. To assess the efficacy of surgical revascularization in this cohort, 96 patients who underwent coronary artery bypass grafting within 6 weeks of an acute myocardial infarction were compared to 485 patients who underwent myocardial revascularization without recent infarction. Fourteen (15%) of the patients with acute infarction were in cardiogenic shock and 82 (85%) patients had unstable angina at the time of surgery. Preoperatively, the patients with acute infarction compared to the patients without acute infarction were older (+3.5 years), had an increased incidence of congestive heart failure (21% vs 13%), and had a lower mean ejection fraction (4% vs 65%). Preoperative intraaortic balloon support was used in 9 patients (65%) with cardiogenic shock, and in 16 patients (19%) with unstable angina. Mean interval to surgery from time of infarction was 14.9 days. Overall operative mortality was 7.3% (7 patients) for the acute infarction group 28% for patients with cardiogenic shock and 3.7% for patients with unstable angina compared to 3.7% for the group of patients without recent infarction. Earlier surgical intervention did not result in a significant increase in operative mortality. Discriminant analysis of the recent infarction cohort demonstrated that preoperative ejection fraction less than 45% and age greater than 70 were the most significant predictors of early mortality. Of the 89 patients surviving surgery, actuarial survival was 97% at 3 years with no late infarctions. At follow-up 95% of survivors were NYHA Class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)