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Published on: January 28, 2020
Outcomes of Early Coronary Angiography or Revascularization After Cardiac Surgery
Vikram Sharma1, Kevin Chen2, Shehab A R Alansari1
1Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio.
Insights
Early coronary ischemia after cardiac surgery is rare but deadly. ST elevation myocardial infarction patients had the lowest mortality, while others faced high risks. Peak troponin T predicted death but not graft issues.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Early coronary ischemic events post-cardiac surgery are infrequent.
- Limited data exists on the management and outcomes of these events.
- This study investigates clinical outcomes of patients with suspected ischemia after index cardiac surgery.
Purpose of the Study:
- To evaluate clinical outcomes of patients undergoing coronary angiography or intervention for suspected ischemia within 3 weeks of cardiac surgery.
- To identify predictors of mortality in this patient cohort.
- To compare outcomes of different management strategies for acute graft failure.
Main Methods:
- Retrospective observational study of 53,287 cardiac surgery patients (1996-2017).
- Included 180 patients with suspected early post-operative coronary ischemia.
- Primary outcome: 1-year all-cause mortality. Statistical analyses included Kaplan-Meier and ROC curves.
Main Results:
- Most interventions occurred within 2 weeks post-surgery.
- 1-year mortality varied by presentation: STEMI/non-STEMI (13.5%) lowest, arrest/hemodynamic instability (38.6%) highest.
- Peak troponin T predicted 1-year mortality (AUC 0.74) but not coronary obstruction.
- Percutaneous coronary intervention showed better 1-year survival for graft failure than redo CABG.
Conclusions:
- Suspected myocardial ischemia early after cardiac surgery is rare but associated with high mortality, especially in non-STEMI presentations.
- Troponin T is a predictor of 1-year mortality but not coronary or graft obstruction.
- Management strategies for early ischemia require careful consideration due to high associated risks.
Background:
Early coronary ischemic events are uncommon after cardiac surgery, with little known about their management or associated outcomes. We evaluated clinical outcomes of patients undergoing coronary angiography ± percutaneous coronary intervention or redo coronary artery bypass grafting for suspected coronary ischemia within 3 weeks after index cardiac surgery.
Methods:
This is a retrospective observational study based on data from 53,287 patients who underwent cardiac surgery at our institution (1996-2017); 180 patients (0.34%) satisfied the inclusion criteria. The primary outcome was 1-year all-cause mortality. Statistical evaluation involved χ2, analysis of variance, Kaplan-Meier, and receiver operating characteristic curve analyses.
Results:
Most coronary angiography ± percutaneous coronary intervention and redo coronary artery bypass grafting procedures occurred in the first 2 weeks after index cardiac surgery. Patients presenting with ST elevation myocardial infarction (STEMI)/non-STEMI had the lowest 1-year mortality (13.5%), followed by patients with ventricular tachycardia/fibrillation (28.1%), and patients with non-ventricular tachycardia/fibrillation arrest or hemodynamic instability alone the worst (38.6%) (χ2 = 17.3, P = .001). Peak troponin T level after cardiac surgery was strongly predictive of 1-year mortality (area under the curve, 0.74; 95% confidence interval, 0.65-0.84; P < .001) but did not predict the presence of coronary compromise. For acute graft failure, 1-year mortality was better with percutaneous coronary intervention (18.2%) than redo coronary artery bypass grafting (23.5%) or no indicated/feasible intervention (29.2%).
Conclusions:
Although suspected myocardial ischemia requiring coronary angiography or intervention early after cardiac surgery was rare, mortality was high, particularly in presentations other than STEMI/non-STEMI. In patients with overt signs and symptoms of myocardial ischemia after index cardiac surgery, troponin T was not a reliable marker of underlying coronary or graft obstruction but was a robust predictor of 1-year mortality.
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