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Coronary artery bypass graft surgery after thrombolytic therapy in the Thrombolysis in Myocardial Infarction Trial,
B J Gersh1, J H Chesebro, E Braunwald
1Mayo Clinic, Rochester, Minnesota.
Insights
Coronary artery bypass graft surgery after thrombolytic therapy shows increased early mortality, especially within 24 hours. However, 1-year survival rates are excellent for survivors, regardless of timing, offering a favorable long-term prognosis.
Area of Science:
- Cardiology
- Cardiac Surgery
- Thrombolytic Therapy
Background:
- Coronary artery bypass graft (CABG) surgery is common post-thrombolytic therapy.
- Limited data exists on early and late outcomes of CABG after thrombolysis.
Purpose of the Study:
- To evaluate outcomes of CABG following thrombolytic therapy in the TIMI II trial.
- To analyze patient characteristics, impact of prior angioplasty, and subgroup morbidity/mortality.
Main Methods:
- Analysis of 3,339 patients from the TIMI II trial.
- Comparison of 390 patients undergoing CABG: 54 within 24 hours, 336 between 24 hours and 42 days.
- Multivariate analysis to identify predictors of perioperative mortality.
Main Results:
- Higher perioperative mortality (16.7% vs. 3.9%) and major hemorrhage (74% vs. 50.9%) in the early (<24h) CABG group.
- Bypass surgery within 24 hours was the sole independent predictor of perioperative mortality.
- Excellent 1-year survival (2.2% and 1.9%) for survivors in both groups, with low recurrent myocardial infarction rates.
Conclusions:
- Increased perioperative mortality with early CABG after thrombolysis necessitates careful risk-benefit assessment.
- Despite higher early risks, 1-year prognosis for survivors is excellent, even for high-risk patients.
- These findings provide a benchmark for future studies on CABG after thrombolytic therapy.
Objectives:
We examined the results of coronary artery bypass graft surgery after thrombolytic therapy in the Thrombolysis in Myocardial Infarction trial, Phase II (TIMI II) with particular emphasis on patient characteristics, the impact of antecedent percutaneous transluminal coronary angioplasty and morbidity and mortality in certain subgroups.
Background:
Coronary bypass surgery is frequently used after thrombolytic therapy, but there is relatively little information with regard to early and late outcomes.
Methods:
We analyzed 3,339 patients enrolled in the TIMI II trial. Bypass surgery was performed in 390 patients (11.7%): 54 (14%) within 24 h after entry into the trial or within 24 h of coronary angioplasty and 336 (86%) between 24 h and 42 days after entry.
Results:
Perioperative mortality rates were, respectively, 16.7% and 3.9% (p < 0.001); perioperative myocardial infarction rates were 5.6% and 6.2%, respectively; and major hemorrhagic events occurred in 74% and 50.9%, respectively (p = 0.002). On multivariate analysis, the only independent predictor of perioperative mortality was bypass surgery within 24 h after entry or after coronary angioplasty. Among patients undergoing bypass surgery within 24 h of entry or after coronary angioplasty, the prevalence of multivessel disease (59.1% vs. 77.8%) and use of the internal thoracic artery (18.5% vs. 62.5%) were lower than in the remaining surgical patients. Among the 322 perioperative survivors, the 1-year mortality rate after discharge was only 2.2% and 1.9%, respectively, in the two groups. Only one patient had a documented recurrent myocardial infarction during the first year.
Conclusions:
The increased mortality rate with bypass surgery after thrombolytic therapy, particularly in patients undergoing operation within 24 h of coronary angioplasty or during the involving phase of infarction, must be balanced against the excellent 1-year prognosis and perioperative survivors, who are in general a group at higher risk of death or recurrent infarction. These data provide a basis for comparison for future studies.
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