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[Emergent coronary artery bypass grafting in patients with acute coronary syndrome]
H Makuuchi1, Y Naruse, T Kobayashi
1Department of Cardiovascular Surgery, Toranomon Hospital.
Insights
Emergent coronary artery bypass grafting (CABG) is less common for acute coronary syndrome due to faster interventions. CABG is now reserved for complex cases, with outcomes depending on patient factors and surgical technique.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Acute Coronary Syndromes
Context:
- The incidence of emergent coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) has declined.
- Advancements in thrombolytic therapy and catheter interventions offer faster, more effective treatments.
- Current CABG indications are primarily for left main trunk lesions or severe triple-vessel disease unresponsive to percutaneous coronary intervention (PCI).
Purpose:
- To analyze the changing indications for emergent CABG in acute coronary syndrome patients.
- To identify factors influencing hospital mortality and early outcomes in patients undergoing CABG.
- To assess the long-term prognosis for CABG survivors and the impact of specific graft choices.
Summary:
- Emergent CABG for ACS is decreasing due to improved non-surgical interventions.
- Indications are now focused on complex cases like left main trunk disease or failed PCI.
- High-risk factors for mortality include low ejection fraction (<30%), age (>70), cardiogenic shock, and low cardiac index (<1.5).
- The interval to acute myocardial infarction (AMI) is not a significant risk factor.
- Operative survivors generally have a good prognosis.
- Internal thoracic artery graft use does not impact early outcomes in stable patients.
- Improving intraoperative myocardial protection and postoperative cardiac support are crucial for better surgical results.
Impact:
- Refines criteria for selecting patients for emergent CABG in ACS.
- Highlights the importance of patient-specific factors in surgical risk stratification.
- Emphasizes the need for enhanced intraoperative and postoperative care to improve CABG outcomes.
Abstract:
The incidence of emergent CABG in patients with acute coronary syndrome has been decreasing, because thrombolytic therapy and/or catheter intervention have proved to be done faster and more efficient. The present indication of CABG is mostly limited to patients with left main trunk lesion or severe triple vessel disease, whose PTCA is failed with persistent chest pain or unstable hemodynamic condition. The factors associated with an increased hospital mortality are ejection fraction < 30%, age > 70 years, presence of cardiogenic shock, and cardiac index < 1.5. The interval between operation and AMI is not a significant risk factor. The prognosis of the operative survivors is relatively good. The use of the internal thoracic artery graft does not influence on the early outcome as far as the preoperative hemodynamic condition is stable. To get better surgical results, improvements in intraoperative myocardial protection and in postoperative cardiac support are imperative.