Coronary Artery Bypass Graft Surgery in Patients With Acute Coronary Syndromes After Primary Percutaneous Coronary Intervention: A Current Report From the North‐Rhine Westphalia Surgical Myocardial Infarction Registry

Abstract

Background Coronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed. Methods and Results We aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North‐Rhine‐Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in‐hospital all‐cause mortality and major adverse cardio‐cerebral event. Patients were 68±11 years of age, had 3‐vessel and left main‐stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non–ST‐segment–elevation myocardial infarction, and 23.5% in ST‐segment–elevation myocardial infarction. A history of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non–ST‐segment–elevation myocardial infarction, and 16.1% in ST‐segment–elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non–ST‐segment–elevation myocardial infarction and 17.2% in ST‐segment–elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In‐hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI <24 hours, and 14.1% with failed PCI ( P <0.003). The in‐hospital major adverse cardio‐cerebral event rate was 16.4% without PCI, but 17.4% with prior PCI >24 hours, 25.6% with prior PCI <24 hours, and 41.3% with failed PCI ( P =0.014). Multivariable logistic regression analysis showed prior PCI ( P =0.039), as well as failed PCI ( P =0.001) to be predictors for in‐hospital all‐cause mortality and major adverse cardio‐cerebral event. Conclusions In the current PCI era, immediately prior or failed PCI before coronary artery bypass grafting in acute coronary syndromes is associated with high perioperative risk, cardiogenic shock, and increased morbidity and mortality.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction

“…In our study, only 2 patients who underwent CAG followed by culprit lesion PCI and none of the patients who underwent culprit lesion PCI before CAG underwent urgent CABG. Moreover, based on previous studies that showed high mortality rates among patients with STEMI who were referred for urgent CABG, current society guidelines recommend that for patients with STEMI and coronary anatomy amenable for CABG (eg, patients with triple vessel disease or significant left main disease), a primary PCI to the culprit lesion should be performed, followed by an elective CABG …”

Culprit vessel revascularization first with primary use of a dedicated transradial guiding catheter to reduce door to balloon time in primary percutaneous coronary intervention

“…It is important to consider that diagnostic angiography before PCI might provide valuable anatomical information that could change the reperfusion strategy, such as an emergency coronary artery bypass graft. However, coronary artery bypass graft was performed as reperfusion therapy in only 0.8% of patients ( 32 ), and patients requiring urgent or emergency coronary artery bypass graft within 24 h of STEMI have mortality rates of 8.2∼15.8% ( 33 , 34 ). In fact, for patients with STEMI and multivessel disease, immediate or staged complete revascularization with PCI significantly improves hard clinical outcomes ( 35 ).…”

SCAI Expert Consensus Statement on Percutaneous Coronary Intervention Without On-Site Surgical Backup

“…Emergency coronary bypass surgery (CABG) after PCI is associated with high mortality rates, ranging between 7.4% and 21%. 21,22,24,25 UK registry data reported in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) of 14%, with a prolonged in-hospital stay of 9 days longer in those surviving surgery. 26 Despite the high perioperative risk of mortality, it appears survivors have a good long-term prognosis.…”