Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North‐Rhine‐Westphalia Surgical Myocardial Infarction Registry

Abstract

Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock ( CS ) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non– ST ‐segment–elevation myocardial infarction ( NSTEMI ) and ST ‐segment–elevation myocardial infarction ( STEMI ). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality ( IHM ) and major adverse cardiocerebral events ( MACCEs ). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI ( P <0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P =0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS . IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI ( IHM 15% versus MACCE 34%; P <0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

On‐pump beating‐heart coronary artery bypass grafting in high‐risk patients: A systematic review and meta‐analysis

“…Cardiogenic shock after acute MI occurs in 10% to 20% of the cases and is the most common cause of in-hospital mortality. 31,35 Urgent intervention is supported by the results of the GUSTO-1 and SHOCK trials. 35 Analysis of the SHOCK trial revealed that, despite a more complex coronary artery disease anatomy and a higher risk profile, CABG had comparable mortality rates to PCI.…”

“…Urgent CABG performed early after acute MI carries a higher risk of mortality compared with percutaneous procedures, but is necessarily indicated in case of failure/complications of percutaneous strategies, unfavorable coronary anatomy for percutaneous coronary intervention (PCI) or persistent myocardial ischemia refractory to medical or percutaneous therapy. 13,28,31,32 However, a recently infarcted myocardium poorly tolerates the additional insult of cardioplegic arrest and ischemia-reperfusion syndrome 13,32 ; those factors might deteriorate cardiac function leading to suboptimal clinical outcomes. 13,32 Maintaining a beating-heart translates into reduced myocardial ischemia and improved function.…”

“…35 Analysis of the SHOCK trial revealed that, despite a more complex coronary artery disease anatomy and a higher risk profile, CABG had comparable mortality rates to PCI. 31,[35][36][37] However, less than 5% of patients across various registries 31,38 are referred for surgery in this situation. The similar success rate of CABG among higher risk patients may be related to a higher rate of complete revascularization (87% in CABG vs 23% in PCI) or a more physiologic flow in the myocardium supplied by the target vessel.…”

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

“…The present multicentric, all‐comers registry, called The Surgical Myocardial Infarction Registry of the Federal State of North‐Rhine Westphalia, was physician‐initiated in 2009 by 4 academic, high‐volume cardiac surgery centers in Germany’s most populous federal state, North‐Rhine Westphalia, as recently described. 5 , 6 All consecutive adult patients with ACS with the intention to undergo a surgical‐based revascularization therapy were included. Patients with ACS who were successfully treated by primary PCI or medical therapy and thus were not referred to CABG surgery were not entered.…”

Coronary artery bypass grafting in the treatment of patients with acute coronary syndrome: current evidence base and unresolved issues

“…Ограниченные данные наблю-дательных исследований у пациентов с шоком и многососудистым поражением позволяют предположить, что КШ следует рассматривать как стратегию дополнительной реперфузии по сравнению с ЧКВ, либо оно может иметь предпочтение в тех случаях, когда полная реваскуляризация методом ЧКВ невозможна. Авторы подчеркивают необходимость проведения крупных рандомизированных исследований для определения оптимальной стратегии реваскуляризации [25].…”