Emergency Coronary Artery Bypass Graft Surgery for Acute Coronary Syndrome

Abstract

Background— Aim of this study was to compare the outcome of beating heart versus conventional coronary artery bypass graft (CABG) strategies in acute coronary syndromes for emergency indications. Methods and Results— 638 consecutive patients with acute coronary syndrome (ACS) receiving emergency CABG surgery via midline sternotomy from January 2000 to September 2005 were evaluated. Propensity score analysis was used to predict the probability of undergoing beating heart (BH) (n=240) versus cardioplegic cardiac arrest (CA) (n=398) strategies. Patients presented with stable hemodynamics (n=531) or in cardiogenic shock (CS) (n=107). Hospital and follow-up outcome was compared by propensity score adjusted multiregression analysis. BH included 116 on-pump and 124 off-pump (OPCAB) procedures. There was a propensity to operate CS patients on the beating heart (multivariate odds ratio [OR], 3.8; P =0.001). Under stable hemodynamics significant predictors for BH selection were logEuroSCORE >20% (OR, 2.05), creatinine >1.8 mg/dL (OR, 4.12), complicated percutaneous coronary intervention (OR, 1.88), ejection fraction <30% (OR, 2.64), whereas left main disease (OR, 0.68), circumflex artery (OR, 0.32), and 3-vessel disease (OR, 0.67) indicated preference for cardioplegic arrest. Time from skin incision to culprit lesion revascularization was significantly reduced in BH patients. BH surgery led to a significant benefit in terms of less drainage loss, less transfusion requirement, less inotropic support, shorter ventilation time, lower stroke rate, and shorter intensive care unit stay. In CS, BH was associated with lower incidence of stroke, inotropic support, acute renal failure, new atrial fibrillation and sternal wound healing complications. In CS patients, hospital mortality rate was reduced when using beating heart strategies ( P =0.048). Overall survival, major adverse cerebral and cardiovascular event rate, and repeated revascularization was comparable during a 5-year follow-up. Conclusions— Beating heart strategies are associated with an improved hospital outcome and comparable long-term results for high-risk patients presenting acute coronary syndrome with or without CS.

Atrial Fibrillation After Cardiac Surgery: Incidence, Risk Factors, and Economic Burden

“…44 In the present study, 14% of patients with POAF had severe postoperative hemodynamic impairment requiring prolonged administration of catecholamines, in comparison to 5.7% of patients without arrhythmia complications (p ϭ 0.005). The relative proarrhythmic effect of a severe hemodynamic impairment per se and that of sympathicomimetic drugs in the development of POAF remain to be clarified.…”

Off-pump surgery for the poor ventricle?

“…Pathophysiologically, this is reflected by an extended degree of inflammatory response [4] and myocardial injury [20,21], especially if the CPB run is prolonged [10]. The activation of numerous inflammatory mediators may compromise myocardial performance, particularly if the LV function is already severely impaired [22,23]. Moreover, due to the transient change of the ventricular geometry and the ischemic cardiac arrest during CPB, the coronary collateral-flow supplying ischemic areas of the myocardium, is limited [23].…”

Diretrizes

“…Não existem estudos comparativos randomizados relacionados a essas opções na presença de IAM, e os estudos observacionais publicados apresentam resultados controversos 351,352 . Por esse motivo, o tipo de abordagem deve seguir a preferência da equipe cirúrgica.…”

“…Nesse sentido, no entanto, resultados melhores têm sido observados quando a revascularização do miocárdio é realizada com o coração batendo, em comparação ao emprego de soluções cardioplégicas 352 . O enxerto da artéria torácica interna para a artéria interventricular anterior, na presença de estenose significante daquele vaso, deve ser utilizado sempre que possível, sendo também importante o uso rotineiro do balão intra-aórtico no pré-operatório.…”

“…Não existem estudos comparativos randomizados relacionados a essas opções na presença de IAM, e os estudos observacionais publicados apresentam resultados controversos 351,352 352 . O enxerto da artéria torácica interna para a artéria interventricular anterior, na presença de estenose significante daquele vaso, deve ser utilizado sempre que possível, sendo também importante o uso rotineiro do balão intra-aórtico no pré-operatório.…”