Perioperative myocardial infarction: late clinical course after coronary artery bypass surgery.

Abstract

SUMMARY The effects of perioperative myocardial infarction (MI) on long-term survival and symptomatic status after coronary bypass surgery was assessed by a 64.9-month follow-up of the survivors (225) THE GOALS of therapy for coronary atherosclerosis include relief of angina pectoris, modification of the incidence of myocardial infarction, protection against sudden death and increased longevity. Considerable debate has centered on the relative merits of medical and surgical therapy in achieving these goals. The occurrence of perioperative myocardial infarction has been cited as a significant limitation to surgical therapy.This attitude has largely been influenced by the long-term result of naturally occurring myocardial infarction, which is associated with serious morbidity and mortality, especially in subsets of patients with ventricular ectopy.'-3 Further, variable reports of the incidence and significance (mortality) of perioperative myocardial infarction in regard to early and intermediate implications have added to the confusion over this issue. Some of these differences have been an expression of the variable criteria used to make the diagnosis. Recent 1185 nary artery bypass surgery, we performed a long-term follow-up study. Electrocardiographic, enzymatic and scintigraphic criteria were used to diagnose perioperative myocardial infarction.Patients and Methods From November 1975 to July 1976, 227 patients (197 male and 30 female) had isolated coronary artery bypass graft surgery and form the basis for this study. The mean age of this group was 57 years. Based on preoperative historical and ECG findings, 104 (46%) had evidence of previous (more than 2 weeks earlier) myocardial infarction. Coronary arteriography revealed significant coronary disease (50% or greater diameter reduction) in 2.4 vessels per patient; 24 patients (11%) had left main stenosis. The mean Friesinger coronary score (maximum score of 15 points represents total occlusion of all three major vessels) was 11 for our patients.8 The mean ejection fraction calculated from the right anterior oblique ventriculogram was 62%.Anesthesia was induced and maintained using i.v. morphine sulfate and diazepam. Supplementation with a mixture of nitrous oxide (50%) and oxygen (50%) was occasionally used. Nitroprusside by i.v. infusion and small doses of i.v. propranolol (0.5-2.0 mg) were used to blunt the hypertension and tachycardia occasionally seen with endotracheal intubation and stemotomy.The surgical technique at that time included cardiopulmonary bypass with a bubble oxygenator, hemodilution and intermittent aortic cross-clamping, with mild-to-moderate systemic hypothermia. The coldest

Perioperative Myocardial Infarction

“…Bateman, Matloff and Gray [9] claimed that, while PMI may confer an ominous short-term outcome, the long term prognosis might be essentially benign, as most of the PMI are small electrophysiological events, thus explaining the lack of influence on long term clinical status or mortality. This is in agreement with the data of Codd and colleagues [24], Gray and colleagues [41] and Balderman and colleagues [7]. On the other hand, Chaitman and colleagues [22], Fennell and colleagues [38], Hacker and colleagues [43] and Namay and colleagues [73], in their follow-up studies, claimed that long term survival is significantly shorter in patients who suffered PMI compared with those who did not, even when allowance is made for the higher perioperative mortality rate in the former group.…”

“…The occurrence of, diagnostic criteria for and mortality from PMI are listed in table V. In these CABG patients PMI is a serious event, with mortality rates varying between 3 % and 34 % [21,37,41,42,84,92] and it accounts for almost 50% of the mortality during CABG. The occurrence of PMI is associated also with arrhythmias, cardiac insufficiency and a longer stay in the ICU [9].…”

Cardiac Troponin T for Prediction of Short- and Long-Term Morbidity and Mortality after Elective Open Heart Surgery

“…In case of nonparametric variables, comparisons were made by Mann-Whitney U-test. Categorical variables were tested by use of 2 or the Fisher exact test. Among related variables, those with the greatest univariate risk were selected for multivariate modeling.…”

“…Perioperative myocardial infarction (PMI) 5 in patients undergoing open heart surgery is a major determinant of postoperative morbidity and mortality (1)(2)(3)(4). The detection of myocardial cell necrosis that may result from electrocardiographically inapparent perioperative acute myocardial infarction (AMI), from patchy areas of irreversible cell injury attributable to incomplete cardioprotection in diffuse coronary artery disease, or from contraction band necrosis attributable to catecholamine release is a challenging task.…”

The prognostic value of troponin release after adult cardiac surgery — a meta-analysis

“…Postoperatively, however, the estimation of prognosis cannot be based solely on riskstratification tools developed for preoperative risk stratification and provider profiling. Perioperative events have a recognised association with morbidity [2][3][4][5][6] and mortality [7,8] but would, therefore, end up being disregarded.…”