Appropriate Timing of Coronary Artery Bypass Grafting after Acute Myocardial Infarction[*]
19 August 2011
01 December 2011
01 May 2012 (online)
Objectives Optimal timing of coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) remains the subject of fierce debate. Therefore, the recommended deferral ranges from immediate intervention to surgery 4 weeks after infarction. Especially, the increasing cohorts of patients at old age or with poor left ventricular function, whose mortality rates are additionally enhanced, may profit from focused analyses. This study aims at clarifying the appropriate timing of CABG after AMI, with special regard to high-risk patients (Age >70 years, left ventricular ejection fraction (LVEF) <30%).
Methods Retrospective analysis was performed in 3475 patients who had undergone isolated CABG between 2005 and 2009. Those 1168 patients with previous AMI (<30 days) were categorized in groups, depending on deferral of surgery: <6 hours after AMI (A), 6 hours–1 day (B), 2–3 days (C), 4–10 days (D), 11–20 days (E), and 21–30 days (F). Furthermore, subgroups with an age >70 years or a LVEF <30% were examined.
Results The mortality rates in groups A–F were 14.8, 10.2, 8.8, 4.2, 2.3, and 2.0%, whereas only the values of groups A–D were significantly increased versus the mortality rate of patients without previous AMI (1.9%). In patients over 70 years, we observed operative mortalities of 26.3, 14.3, 11.9, 6.1, 4.2, and 3.1% (groups A–F) versus 2.5% (no previous AMI), while 27.4, 15.4, 11.7, 6.0, 3.7, and 2.8% (groups A–F) versus 2.7% (no previous AMI) of patients with a LVEF <30% died during the first 30 days after surgery. In both subanalyses of high-risk patients, the enhanced mortalities of groups A–E reached significance. Multivariate analysis of operative risk factors revealed that CABG within 10 days after AMI and age over 60 years are independently associated with operative mortality.
Conclusions CABG early after AMI (<10 days) is accompanied by significantly increased mortality, especially in elderly patients or in patients with a severely impaired LVEF. At least the critical time period of 3 days should be avoided–whenever the hemodynamics is stable enough.
Keywordsacute myocardial infarction - coronary artery bypass grafting - surgical timing - operative mortality - delayed revascularization
* The content of this paper was presented at the 40th annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Stuttgart, February 15th, 2011.
- 1 Ketonen M, Pajunen P, Koukkunen H , et al; FINMONICA/FINAMI Study Group. Long-term prognosis after coronary artery bypass surgery. Int J Cardiol 2008; 124 (1) 72-79
- 2 Nalysnyk L, Fahrbach K, Reynolds MW, Zhao SZ, Ross S. Adverse events in coronary artery bypass graft (CABG) trials: a systematic review and analysis. Heart 2003; 89 (7) 767-772
- 3 Coleman WS, DeWood MA, Berg Jr R, Selinger SL, Leonard JJ, Siwek LG. Surgical intervention in acute myocardial infarction: an historical perspective. Semin Thorac Cardiovasc Surg 1995; 7 (4) 176-183 Review
- 4 Every NR, Maynard C, Cochran RP, Martin J, Weaver WD. Myocardial Infarction Triage and Intervention Investigators. Characteristics, management, and outcome of patients with acute myocardial infarction treated with bypass surgery. Circulation 1996; 94 (9, Suppl) II81-II86
- 5 Sintek CF, Pfeffer TA, Khonsari S. Surgical revascularization after acute myocardial infarction. Does timing make a difference?. J Thorac Cardiovasc Surg 1994; 107 (5) 1317-1321 , discussion 1321–1322
- 6 Lee DC, Oz MC, Weinberg AD, Lin SX, Ting W. Optimal timing of revascularization: transmural versus nontransmural acute myocardial infarction. Ann Thorac Surg 2001; 71 (4) 1197-1202 , discussion 1202–1204
- 7 Lee DC, Oz MC, Weinberg AD, Ting W. Appropriate timing of surgical intervention after transmural acute myocardial infarction. J Thorac Cardiovasc Surg 2003; 125 (1) 115-119 , discussion 119–120
- 8 Weiss ES, Chang DD, Joyce DL, Nwakanma LU, Yuh DD. Optimal timing of coronary artery bypass after acute myocardial infarction: a review of California discharge data. J Thorac Cardiovasc Surg 2008; 135 (3) 503-511 , 511, e1–e3
- 9 Voisine P, Mathieu P, Doyle D , et al. Influence of time elapsed between myocardial infarction and coronary artery bypass grafting surgery on operative mortality. Eur J Cardiothorac Surg 2006; 29 (3) 319-323
- 10 Kolh P, Wijns W, Danchin N , et al; Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI).. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010; 38 (Suppl) S1-S52
- 11 Selinger SL, Berg Jr R, Leonard JL, Grunwald RP, O'Grady WP. Surgical treatment of acute evolving anterior myocardial infarction. Circulation 1981; 64 (2 Pt 2) II28-II33
- 12 DeWood MA, Spores J, Berg Jr R , et al. Acute myocardial infarction: a decade of experience with surgical reperfusion in 701 patients. Circulation 1983; 68 (3 Pt 2) II8-II16
- 13 Weiss JL, Marino PN, Shapiro EP. Myocardial infarct expansion: recognition, significance and pathology. Am J Cardiol 1991; 68 (14) 35D-40D
- 14 Berg Jr R, Selinger SL, Leonard JJ, Coleman WS, DeWood M. Acute evolving myocardial infarction. A surgical emergency. J Thorac Cardiovasc Surg 1984; 88 (5 Pt 2) 902-906
- 15 Creswell LL, Moulton MJ, Cox JL, Rosenbloom M. Revascularization after acute myocardial infarction. Ann Thorac Surg 1995; 60 (1) 19-26
- 16 Chen JM, DeRose JJ, Slater JP , et al. Improved survival rates support left ventricular assist device implantation early after myocardial infarction. J Am Coll Cardiol 1999; 33 (7) 1903-1908
- 17 Anzai T, Yoshikawa T, Shiraki H , et al. C-reactive protein as a predictor of infarct expansion and cardiac rupture after a first Q-wave acute myocardial infarction. Circulation 1997; 96 (3) 778-784
- 18 Roberts CS, Schoen FJ, Kloner RA. Effect of coronary reperfusion on myocardial hemorrhage and infarct healing. Am J Cardiol 1983; 52 (5) 610-614
- 19 Braxton JH, Hammond GL, Letsou GV , et al. Optimal timing of coronary artery bypass graft surgery after acute myocardial infarction. Circulation 1995; 92 (9, Suppl) II66-II68