Emergency Coronary Artery Bypass Surgery in the Contemporary Percutaneous Coronary Intervention Era

Abstract

Background-Since the advent of percutaneous coronary interventions (PCIs), technological advances, adjunctive pharmacotherapy, and increasing operator experience have contributed to lowering the occurrence of major complications. However, emergency coronary artery bypass surgery (CABG) for failed PCI is still associated with important morbidity and mortality, even in the era of coronary stenting. We sought to determine the prevalence, indications, predictors, and complications of emergency CABG after PCI in the past decade. Methods and Results-We reviewed 18 593 PCIs performed from 1992 through 2000. There was a need for emergency CABG in 113 (0.61%) cases. The major indications were extensive dissection (nϭ61, 54%), perforation/tamponade (nϭ23, 20%), and recurrent acute closure (nϭ23, 20%). Prevalence of emergency CABG decreased from 1.5% of PCIs in 1992 to 0.14% in 2000 (PϽ0.001). Independent predictors of the need for emergency CABG included the worst ACC/AHA scoring of the intervened lesion (PϽ0.001) and female sex (Pϭ0.028), whereas history of prior bypass surgery and use of stents resulted in a decreased need for emergency CABG (PϽ0.001 for both). In patients undergoing emergency CABG, there were 17 (15%) in-hospital deaths, 14 (12%) perioperative Q-wave myocardial infarctions, and 6 (5%) cerebrovascular accidents. Conclusions-The need for emergency CABG has considerably decreased over time. Risk factors include female sex and a higher ACC/AHA score of the intervened lesion. However, morbidity and mortality of emergency CABG remain high even in the new millennium.

Guidelines on myocardial revascularization

“…Revascularization for acute failure after percutaneous coronary intervention If repeat PCI fails to abort evolving significant MI, immediate CABG is indicated [172]. When severe haemodynamic instability is present, IABP should be inserted prior to emergency revascularization.…”

Outcomes of a System-Wide Protocol for Elective and Nonelective Coronary Angioplasty at Sites Without On-site Surgery: The Mayo Clinic Experience

“…Third, the mortality rate after emergent CABG due to failed PCI continues to be high despite a dramatic decrease in the incidence. 4,12 Few data are available regarding the indications and outcomes of patients requiring transfer to a surgical institution after PCI. Fourth, the lack of a protocol that provides the necessary framework to ensure procedural safety and effectiveness poses an important barrier.…”

Emergency cardiac surgery after a failed percutaneous coronary intervention in an interventional centre without on-site cardiac surgery

“…4 The incidence of emergency coronary artery surgery after PCI further declined to 0.14-0.3% with increasing operator experience and improved wire, balloon and stent design. 5,6 This improvement of PCI outcome led to an increase in PCI procedures encompassing the total spectrum of the coronary artery disease. Additionally, PCI was performed in centres without on-site cardiac surgery.…”