Postcardiac surgery myocardial ischemia: Why, when, and how to intervene

Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association

“…71 The increased mortality associated with acute PMI does not significantly differ by treatment modality (12% for PCI, 20% for redo CABG, and 14.8% for conservative therapy). 4 Patients with acute PMI also have higher rates of kidney injury and stroke ( P <0.001), 23 with an acute decline in LV ejection fraction that appears to recover at follow-up ( P <0.001). 7…”

“…1 In recent studies, the incidence of myocardial infarction has been reported to range from 0.3% to 9.8% after isolated CABG and from 0.7% to 11.8% after concomitant valvular surgery (Table 1). 4 In other series, the incidence of myocardial infarction after CABG has been reported to be as high as 14% when assessed with cardiac biomarkers and electrocardiographic findings such as new Q waves or left bundle-branch block and 20% to 30% with cardiac magnetic resonance (CMR) imaging. 3 For isolated mitral valve replacement and mitral valve repair, the incidence is 1.7% and 2.2%, respectively, and is often related to circumflex artery injury.…”

“…Graft-related factors represent the most common cause of acute PMI after CABG. 4 A meta-analysis of 9 studies and 1104 patients with acute PMI after CABG showed that, among 1056 patients who underwent subsequent angiography, 62.1% had acute graft failure (95% CI, 56.6%–67.6%), 6.1% had incomplete revascularization (95% CI, 0.4%–12.5%), and 3.5% had new native coronary artery lesions (95% CI, 1.4%–5.7%). 28 Notably, 31.7% of patients did not have any abnormal findings on angiography (95% CI, 25.6%–37.8%).…”

“… Algorithm for the treatment of postoperative myocardial ischemia after cardiac surgery. 4 CABG indicates coronary artery bypass grafting; IABP, intra-aortic balloon pump; ICU, intensive care unit; ITA, internal thoracic artery; LV, left ventricular; MCS, mechanical circulatory support; OR, operating room; PCI, percutaneous coronary intervention; RV, right ventricular; SVG, saphenous vein graft; and VA ECMO, venoarterial extracorporeal membrane oxygenation. *The device listed here serves only to illustrate an example of this type of device.…”

Volatile Anaesthesia versus Total Intravenous Anaesthesia for Cardiac Surgery—A Narrative Review

“…Perioperative MI in patients undergoing CABG surgery has a wide range of presentations, from clinically silent to hemodynamically significant, including LCOS, difficult weaning from CPB, concomitant vasoplegia and vasodilatory shock, AKI and stroke, which increase the risk of adverse short and long-term outcomes as compared with asymptomatic patients [ 71 ]. By attenuating apoptosis and necrosis, VA may reduce the infarct size and myocardial dysfunction after IR injury [ 15 , 19 ].…”