Timing of bypass surgery in stable patients after acute myocardial infarction

Abstract

R Raghavan, BS Benzaquen, L Rudski. Timing of bypass surgery in stable patients after acute myocardial infarction. Can J Cardiol 2007;23(12):976-982.OBJECTIVES: To determine the optimal timing for bypass surgery in stable patients after acute myocardial infarction (MI). BACKGROUND: Coronary artery bypass graft surgery (CABG) is a proven treatment for coronary artery disease. Because of the hypothesized risk of hemorrhagic transformation, it had become common practice to wait four to six weeks after MI. Recently, improvements in surgical and perioperative management, as well as an increase in pre-CABG in-hospital waiting times and excess burden on health care resources, have pushed surgeons to operate earlier. The optimal timing for a stable patient to undergo CABG after MI is unclear, because there have been no randomized trials to answer this question. METHODS:The published literature comparing early versus late surgical revascularization procedures in stable post-MI patients was reviewed. RESULTS: No randomized, prospective trials were found; however, several retrospective studies were identified. Most series examining Q wave MIs showed that mortality is higher in the early stages post-MI and progressively decreases with time post-MI. When studies examined non-Q wave MIs separately, there appeared to be less of a mortality difference between early and late surgical revascularization. There was a large disparity between the definitions of early surgery post-MI among the studies, some as early as 6 h and others up to eight days. Factors that increased mortality include abnormal left ventricular function and urgency of surgery, and some studies found risk models helpful to define increased risk after infarction. The possible increased risk of early surgery may be balanced against the potential for improved remodelling, improved quality of life and decreased hospital stay costs. CONCLUSIONS: There is a need for a randomized, prospective trial examining the optimal timing for CABG in stable post-MI patients.

Cirurgia de revascularização miocárdica na fase aguda do infarto

“…Other authors note that the surgery within the first three days after infarction is a predictor of mortality, especially in STEMI. Furthermore, patients with NSTEMI require more than IBA and vasoactive drugs [9,10]. In this study, we found no statistical difference between these groups.…”

“…However, actual results of the CABG can not be compared to those obtained in the 70s. Studies that compare current strategies for this invasive reperfusion with conservative medical management group note that the invasive (surgical or percutaneous) presents a shorter hospital stay, less re-hospitalization frequency, lower incidence of nonfatal reinfarction and lower mortality [10,11]. Otherwise, we will have a greater chance of reinfarction, due to lingering injuries, and expansion of the infarcted area, with consequent ventricular remodeling and greater likelihood of aneurysm formation.…”

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“…In the past years, the invasive rescue and primary PCI saved lives avoiding the risk of early CABG. But still some patients who are not candidates for primary PCI are in great risk to do CABG because of fresh infraction risks or because of the risk of waiting till remodeling which might might end in heart failure or ventricular aneurysm [30,31]. In our work there was a mortality range of 9% in both groups with almost no differences regarding the technique.…”

“…The prompt regain of the blood flow is difficult using surgical techniques but it is fast by fibrinolysis and best by PCI, which may lead to limitation of the infarct size decreasing the early remodeling, unfortunately late remodeling may lead eventually to LV failure with poor surgical prognosis [3]. Despite the fast restoration of the blood flow using PCI and fibrinolysis and their superiority to surgery; yet remains surgery as a rescue for special cases as non indicated patients for PCI or partially solved problems by PCI or even failed PCI [4].…”

Timing and Outcome of Coronary Artery Bypass Grafting in STEMI: On-Pump and off-Pump Dilemma

“…The long term and also the short term outcomes for revascularization after STEMI depends on how fast we revascularize; All the available data are based on retrospective studies with lack or even non-available prospective randomized studies [4]. In cases of elective coronary artery revascularization, there is no debate related to the timing Volume 8 Issue 1 -2017 or even the technique weather it is on pump or off-pump, yet in acute STEMI the debate of timing or the technique may affect the survival or later complications as well as the financial resources of the patient, the hospital or the country [7].…”