Ann Thorac Surg 2009;88:1792. doi:10.1016/j.athoracsur.2009.09.011
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Rohinton J. Morris, MD
Division of Cardiothoracic Surgery, University of Pennsylvania Health Systems, PHI Bldg, 51 N 39th St, Suite 2D, Philadelphia, PA 19104
(Email: rohinton.morris{at}uphs.upenn.edu).
Management of acute myocardial infarction, characterized by ST-segment elevation (STEMI) remains a vexing problem. With the advent of routine and early antiplatelet and antithrombotic drug therapy (clopidogrel, and so forth), prompt institution of intra-aortic balloon pump (IABP) support and aggressive percutaneous coronary intervention have changed the landscape of treatment. Although surgical revascularization remains a viable option, many factors have precluded widespread, early referral to the cardiac surgeon. Hagl and colleagues [1] report their experience, spanning a 5-year period, in which emergent surgical revascularization was performed on patients with STEMI. All patients were revascularized within 48 hours from the onset of symptoms. Of note, 33% of patients presented with cardiogenic shock, but only 10% had an IABP inserted prior to surgery. The overall 30-day mortality was significant at 20%, but the highest mortality occurred in patients with cardiogenic shock. This highly sick group exhibited a mortality of 27%, as compared with 8.6% in patients without shock. Still, the surgeons are to be credited in showing improved survival in shock patients when compared with historical controls.
Some daunting questions remain. Regarding the timing of surgical intervention, previous authors have demonstrated an even earlier (< 6-hour) interval to surgery can decrease mortality, but the 7-hour to 24-hour interval period may be the most dangerous [2]. With door-to-balloon time becoming a highly important marker of infarct limitation, and minimization of end-organ damage, it would seem prudent to include this tool in future management of such patients. Considerable publications have also reported the use of pharmacotherapies to aid in remodeling, limiting ischemia-reperfusion injury, and modulating the immune response. The horizon of stem-cell therapy for this subset of patients is promising, and the ability to deliver combined drug therapies with complete revascularization is a laudatory goal. The use of mechanical assist, in terms of short-term support, also seems to be gaining a foothold in the surgeon's and interventionalist's approach.
The authors are to be commended for showing that coronary bypass grafting can be safely performed within an aggressive approach to STEMI patients. The cardiac surgeon should be integrated as a fundamental part of the therapeutic armamentarium. As hybrid operating rooms are increasingly being used, a conjoined approach with cardiologists and cardiac surgeons will no doubt benefit this patient population.
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- Hagl C, Khaladj N, Peterss S, et al. Acute treatment of ST-segment-elevation myocardial infarction: is there a role for the cardiac surgeon? Ann Thorac Surg 2009;88:1786-1792.[Abstract/Free Full Text]
- Thielmann M, Neuhauser M, Marr A, et al. Predictors and outcomes of coronary artery bypass grafting in ST elevation myocardial infarction Ann Thorac Surg 2007;84:17-24.[Abstract/Free Full Text]
Related Article
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Acute Treatment of ST-Segment-Elevation Myocardial Infarction: Is There a Role for the Cardiac Surgeon?
- Christian Hagl, Nawid Khaladj, Sven Peterss, Andreas Martens, Ingo Kutschka, Heidi Goerler, Malakh Shrestha, and Axel Haverich
Ann. Thorac. Surg. 2009 88: 1786-1792.
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