Ann Thorac Surg 2007;84:24
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Christoph Knosalla, MD, PhD
Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, Berlin, D-13353 Germany
(Email: knosalla{at}dhzb.de).
Significant recent advances have been made in strategies for managing ST-segment elevation myocardial infarction (STEMI); randomized controlled trials have guided the introduction of increasingly advanced reperfusion, revascularization, and secondary prevention strategies with resulting improvements in mortality.
Although the surgical management of patients with acute myocardial infarction has been clearly superseded by medical therapy, including percutaneous coronary intervention (PCI), a significant number of patients still require surgical intervention. Thielmann and colleagues [1] report meaningful data regarding predictors and outcome of coronary artery bypass grafting (CABG) in patients with STEMI. Prospective randomized trials comparing interventional and surgical revascularization in this field are limited, and the reasons for referral for surgical revascularization (ie, ongoing ischemia or infarction, failed PCI, hemodynamic compromise, and so forth), as well as the timing of the surgical intervention, may vary depending on logistic factors. This report provides one more indicator that CABG can be performed successfully in this difficult group of patients.
This article confirms that preoperative age, gender, the presence of cardiogenic shock, and the extent of myocardial injury are predictors of adverse outcome in this setting; however, in addition the authors were able to define the optimum timing of revascularization more clearly. According to this study, revascularization should be performed within 6 hours of the onset of symptoms (as for PCI), thus limiting the infarct size and subsequent ventricular remodeling; operative intervention at this time is associated with an acceptable, although not negligible mortality rate. Alternatively, to avoid the major reperfusion-injury potentially responsible for the dramatic increase of in-hospital mortality when CABG is performed within 24 hours, the patient should be medically stabilized and surgery delayed (if possible) for at least 24 hours and at best for 7 days.
The authors report the results of conventional CABG using cold crystalloid cardioplegia in patients with STEMI. Based on our own experience, on-pump beating or off-pump coronary artery bypass surgeries have the potential to further improve the results, particularly in the early phase after myocardial infarction. In the effort to limit infarct size and minimize in-hospital morbidity and mortality, the use of hybrid rooms that merge diagnostic and therapeutic efforts will offer important logistic and therapeutic advances. This approach will also certainly help to redefine the role of CABG in acute myocardial infarction and further improve the outcomes of patients with acute myocardial infarction.
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References
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- Thielmann M, Neuhäuser 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]
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Predictors and Outcomes of Coronary Artery Bypass Grafting in ST Elevation Myocardial Infarction
- Matthias Thielmann, Markus Neuhäuser, Anja Marr, Ulf Herold, Markus Kamler, Parwis Massoudy, and Heinz Jakob
Ann. Thorac. Surg. 2007 84: 17-24.
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