Thielmann Matthias, Massoudy Parwis, Jaeger Beate R, Neuhäuser Markus, Marggraf Günter, Sack Stephan, Erbel Raimund, Jakob Heinz
Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital of Essen, Hufelandstrasse 55, 45122 Essen, Germany.
Eur J Cardiothorac Surg. 2006 Jul;30(1):117-25. doi: 10.1016/j.ejcts.2006.03.062. Epub 2006 May 24.
Perioperative graft failure following coronary artery bypass grafting (CABG) results in acute myocardial ischemia/infarction (PMI), which may necessitate an acute secondary revascularization procedure to salvage myocardium, in order to preserve ventricular function and improve patient outcome. Whether acute percutaneous coronary (re)intervention (PCI), emergency reoperation, or conservative intensive care treatment should be applied, is currently unknown.
In order to identify the source of PMI and to pursue the appropriate re-revascularization strategy, coronary repeat angiography was emergently performed in 118 among 5427 consecutive isolated CABG patients with evidence of PMI. As a result, patients immediately underwent acute PCI (group 1), emergency reoperation (group 2), or were treated conservatively (group 3). Primary study endpoint was postoperative myocardial infarct size, as measured by peak cardiac troponin I (cTnI) serum levels. Secondary endpoints were perioperative left ventricular ejection fraction (LVEF%), assessed by transesophageal echocardiography, major adverse cardiac events, and short- and midterm mortality.
Repeat coronary angiography revealed early perioperative bypass graft failure in 67 among 118 patients and 84 among 214 bypass grafts after CABG. The number and type of failing bypass grafts were comparable between groups 1 and 2, but significantly different to that of group 3 (P<0.007). Acute PCI was applied in 25 patients, redo-CABG in 15 patients, and conservative treatment in 27 patients. Procedural peak cTnI serum levels were significantly different between groups 1 and 2 (81+/-18 ng/ml vs 178+/-62 ng/ml; P<0.001). Global LVEF was reduced during the acute ischemic event when compared with preoperative values (P<0.01). Thereafter, LVEF improved during follow-up within each group (P<0.001), but did not differ between the three groups. In-hospital and 1-year mortality were 12.0% and 20.0% in group 1, 20.0% and 27% in group 2, and 14.8% and 18.5% in group 3, respectively (P=NS).
Re-revascularization with emergency PCI may limit the extent of myocardial cellular damage compared with the surgical-based treatment strategy in patients with acute perioperative myocardial ischemia due to early graft failure following CABG.
冠状动脉旁路移植术（CABG）后围手术期移植物失败会导致急性心肌缺血/梗死（PMI），这可能需要进行急性二次血运重建术以挽救心肌，从而保留心室功能并改善患者预后。目前尚不清楚应采用急性经皮冠状动脉（再）介入治疗（PCI）、急诊再次手术还是保守的重症监护治疗。
为了确定PMI的来源并寻求合适的再次血运重建策略，对5427例连续接受单纯CABG且有PMI证据的患者中的118例紧急进行了冠状动脉重复血管造影。结果，患者立即接受了急性PCI（第1组）、急诊再次手术（第2组）或保守治疗（第3组）。主要研究终点是术后心肌梗死面积，通过心肌肌钙蛋白I（cTnI）血清峰值水平来衡量。次要终点包括经食管超声心动图评估的围手术期左心室射血分数（LVEF%）、主要不良心脏事件以及短期和中期死亡率。
重复冠状动脉造影显示，118例患者中有67例在围手术期早期出现旁路移植物失败，CABG术后214条旁路移植物中有84条出现失败。第1组和第2组失败的旁路移植物数量和类型相当，但与第3组有显著差异（P<0.007）。25例患者接受了急性PCI，15例患者进行了再次CABG，27例患者接受了保守治疗。第1组和第2组的术中cTnI血清峰值水平有显著差异（81±18 ng/ml对178±62 ng/ml；P<0.001）。与术前值相比，急性缺血事件期间整体LVEF降低（P<0.01）。此后，每组随访期间LVEF均有所改善（P<0.001），但三组之间无差异。第1组的住院死亡率和1年死亡率分别为12.0%和20.0%，第2组为20.0%和27%，第3组为14.8%和18.5%（P=无显著性差异）。
对于CABG后因早期移植物失败导致急性围手术期心肌缺血的患者，与基于手术的治疗策略相比，采用急诊PCI进行再次血运重建可能会限制心肌细胞损伤的程度。
