Emergency coronary bypass not associated with preoperative cardiogenic shock in failed angioplasty, after thrombolysis, and for acute myocardial infarction.

We have reviewed the literature and supplemented it with our own experience to provide a current viewpoint on emergency coronary bypass in three settings in which cardiogenic shock did not exist preoperatively. Acute failure of coronary angioplasty led to emergency operation in 701 patients with 25 (3.6%) deaths. There was a 37.6% incidence of perioperative infarction. Thrombolytic therapy for acute myocardial infarction, sometimes followed by angioplasty, led to emergency operation within 8 hours in 145 instances with four (2.1%) deaths. Emergency coronary bypass was primary therapy for 1,051 patients with acute myocardial infarction with 51 (4.9%) hospital deaths. Emergency operation for failed angioplasty is frequently mandated in the setting of surgical standby and iatrogenic ischemia although some operations could be postponed to an elective status. Emergency operation after thrombolytic therapy has been used for unsuccessful angioplasty of the infarct vessel, left main stenosis of greater than 50%, left main equivalent, multivessel disease with complex lesions not amenable to angioplasty, or failure to restore patency of the infarct vessel with thrombolysis. Operation within 12 hours of thrombolytic therapy is associated with a coagulopathy causing increased bleeding, the need for transfusion, and a greater incidence of reoperation for perioperative bleeding.