Hochberg M S, Parsonnet V, Gielchinsky I, Hussain S M, Fisch D A, Norman J C
J Thorac Cardiovasc Surg. 1984 Dec;88(6):914-21.
Evidence of ischemia after acute myocardial infarction is a serious complication. If angiography reveals significant coronary artery disease, the precise timing of myocardial revascularization may be of critical importance. From 1978 through 1982, 174 patients underwent myocardial revascularization within 7 weeks of a documented myocardial infarction. The male:female ratio was 138:36, the average age was 58 +/- 1 (SEM) years; and the ejection fractions averaged 41% +/- 1%. Forty-four (25%) patients required preoperative intra-aortic balloon pump support, and an additional 18 (10%) required intra-aortic balloon pumping to be separated from cardiopulmonary bypass. An average of 2.9 +/- 0.1 vessels per patient were bypassed. The hospital mortality for these 174 patients was 16%. When mortalities were categorized according to the postinfarction week in which operation was performed, hospital mortality fell from 46% for those patients operated upon within 1 week of infarction to 6% for those patients operated upon 7 weeks after infarction. Of those patients operated upon within the first week after infarction, 23% were in cardiogenic shock and 62% required preoperative balloon pumping. Clearly the most critically ill patients were operated upon during the early postinfarction period. However, there was a marked difference in survival when patients in each of the seven weekly groups were classified according to ejection fraction. All patients with an ejection fraction greater than or equal to 50% (50 patients) operated upon at any time after infarction survived their hospital course, with only one late death. Conversely, among the 124 patients with an ejection fraction less than 50% operated upon during this 7 week interval, there were 27 (22%) hospital deaths. In this latter group, survival rates steadily improved if revascularization was performed at a time more remote from the infarction. The difference in early and late survival rates of patients operated upon with an ejection fraction greater than or equal to 50% compared to patients with an ejection fraction less than 50% is highly significant (p less than 0.001). We conclude that myocardial revascularization is safe at any time after myocardial infarction for those individuals with an ejection fraction greater than or equal to 50%. However, if the ejection fraction is less than 50%, then operation after myocardial infarction should be delayed at least 4 weeks.
急性心肌梗死后出现缺血迹象是一种严重的并发症。如果血管造影显示存在严重的冠状动脉疾病，心肌血运重建的精确时机可能至关重要。1978年至1982年期间，174例患者在记录到心肌梗死后7周内接受了心肌血运重建。男女比例为138:36，平均年龄为58±1（标准误）岁；射血分数平均为41%±1%。44例（25%）患者术前需要主动脉内球囊泵支持，另外18例（10%）患者需要在脱离体外循环时进行主动脉内球囊泵辅助。平均每位患者有2.9±0.1支血管接受了搭桥。这174例患者的医院死亡率为16%。当根据心肌梗死后进行手术的周数对死亡率进行分类时，医院死亡率从梗死1周内手术的患者的46%降至梗死7周后手术的患者的6%。在梗死第一周内接受手术的患者中，23%处于心源性休克，62%术前需要球囊泵辅助。显然，病情最危重的患者在心肌梗死后早期接受了手术。然而，当根据射血分数对七个每周分组中的患者进行分类时，生存率存在显著差异。梗死后期任何时间接受手术的射血分数大于或等于50%的所有患者（50例）均存活至出院，仅有1例晚期死亡。相反，在这7周期间接受手术的射血分数小于50%的124例患者中，有27例（22%）医院死亡。在后者这组中，如果在离梗死时间更远的时候进行血运重建，生存率会稳步提高。射血分数大于或等于50%的患者与射血分数小于50%的患者早期和晚期生存率的差异非常显著（p<0.001）。我们得出结论，对于射血分数大于或等于50%的个体，心肌梗死后任何时间进行心肌血运重建都是安全的。然而，如果射血分数小于50%，那么心肌梗死后手术应至少推迟4周。
