Perioperative Features in Patients with Acute Myocardial Infarction

Abstract

Surgical myocardial revascularization in the setting of acute myocardial infarction (MI) remains one of the most challenging areas of coronary surgery. Timely restoration of coronary blood flow in the infarct-related artery is a key determinant of patient prognosis. However, the presence of multivessel coronary artery disease, as well as mechanical and thrombotic complications of MI, limits the feasibility of endovascular interventions and often necessitates open cardiac surgery, which is performed in only 1.2–5 % of MI patients. At present, retrospective data analysis remains the primary method to assess the role of coronary artery bypass grafting (CABG) in MI, as initiating large prospective studies is unlikely to gain support from the majority of cardiologists and cardiac surgeons.

Aim. To study the features of the perioperative period for patients with acute myocardial infarction (MI).

Materials and Methods. A retrospective analysis was performed on 26 randomly selected cardiac surgery patients with acute MI who underwent surgery and were subsequently discharged from the GF “Amosov National Institute of Cardiovascular Surgery NAMS of Ukraine”. All patients received standard clinical and laboratory evaluations, including ECG, echocardiography, coronary angiography, and cardiac surgical intervention.

Results. The average age of the patients was 60.6 ± 9.3 years [range 39-80 years], Charlson index – 5.53 ± 1.57, EuroSCORE II – 13.9 % [range 5.01-68.2 %]. MI of up to 3 hours’ duration was registered in 4 (15.4 %) patients, MI of 6 hours’ duration – in 3 (11.5 %), MI of 12-24 hours’ duration – in 4 (15.4 %), MI of 2-5 days’ duration – in 5 (19.2 %), MI of 6-8 days’ duration – in 4 (15.4 %), MI of 10-20 days’ duration – in 6 (23.07 %). Q-MI was detected in 13 (50 %) patients, and non-Q MI was diagnosed in 13 (50 %) cases. Surgery was performed on the beating heart in 19 (73.07 %) cases. Two patients with cardiogenic shock on the 2nd day of Q-MI underwent coronary bypass grafting on-pump with intraaortic balloon counterpulsation. In complicated forms of CAD, operations were performed on-pump and coronary bypass grafting was supplemented with resection of left ventricular aneurysm (n=4), ventricular septal rupture repair (n=2), thrombectomy of left ventricular aneurysm (n=2), and mitral valve replacement (n=1). The average duration of stay in the intensive care unit was 4.4 ± 3.6 days [range 2-15 days], and patients were discharged on average 10.6 ± 5.6 days after surgery.

Conclusions. The key to successful surgical myocardial revascularization is the optimization of operative timing and an individualized approach. Most patients (61.5 %) with non-Q MI underwent cardiac surgery on the 1st day after MI onset, whereas in patients with Q-MI, 69.2 % underwent surgery between the 8th and 20th day. Patients with transmural MI complicated by cardiogenic shock should undergo emergency on-pump CABG with preventive IABP. In cases of mechanical complications of MI, daily echocardiographic monitoring is necessary for dynamic assessment of the size of the VSR, the thickness of the left ventricular wall in postinfarction aneurysms, and the mobility of thrombotic masses.