From surgical to interventional standby?

Abstract

Life threatening Q-infarction because of bypassgraft occlusion may occurr in 5-8% of the patients during the first days after CABG, and most patients are treated by immediate reoperation. This treatment may however be delayed because operating rooms might not be available immediately. We prospectively studied the feasability and safety of immediate coronary angiography and PTCA, if appropriate, in patients with severe ischemic in-hospital complications after CABG. From January till December 1995 1263 patients had CABG: mean age 64.9 +/- 10 y, 24% female, 7.1% emergencies (CABG < 24 h after coronary angiography). A 24 hours interventional standby was provided to perform immediate catheterization and PTCA in patients with signs of evolving myocardial infarction after CABG (ST-elevation in > or = 2 leads and hemodynamic compromise or new LV hypocinesia in the transoesophageal echocardiogramm). 3/1263 patients had immediate reoperation without angiography. 55/1263 patients were catheterized, all within 1 hour after the onset of Stelevation. 14/1263 had normal grafts and complete revascularization. Their ischemia was either transient (spasm) or the ECG was misinterpreted (pericarditis). Catheterization caused no severe complications. 2 patients had major bleeding at the puncture site. 41 patients presented with envolving Q-MI: 1 patient had immediate reoperation, 29 patients received immediate PTCA and 11 patients were treated medically. 8/29 PTCA-patients were in cardiogenic shock. We dilated 4 IMA-anastomoses, 3 distal veingraft anastomoses, 18 native vessels with occluded veingrafts and 4 native vessels, having not been grafted. Angiographic success was achieved in 20/29 (69%), clinical success in 65% (residual stenosis < 50%, no severe complications during hospital stay). 2 patients died during the first 30 days (none due to the PTCA procedure or PTCA-related delay of reoperation), Q-MI occurred in 2/29, NonQ-MI in 7/29, reoperation appeared necessary in 4/29, no bleeding complications were noticed. Immediate coronary angiography after CABG is feasable and safe. Salvage-PTCA early after CABG is an alternative treatment in patients with evolving Q-MI. Interventional standby might therefore be useful for institutions with a busy cardiac surgical program.