Acute Myocardial Infarction Revascularization Research Articles

Impact of Complete Revascularization for Acute Myocardial Infarction In Multivessel Coronary Artery Disease Patients With Diabetes Mellitus.

The clinical benefits of complete revascularization (CR) in acute myocardial infarction (AMI) patients are unclear. Moreover, the benefit of CR is unknown in AMI with diabetes mellitus (DM) patients. We sought to compare the prognosis of CR and incomplete revascularization (IR) in patients with AMI and multivessel disease, according to the presence of DM. A total of 2,150 AMI patients with multivessel coronary artery disease were analyzed. CR was defined based on the angiographic image. The primary endpoint of this study was the patient-oriented composite outcome (POCO) defined as a composite of all-cause death, any myocardial infarction, and any revascularization within 3 years. Overall, 3-year POCO was significantly lower in patients receiving angiographic CR (985 patients, 45.8%) compared with IR (1,165 patients, 54.2%). When divided into subgroups according to the presence of DM, CR reduced 3-year clinical outcomes in the non-DM group but not in the DM group (POCO: 11.7% vs. 23.2%, p<0.001, any revascularization: 7.2% vs. 10.8%, p=0.024 in the non-DM group, POCO: 24.3% vs. 27.8%, p=0.295, any revascularization: 13.3% vs. 11.3%, p=0.448 in the DM group, for CR vs. IR). Multivariate analysis showed that CR significantly reduced 3-year POCO (hazard ratio, 0.52; 95% confidence interval, 0.36-0.75) only in the non-DM group. In AMI patients with multivessel disease, CR may have less clinical benefit in DM patients than in non-DM patients.

100.72 - FFR-Guided Revascularization Versus Non-FFR-Guided Partial or Complete Revascularization in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

100.72 - FFR-Guided Revascularization Versus Non-FFR-Guided Partial or Complete Revascularization in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Culprit-Only Revascularization, Single-Setting Complete Revascularization, and Staged Complete Revascularization in Acute Myocardial Infarction: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials.

Complete revascularization improves cardiovascular outcomes compared with culprit-only revascularization in patients with acute myocardial infarction ([MI]; ST-segment-elevation MI or non-ST-segment-elevation MI) and multivessel coronary artery disease. However, the timing of complete revascularization (single-setting versus staged revascularization) is uncertain. The aim was to compare the outcomes of single-setting complete, staged complete, and culprit vessel-only revascularization in patients with acute MI and multivessel disease. PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized controlled trials that compared 3 revascularization strategies. From 16 randomized controlled trials that randomized 11 876 patients with acute MI and multivessel disease, both single-setting complete and staged complete revascularization reduced primary outcome (cardiovascular mortality/MI; odds ratio [OR], 0.52 [95% CI, 0.41-0.65]; OR, 0.74 [95% CI, 0.62-0.88]), composite of all-cause mortality/MI (OR, 0.52 [95% CI, 0.40-0.67]; OR, 0.78 [95% CI, 0.67-0.91]), major adverse cardiovascular event (OR, 0.42 [95% CI, 0.32-0.56]; OR, 0.62 [95% CI, 0.47-0.82]), MI (OR, 0.39 [95% CI, 0.26-0.57]; OR, 0.73 [95% CI, 0.59-0.90]), and repeat revascularization (OR, 0.30 [95% CI, 0.18-0.47]; OR, 0.46 [95% CI, 0.30-0.71]) compared with culprit-only revascularization. Single-setting complete revascularization reduced cardiovascular mortality/MI (OR, 0.70 [95% CI, 0.55-0.91]), major adverse cardiovascular event (OR, 0.67 [95% CI, 0.50-0.91]), and all-cause mortality/MI driven by a lower risk of MI (OR, 0.53 [95% CI, 0.36-0.77]) compared with staged complete revascularization. Single-setting complete revascularization ranked number 1, followed by staged complete revascularization (number 2) and culprit-only revascularization (number 3) for all outcomes. The results were largely consistent in subgroup analysis comparing ST-segment-elevation MI versus non-ST-segment-elevation MI cohorts. Single-setting complete revascularization may offer the greatest reductions in cardiovascular events in patients with acute MI and multivessel disease. A large-scale randomized trial of single-setting complete versus staged complete revascularization is warranted to evaluate the optimal timing of complete revascularization.

ICU management of cardiogenic shock before mechanical support.

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS). Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock. Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

Finding the Optimal Strategy for Nonculprit Revascularization in Acute Myocardial Infarction: The Role of Angiography-Derived Physiology.

Finding the Optimal Strategy for Nonculprit Revascularization in Acute Myocardial Infarction: The Role of Angiography-Derived Physiology.

Impact of Sex Differences on Clinical Outcomes in Patients Following Primary Revascularization for Acute Myocardial Infarction - Insights From the Japanese Nationwide Registry.

Women with acute myocardial infarction (AMI) often present a worse risk profile and experience a higher rate of in-hospital mortality than men. However, sex differences in post-discharge prognoses remain inadequately investigated. We examined the impact of sex on 1-year post-discharge outcomes in patients with AMI undergoing percutaneous coronary intervention. We extracted patient-level data for the period January 2017-December 2018 from the J-PCI OUTCOME Registry, endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics. One-year all-cause and cardiovascular mortality and major adverse cardiovascular events were compared between men and women. In all, 29,856 AMI patients were studied, with 6,996 (23.4%) being women. Women were significantly older and had a higher prevalence of comorbidities than men. Crude all-cause mortality was significantly higher among women than men (7.5% vs. 5.4% [P<0.001] for ST-elevation myocardial infarction [STEMI]; 7.0% vs. 5.2% [P=0.006] for non-STEMI). These sex-related differences in post-discharge outcomes were attenuated after stratification by age. Multivariate analysis demonstrated an increase in all-cause mortality in both sexes with increasing age and advanced-stage chronic kidney disease (CKD). Within this nationwide cohort, women had worse clinical outcomes following AMI than men. However, these sex-related differences in outcomes diminished after adjusting for age. In addition, CKD was significantly associated with all-cause mortality in both sexes.

Impact of CYP2C19 gene polymorphisms on clinical outcomes in patients with myocardial infarction during 60 months of follow-up

Objective: To evaluate the effect of CYP2C19 gene polymorphisms on clinical outcomes in patients after successful revascularization for acute myocardial infarction with and without ST segment elevation during clopidogrel therapy for 60 months of follow-up.Methods: From 2011 to 2012, 363 patients with acute myocardial infarction who underwent coronary revascularization were included in the study. In the postoperative period, the patients underwent genetic analysis for the CYP2C19 gene polymorphism. All patients received dual antiplatelet therapy with aspirin and clopidogrel. The 60-month follow-up period assessed the primary composite endpoint of the cumulative incidence of all-cause mortality, recurrent myocardial infarction, and stroke.Results: At 60 months after the initial intervention, 71 patients had a composite primary endpoint event (all-cause death, recurrent myocardial infarction, or stroke): 50 (20%, 95% CI 16–25) in the group patients with "wild genotype" and 21 patients of the "loss of function (LOF) *2+*3" group (19%, 95% CI 13–27). No significant relationship was observe between carriage of LOF alleles of the CYP2C19 and the primary endpoint during the 60-month follow-up (HR 0.99, 95% CI 0.59–1.65, P = .965), as well as between carriage of the homozygous CYP2C19 variant (*2/*2) and the development of myocardial infarction during the same period (HR 1.26, 95% CI 0.30–5.20, P = .752).Conclusion: No correlation was observed between the CYP2C19 gene polymorphisms (*2, *3 alleles) and the incidence of ischemic events in patients with myocardial infarction after myocardial revascularization throughout a 60-month follow-up period. Received 27 November 2022. Revised 25 September 2023. Accepted 26 September 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: I.O. GrazhdankinData collection and analysis: I.O. GrazhdankinStatistical analysis: V.L. LukinovDrafting the article: I.O. Grazhdankin, A.A. Prokhorikhin, V.I. Baystrukov, E.I. Kretov, V.L. LukinovCritical revision of the article: A.M. ChernyavskiyFinal approval of the version to be published: I.O. Grazhdankin, A.A. Prokhorikhin, V.I. Baystrukov, E.I. Kretov, A.M. Chernyavskiy, V.L. Lukinov

Abstract 15373: Guiding Modalities for Non-Culprit Artery Revascularization in Acute Myocardial Infarction With Multivessel Disease: A Pooled Analysis of FLOWER-MI and FRAME-AMI

Background: Currently, it is not yet clear whether angiography or fractional flow reserve (FFR) is better in guiding percutaneous coronary intervention (PCI) for non-culprit artery revascularization in patients with acute myocardial infarction (AMI) and multivessel disease (MVD) after primary PCI. Therefore, a pooled analysis is conducted to summarize the findings from two only available trials, i.e., FRAME-AMI and FLOWER-MI. Aim: To compare major cardiac adverse event (MACE) between angiography-guided and FFR-guided non-culprit artery revascularization in AMI and MVD Method: MACE defined as a primary endpoint of all-cause death, non-fatal myocardial infarction, or unplanned revascularization was the primary outcome while all-cause death was the secondary outcome. Pooled cumulative probability of developing the primary endpoint curves were constructed from extracted Kaplan-Meier curves using Weibull distribution, and a meta-analysis was performed to pool extracted hazard ratio (HR) and 95% confidence intervals (CI). Furthermore, a subgroup analysis of STEMI and NSTEMI groups was performed. Result: Cumulative probability curve is displayed in Figure 1A. A pooled analysis showed no difference between two guiding modalities both in MACE and all-cause death risk reduction. FFR-guided PCI reduced MACE risk by 24% (HR 0.76, 95% CI 0.25-2.27) and risk of all-cause death by 47% (HR 0.53, 95% CI 0.18-1.54) compared to angiography-guided PCI but not statistically significant as shown in Figure 1B. Regarding subgroup analysis concerning MACE, FFR-guided PCI was not superior to angiography-guided PCI in STEMI (HR 1.06, 95% CI 0.60-1.90) despite significantly superior to angiography-guided PCI in FRAME-AMI NSTEMI group. Conclusion: FFR-guided PCI is not superior to angiography-guided PCI in non-culprit artery revascularization in AMI and MVD concerning risk reduction of MACE and all-cause death, but might show superiority in the NSTEMI subgroup.

Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates. Primary percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with CS. To investigate the immediate mortality rates in patients with CS undergoing primary PCI and identify mortality predictors. We conducted a retrospective analysis of 305 patients with CS who underwent primary PCI at the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between January 2018 and December 2022. The primary outcome was immediate mortality, defined as mortality within index hospitalization. Univariate and multivariate logistic regression analyses were performed to identify predictors of immediate mortality. In a sample of 305 patients with 72.8% male patients and a mean age of 58.1 ± 11.8 years, the immediate mortality rate was found to be 54.8% (167). Multivariable analysis identified Killip class IV at presentation [odds ratio (OR): 2.0; 95% confidence interval (CI): 1.2-3.4; P = 0.008], Multivessel disease (OR: 3.5; 95%CI: 1.8-6.9; P < 0.001), and high thrombus burden (OR: 2.6; 95%CI: 1.4-4.9; P = 0.003) as independent predictors of immediate mortality. Immediate mortality rate in patients with CS undergoing primary PCI remains high despite advances in treatment strategies. Killip class IV at presentation, multivessel disease, and high thrombus burden (grade ≥ 4) were identified as independent predictors of immediate mortality. These findings underscore the need for aggressive management and close monitoring of patients with CS undergoing primary PCI, particularly in those with these high-risk characteristics.

MULTi-vessel Immediate vs. STAged RevaScularization in Acute Myocardial Infarction: the MULTISTARS AMI trial.

MULTi-vessel Immediate vs. STAged RevaScularization in Acute Myocardial Infarction: the MULTISTARS AMI trial.

Acute mitral regurgitation with and without acute heart failure.

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

A-37 | Fractional Flow Reserve vs Angiography Guided Revascularization in Acute Myocardial Infarction With Multivessel Coronary Artery Disease: A Meta-Analysis of Randomized Trials

A-37 | Fractional Flow Reserve vs Angiography Guided Revascularization in Acute Myocardial Infarction With Multivessel Coronary Artery Disease: A Meta-Analysis of Randomized Trials

Characteristics and outcomes of patients with no standard modifiable risk factors undergoing primary revascularization for acute myocardial infarction: Insights from the nationwide Japanese percutaneous coronary intervention registry

Identification of and therapeutic approaches to standard modifiable risk factors (SMuRFs), including hypertension, diabetes, dyslipidemia, and smoking, have led to improved survival of patients at risk for coronary events. However, recent studies have indicated that a significant proportion of patients with acute myocardial infarction (AMI) have no SMuRFs. We aimed to assess in-hospital outcomes and the prevalence of these patients using the Japanese nationwide percutaneous coronary intervention (J-PCI) registry. The J-PCI is a procedure-based registration program in Japan. A total of 115,437 PCI procedures were performed on patients with AMI between January 2019 and December 2020. The participants were divided into 2 groups: those with at least 1 SMuRF and those without any SMuRFs. The primary outcome was in-hospital mortality. Of the 115,437 patients with AMI, 1,777 (1.6%) had no SMuRFs. Patients without SMuRFs were older; more likely to have left main disease; and more likely to present with heart failure, cardiogenic shock, and cardiac arrest than those with SMuRFs, resulting in higher rates of mechanical circulatory support use and impaired post-PCI coronary blood flow. In-hospital mortality was significantly higher in patients without SMuRFs than in those with SMuRFs (18.3% vs 5.3%, P < .001), irrespective of the presence or absence of ST-segment elevation. In Japan, where annual health checks are mandated under universal health care coverage, the vast majority of patients with AMI undergoing PCI have SMuRFs. However, although small in number, patients without SMuRFs are more likely to present with life-threatening conditions and have worse in-hospital survival.

Complete revascularization in acute myocardial infarction: a clinical review.

In patients with ST segment elevation and non-ST elevation myocardial infarction (MI), multivessel (MV) coronary artery disease is found in approximately 50%, leading to worse clinical outcomes. Recent data have suggested that complete revascularization with MV percutaneous coronary intervention is associated with a reduced risk of major adverse cardiovascular events as compared to culprit vessel-only revascularization. However, the optimal timing of MV intervention, appropriate non-culprit lesion assessment, and the best revascularization strategy in specific subsets such as cardiogenic shock remain to be established. This review article summarizes current evidence on revascularization strategies in patients with acute MI and MV disease.

Abstract 14875: Topological Data Analysis of Electronic Health Record Features Predicts Major Cardiovascular Outcomes After Revascularization for Acute Myocardial Infarction

Introduction: Topological data analysis (TDA) is an emerging mathematical technique that imposes structure on a dataset and examines the shapes (or topological features) that arise. The TDA algorithm Mapper Plus is proposed to study the spatial characteristics of clinical data for the purpose of patient classification. This is a data-driven and hypothesis-free approach to clinical risk stratification. Hypothesis: The hypothesis is that Mapper Plus can classify distinctive subsets of patients receiving optimal treatments post-acute myocardial infarction (AMI). Our goal is to identify subgroups who remained at risk of having a future adverse event (AE) i.e., death, heart failure hospitalization, or recurrent MI Methods: A single-center, retrospective analysis of 31 clinical variables from the electronic health record (EHR) was conducted on 798 AMI subjects. Risk was defined as high or low in relation to the average probability of survival without AE for the entire cohort at the 1 year mark. Results: TDA identified six subsets of patients. Four subsets (n=597) had &gt; 1-fold change on the probability of survival free of AEs; these became the low-risk subgroup. Two subsets (n=344) had &lt; 1-fold change on the probability of survival free of AEs; these became the high-risk subgroup. Because Mapper Plus allows for subject overlap across subgroups, 143 subject (18%) were shared between the high (n=201, 25%)- and low-risk (n=454, 57%) subgroups and were extracted into a 3rd intermediate risk subgroup (see figure). Conclusions: TDA significantly stratified AMI patients into 3 subgroups with distinctive incidences of AE up to 3 years post AMI. This is a new framework for EHR-based risk stratification that requires no additional patient interaction, is agnostic to prior knowledge, and is driven by the topological features of the included data. Further studies will be needed to validate TDA across different patient cohorts before it can be applied to clinical practice.

MitraClip as Last-Resort Interventional Therapy for Refractory Mitral Regurgitation After Complete Revascularization for Acute Myocardial Infarction.

MitraClip as Last-Resort Interventional Therapy for Refractory Mitral Regurgitation After Complete Revascularization for Acute Myocardial Infarction.

Association between race/ethnicity and income on the likelihood of coronary revascularization among postmenopausal women with acute myocardial infarction: Women's health initiative study

Historically, race, income, and gender were associated with likelihood of receipt of coronary revascularization for acute myocardial infarction (AMI). Given public health initiatives such as Healthy People 2010, it is unclear whether race and income remain associated with the likelihood of coronary revascularization among women with AMI. Using the Women's Health Initiative Study, hazards ratio (HR) of revascularization for AMI was compared for Black and Hispanic women vs White women and among women with annual income <$20,000/year vs ≥$20,000/year over median 9.5 years follow-up(1993-2019). Proportional hazards models were adjusted for demographics, comorbidities, and AMI type. Results were stratified by revascularization type: percutaneous coronary intervention and coronary artery bypass grafting(CABG). Trends by race and income were compared pre- and post-2010 using time-varying analysis. Among 5,284 individuals with AMI (9.5% Black, 2.8% Hispanic, and 87.7% White; 23.2% <$20,000/year), Black race was associated with lower likelihood of receiving revascularization for AMI compared to White race in fully adjusted analyses [HR:0.79(95% Confidence Interval:[CI]0.66,0.95)]. When further stratified by type of revascularization, Black race was associated with lower likelihood of percutaneous coronary intervention for AMI compared to White race [HR:0.72(95% CI:0.59,0.90)] but not for CABG [HR:0.97(95%CI:0.72,1.32)]. Income was associated with lower likelihood of revascularization [HR:0.90(95%CI:0.82,0.99)] for AMI. No differences were observed for other racial/ethnic groups. Time periods (pre/post-2010) were not associated with change in revascularization rates. Black race and income remain associated with lower likelihood of revascularization among patients presenting with AMI. There is a substantial need to disrupt the mechanisms contributing to race, sex, and income disparities in AMI management.

PROGNOSTIC VALUE OF ENDOTHELIAL MONOCYTE ACTIVATING POLYPEPTIDE – ІІ ON THE DEVELOPMENT OF ACUTE LEFT VENTRICULAR FAILURE IN HOSPITAL PERIOD OF ACUTE MYOCARDIAL INFARCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

Introduction. 20% of patients with acute myocardial infarction are diagnosed as having type 2 diabetes: this is much higher than in the entire population. In the presence of this comorbid disease, the incidence of acute left ventricular failure with cardiogenic shock is also much higher than could be predicted based on the size of the infarction zone that poses a challenge for modern cardiology. Endothelial dysfunction is known to underlay the etiopathogenesis of acute myocardial infarction and concomitant type 2 diabetes. Endothelial monocyte activating polypeptide – ІІ is a multifunctional peptide with proinflammatory and angiogenesis properties, it activates a number of proinflammatory cytokines, inducing inflammatory changes in blood vessels. It plays a significant role in the process of myocardial tissue revascularization in acute myocardial infarction (AMI). The aim of this study is to investigate the relationship between the activity of endothelial monocyte activating polypeptide – ІІ and acute left ventricular failure in patients with acute myocardial infarction in hospital period and type 2 diabetes mellitus, as well as to evaluate the prognostic properties of endothelial monocytactating peptide II in this cohort of patients with following design of prognostic model. Material and methods. The study involved 120 patients (60 men and 60 women) with AMI, whose mean age was 66.35 ± 0.91 years, (p &lt;0.05). The participants were divided into 2 groups: group 1 patients with concomitant type 2 diabetes (n = 70), group 2 patients with isolated AMI (n = 50). The control group included 20 healthy individuals. All participants underwent standard routine clinical and instrumental examinations. According to the objectives of this study, on the 1st day after AMI diagnosis was confirmed, the level of EMARII was evaluated in all participants using a commercial test system "Human Endothelial monocyte activating polypeptide – ІІ ELISA KIT". The findings data obtained were processed by the software package "Statistica 6.0" (StatSoft Inc, USA). Results. The patients of the 1 group had higher level of endothelial monocytic peptide-II 1.65 times than the patients of the 2nd group (4.54 ± 0.331 ng / ml vs. 2.74 ± 0.21 ng / ml, respectively, (p &lt;0,05). In the control group, the average value of this indicator was 1.1 ± 0.037 ng / ml. Class IV by the Killip scale was detected in 44% of the patients included in the group of the 3rd tertile according to the level of endothelial monocyte activating polypeptide – ІІ. The value of endothelial monocyte activating polypeptide – ІІ &gt; 6.45 ng / ml in patients of the 1 group and &gt; 3.31 ng / ml in the patients of the 2 group is a predictor for occurrence of left-ventricular failure resulting in cardiogenic shock. Based on the results of the study, a multifactor logistic regression model for the prognosis of acute left-ventricular cardiac failure with cardiogenic shock in the hospital course of AMI in patients with type 2 diabetes was developed. Conclusions. Thus, endothelial monocyte activating polypeptide – ІІ acts as a predictor for acute left ventricular failure resulting in cardiogenic shock in the hospital period of acute myocardial infarction in patients with type 2 diabetes.

The timing of surgical revascularization in acute myocardial infarction: when should we intervene?

Coronary artery bypass grafting (CABG) is a crucial intervention in acute myocardial infarction (AMI), particularly when AMI is not amenable for management with primary percutaneous coronary intervention (PCI). To optimize outcome in these patients, surgical teams must consider a host of predictive factors, with the most prominent being the timing of CABG. Despite numerous studies exploring timing of CABG following AMI in the past, optimal surgical timing remains controversial. The mortality rates vary with timing of CABG, but confounding factors such as age, impaired pulmonary function, renal insufficiency, and poor left ventricular function may contribute to varied outcomes reported. An electronic literature search of articles that discussed acute myocardial presentation and urgent in-patient or elective CABG was conducted. The evidence was synthesized based on each reported article and their outcomes. Current literature suggests multiple factors can guide CABG timing including, type of AMI at initial presentation, distinctive pathological status, and patient characteristics. Thus, there is a need for large, multi-center studies to identify optimal CABG timing in complex coronary artery disease or failed PCI in patients with AMI. Future guidelines should emphasize patient cohorts by taking their risk factors into consideration. As such, a need for greater cardiac screening methods and development of scoring systems can aid in the optimization of CABG timing.

Veno-occlusive unloading of the heart reduces infarct size in experimental ischemia\u2013reperfusion

Mechanical unloading of the left ventricle reduces infarct size after acute myocardial infarction by reducing cardiac work. Left ventricular veno-occlusive unloading reduces cardiac work and may reduce ischemia and reperfusion injury. In a porcine model of myocardial ischemia–reperfusion injury we randomized 18 pigs to either control or veno-occlusive unloading using a balloon engaged from the femoral vein into the inferior caval vein and inflated at onset of ischemia. Evans blue and 2,3,5-triphenyltetrazolium chloride were used to determine the myocardial area at risk and infarct size, respectively. Pressure–volume loops were recorded to calculate cardiac work, left ventricular (LV) volumes and ejection fraction. Veno-occlusive unloading reduced infarct size compared with controls (Unloading 13.9 ± 8.2% versus Control 22.4 ± 6.6%; p = 0.04). Unloading increased myocardial salvage (54.8 ± 23.4% vs 28.5 ± 14.0%; p = 0.02), while the area at risk was similar (28.4 ± 6.7% vs 27.4 ± 5.8%; p = 0.74). LV ejection fraction was preserved in the unloaded group, while the control group showed a reduced LV ejection fraction. Veno-occlusive unloading reduced myocardial infarct size and preserved LV ejection fraction in an experimental acute ischemia–reperfusion model. This proof-of-concept study demonstrated the potential of veno-occlusive unloading as an adjunctive cardioprotective therapy in patients undergoing revascularization for acute myocardial infarction.