Underwent Emergency Coronary Artery Bypass Research Articles

Effects of Preoperative Nutritional Status and Lymphocyte Count on the Development of Early-term Atrial Fibrillation After Coronary Artery Bypass Grafting: A Retrospective Study.

Although there are publications in the literature stating that parameters related to the nutritional status of patients are associated with the clinical outcomes of those with coronary artery disease, it is also stated that there is insufficient data on the relationship between nutritional indices and long-term outcomes and major adverse cardiovascular events in patients undergoing isolated coronary artery bypass grafting. This retrospective study was conducted with patients who underwent isolated elective on-pump coronary artery bypass grafting in our hospital. Patients who underwent emergency coronary artery bypass grafting or those with known atrial fibrillation in the preoperative period were excluded. Patients were analyzed and compared in two groups according to the development of postoperative atrial fibrillation. The data of 93 coronary artery bypass grafting patients (71 [76%] males) with a mean age of 62.86 ± 9.53 years included in the study were evaluated. Both groups had similar preoperative ejection fraction value, hemoglobin level, age, number of distal bypasses, and postoperative mortality rates. Although the mean cardiopulmonary bypass and aortic cross-clamping times were higher in Group 1, they were not statistically significant. In our study, the mean prognostic nutrition index value was 51.76 ± 3002. According to our study results, there was no statistically significant difference between prognostic nutrition index values and the development of atrial fibrillation after coronary artery bypass grafting, which is similar to some publications in the literature. We think that it would be beneficial to conduct randomized studies involving more patients on this subject.

The relationship between prognostic nutritional index and long-term mortality in patients undergoing emergency coronary artery bypass graft surgery for acute-ST elevation myocardial infarction.

Malnutrition and the prognosis of coronary artery disease (CAD) are shown to be correlated. The significance of nutritional status has been evaluated in patients with ST elevation myocardial infarction (STEMI), stable CAD, and elective coronary artery bypass graft (CABG) surgery. However, the prognostic impact of poor nutritional status on STEMI patients who underwent emergent CABG is not known. In this study, we aimed to investigate the relationship between nutritional status assessed by the prognostic nutritional index (PNI) and long-term mortality in STEMI patients who underwent emergent CABG. To the best of our knowledge, our study is the first one to evaluate the PNI effect on this specific population. 131 consecutive patients with STEMI who did not qualify for primary percutaneous coronary intervention and required emergent CABG between 2013 and 2018 were included in our study. The study population was divided into two groups: survivors and non-survivors. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3) for both groups, using the preoperative data. The optimal cut-off value was obtained by receiver operating characteristic (ROC) analysis. According to the cut-off value, we investigated the relationship between PNI and long-term mortality. The mean age of the study population was 57.0±10.6. During the median 92.7 (70.0-105.3)-month follow-up, 32 of the 131 patients (24.4%) died. Regression analysis showed a significant association between glucose levels (hazard ratio (HR), 1.007; 95% confidence interval (CI), 1.002-1.012; p=0.011) and PNI (HR, 0.850; 95% CI, 0.787-0.917; p<0.001) and long-term mortality. Accord-ing to the ROC analysis, the cut-off value for PNI to predict all-cause mortality was found to be 44.9, with a sensitivity of 81.3% and a specificity of 89.9%. In addition, age, ejection fraction, glomerular filtration rate, Killip classification, and left anterior descending-left internal mammary artery graft use are significantly associated with long-term all-cause mortality in STEMI patients undergoing emergency CABG. The PNI was significantly associated with long-term mortality in patients with STEMI who underwent emergent CABG. PNI can be used to improve the accuracy of the risk assessment of STEMI patients undergoing emergent CABG.

Comparative analysis of in-hospital and long-term results of patients with acute dysfunction of coronary bypass grafts depending on treatment tactics

Comparative analysis of in-hospital and long-term mortality of patients in whom acute dysfunction of coronary bypass grafts was detected in the early postoperative period depending on conservative or surgical tactics. The study is a retrospective analysis of data from 8801 patients who underwent elective coronary artery bypass grafting (CABG) between 2011 and 2022 at the Federal Center for Cardiovascular Surgery (Russia, Chelyabinsk). Among them, 196 patients underwent emergency coronary artery bypass grafting due to suspected perioperative myocardial infarction in the early postoperative period. In 119 patients, dysfunction of coronary bypass grafts was detected, in 77 patients no pathological changes were found. The criteria for inclusion in the study were patients with dysfunction of coronary bypass grafts (n=119). The 1st group included patients who underwent conservative therapy (n=33), the 2nd group (n=86) included those who underwent repeated myocardial revascularization. The primary endpoint was hospital mortality, secondary endpoints were long-term mortality and adverse cardiovascular events (myocardial infarction, stroke, repeat myocardial revascularization). Patients were surveyed via telephone. In-hospital mortality in the group of surgical reintervention was 8.1%, in the group of conservative treatment - 9.1% (p=0.867). According to the results of multivariate analysis, predictors of hospital mortality in patients of both groups were extracorporeal membrane oxygenation (p=0.014), time of artificial circulation (p=0.031), duration of artificial ventilation (p=0.001), number of days in intensive care (p<0.001). When analyzing long-term mortality using the Kaplan-Meier method in group 1 and group 2, no statistically significant differences were found; in the group of conservative therapy - 85±9.6 [66.2-103.7] months versus 108.2±4.8 [98.8-117.6] months in the surgery group (log-rank p=0.06). When analyzing long-term mortality from cardiovascular causes and the occurrence of adverse cardiovascular events, statistically significant differences were determined: in the group of conservative therapy - 92.5±9.3 [74.2-110.7] months versus 117.8±3.3 [111.2-124.3] months in the surgical treatment group (log-rank p=0.007) and 78.1±9.2 [60-96.3] months versus 98.9±3.9 [91.3-106.5] months (log-rank p=0.008), respectively. In-hospital mortality was comparable between groups. Long-term mortality from cardiovascular causes and the number of adverse cardiovascular events were significantly higher in the conservative therapy group. With timely detection of acute dysfunction of coronary bypass grafts, an active surgical approach has an advantage over conservative tactics and can improve the long-term prognosis of patients.

Coronary Artery Perforation following Percutaneous Coronary Intervention in an Elderly Patient: A case report

Percutaneous coronary intervention (PCI) is widely used in the diagnosis and treatment of symptomatic coronary artery disease. However, much like any other procedure, it has its risks; one such rare but lethal complication is coronary artery perforation (CAP) which requires immediate intervention. Prompt recognition and appropriate treatment strategy are of utmost importance in reducing the mortality and morbidity. We herein report a case of Ellis Type III perforation of the left anterior descending coronary artery (LAD) during PCI who underwent emergency coronary artery bypass grafting (CABG) refractory to conventional coronary stent placement and balloon tamponade. The patient recovered well despite excessive initial postoperative bleeding and was discharged from the hospital. Bangladesh Med J. 2022 May; 51(2): 54-58

Medikal Tedavi ile İyileşen Yaygın, İdiyopatik, Tekrarlayan Spontan Koroner Arter Diseksiyonu

Spontaneous coronary artery dissection is a rare cause of sudden cardiac death and acute coronary syndrome, and mainly affects young female. Treatment of this condition depends on the clinical features, hemodynamic and angiographic findings of the patient, but due to the rarity of the disease, guideline support was insufficient until the last period. Depending on the condition of the patient and the coronary blood flow, medical observation, percutaneous coronary intervention or coronary artery bypass graft surgery are used in the treatment. We present a young female patient who underwent emergency coronary artery bypass graft surgery after spontaneous left main coronary artery dissection four years ago and was recently diagnosed with extensive spontaneous coronary artery dissection in her right coronary artery. After the diagnosis, the patient was given medical treatment and recovered completely.

Indications to coronary artery bypass graft angiography in the early postoperative period

Aim. To determine indications to emergency coronary artery bypass angiography.Methods. 7,616 medical records of patients with coronary artery disease who underwent isolated CABG in the period from 2012 to 2019 at the Federal Center for Cardiovascular Surgery were reviewed. Of them, 103 (1.35%) patients underwent emergency coronary artery bypass graft angiography in the early postoperative period to verify signs of myocardial damage. Patients were assigned to two groups based on angiographic findings and selected treatment strategy. Out of 75 patients, 57 patients from Group 1 had no severe angiographic signs of occlusive changes of the grafts and native arteries. But 18 patients reported failed graft and required conservative management. Group 2 (n = 28) included patients who had failed coronary artery bypass grafts according to angiography findings. 20 patients underwent endovascular treatment, and 8 patients underwent repeated surgery. The control group included 30 patients (0.39%) without any signs of ischemic myocardial damage. Intraoperative flow was assessed as well as postoperative electrocardiographic and echocardiographic records. Biochemical markers of myocardial damage were measured.Results. Blood flow velocity was less than 20 ml/min, and the pulsatility index exceeded 3.0 according to the intraoperative flow assessment of coronary artery bypass grafts with impaired blood flow according to angiography findings. There was no relationship found between ischemic changes according to ECG, ECHO-CG, and angiographic findings. Significant differences were found in troponin I levels between Group 1 (patients with coronary artery graft dysfunction) and the control group (Group 3) at all time intervals (1, 6, 12, 24 and 48 hours).Conclusion. The predictors of failed coronary artery bypass grafts in the early postoperative period allowed identifying indications to emergency angiography.

Effect of the fresh whole blood transfusion on perioperative bleeding in adult patients undergoing emergency coronary artery bypass grafting surgery: a randomized study

Objective The present study aimed to assess the hemostatic effects of fresh whole blood (FWB) transfusion on bleeding and blood product transfusion in patients on clopidogrel undergoing emergency coronary artery bypass grafting surgery (CABG). Design A randomized study was conducted. Setting The study was conducted at a cardiac center. Patients and methods The study included 124 patients undergoing CABG surgery. The patients were divided into two groups: FWB group patients received two to six units of FWB after weaning off cardiopulmonary bypass and in the cardiac surgery ICU. Control group patients received blood products (packed red blood cells, platelets, fresh frozen plasma, or cryoprecipitate) after weaning off cardiopulmonary bypass and after surgery in cardiac surgery ICU. Total number of the transfused FWB, platelets, packed red blood cell, fresh frozen plasma, and cryoprecipitate (intraoperative and postoperative transfusion), bleeding time, and platelet aggregation function were measured. Moreover, the thorax closure time and amount of blood losses, re-exploration, pulmonary edema, and postoperative mechanical ventilation were monitored. Results FWB significantly decreased the blood loss and blood product transfusion compared with the control group (P=0.001 and 0.001, respectively). The bleeding time and platelet aggregation function were better in the FWB group compared with the control group (P=0.020 and 0.034, respectively). Moreover, the thorax closure time, cardiac tamponade, re-exploration, pulmonary edema, and postoperative mechanical ventilation decreased significantly in the FWB group compared with the control group (P Conclusion FWB decreased the blood loss, blood product transfusion, cardiac tamponade, and re-exploration in patients on preoperative clopidogrel undergoing emergency CABG.

Timely extracorporeal membrane oxygenation assist reduces mortality after bypass surgery in patients with acute myocardial infarction

Patients with acute myocardial infarction (AMI) are at high risk when undergoing emergency coronary artery bypass graft (CABG)-surgery. Their outcome remains poor despite increased use of extracorporeal membrane oxygenation (ECMO). We investigated the impact of timing for perioperative ECMO-support in these patients. In this retrospective double-center study, we evaluated 201 patients with AMI undergoing CABG, dividing them into the following groups: No-ECMO (n = 101), preoperative ECMO (pre-ECMO, n = 6), intraoperative ECMO (ECC-ECMO, n = 67), and postoperative ECMO (post-ECMO, n = 27). We evaluated the impact of ECMO timing on postoperative mortality, organ function, and length of stay, comparing these to predicted outcome using different risk-scores. Post-ECMO patients showed lowest 30-day-survival (40.7%), while earlier ECMO-start was associated with better outcome (50.7% in extracorporeal circulation [ECC]-ECMO and 66.7% in pre-ECMO patients). On admission, only pre-ECMO and ECC-ECMO patients showed higher surgery- and intensive-care-unit (ICU)-related risk-scores. In pre- and ECC-ECMO patients, the first significant increase in lactate-levels (>4 mmol/L) was observed preoperatively, while this occurred 1 hour postoperatively in post-ECMO patients. Bilirubin was increased in all patients, decreasing after 3 and 12 days in pre- and ECC-ECMO patients, respectively, but only after 18 days in post-ECMO patients. Multiple ICU risk-scores did not discriminate survival-probability correctly. Only the ECMO-related survival after veno-arterial-ECMO-score correctly predicted the significantly lower survival in post-ECMO patients. Our study shows that timely ECMO-support is associated with earlier bilirubin-downtrend and higher survival in patients with AMI after CABG. Lactate-increase greater than 4 mmol/L seems to be a helpful threshold to trigger the timely onset of ECMO-therapy, providing better survival.

Mediastinal thymolipoma: a rare occurrence with striated myoid cells.

We describe a 49-year-old man who presented to hospital with unstable angina and who underwent emergency coronary artery bypass grafting. During the surgical procedure, an incidental anterior mediastinal mass was discovered. Histological examination of this mediastinal mass revealed a thymolipoma containing numerous polygonal, striated myoid cells that were immunoreactive for desmin, muscle-specific actin and myoglobin. Electron microscopy demonstrated numerous Z band structures confirming myoid differentiation. Even though the appearance of myoid cells in thymolipoma may be alarming, this tumor should be recognized as a benign entity. Thymolipomas containing striated myoid cells should be differentiated from more ominous thymic neoplasms, including teratomas and thymic liposarcomas. To our knowledge, this is only the third reported case of thymolipoma containing striated myoid cells.

Cystatin C and NGAL as Biomarkers for Early Detection of Acute Kidney Injury in Geriatrics

Acute kidney injury (AKI) is associated with cardiovascular mortality and morbidity especially in high-risk patients undergoing cardiac surgery. It ranges from 7.7% to 28.1% in different studies. The aim of this study was to compare cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) with Creatinine as an early marker for acute kidney injury in geriatrics. From 2013 through 2015, 307 consecutive high-risk elderly patients older than 70 years undergoing emergency coronary artery bypass grafting using extracorporeal circulation were studied. All patients underwent diagnostic coronary angiography and the surgical procedure within 1 week in single hospital stay and were randomized according to timing of interval between coronary angiographyand cardiac procedure as follows: group I, less than 2 days; group II, between 2 and 4 days; and group III, higher than 4 days. Renal function was analyzed by serum cystatin C, NGAL, and creatinine. Blood samples were obtained from each patient at five time points: basal value before operation, in the four hours after operation, and on the first, third, and fifth postoperative days. Glomerular filtration rate (GFR) was calculated by Cockcroft-Gault (CG). A total of 56 patients developed postoperative acute kidney failure according to the risk, injury, and failure; and loss; and end-stage kidney disease classification. Perioperative fluid requirements, urine output, and vasopressor need during and after cardiopulmonary bypass were similar. 30-day mortality in groups was higher in group I than group II and group III (P = 0.025). AKI was least prominent in group III compared to group I and group II (P = 0.001) and expectedly, postoperative dialysis requirement was least common in group III (15, 16.66%). Patients in group III had the most favorable clinical outcome with regards to the length of ICU and hospital stay. Overall serum creatinine, cystatin C, and urine NGAL levels changed significantly throughout the entire length of following-up period in group I and group II, but not in group III. Changes in serum levels of cystatin, creatinine, and creatinine clearance were prominent in later than 24 hours. Urinary NGAL was the first variable to rise in the immediate postoperative period. Cystatin GFR was a more rapid marker than serum creatinine GFR to show acute kidney injury in three groups was a significant marker.

External Compression of Right Coronary Cleft Resulting From ECMO Cannula Causing Refractory Ventricular Fibrillation: An Unusual Adverse Event

72-year old man with severe left main disease and ischemic cardiomyopathy presented with ventricular tachycardia (VT) and cardiac arrest, and underwent emergency coronary artery bypass grafting and mitral valve repair. He required extracorporeal membrane oxygenation (ECMO) support through the ascending aorta and right atrium. The chest was left open by use of a metal bridge and a vacuum dressing. On the second postoperative day, he experienced refractory VT and ventricular fibrillation, requiring urgent catheterization, which showed that the vein graft to the right coronary artery (RCA) had 80% smooth narrowing in the proximal third (Fig 1, white arrow), and appearance that was consistent with external compression. On urgent reexploration, there was external compression of the RCA graft because the heart was significantly distended and was pushing the vein graft against the venous cannula (Fig 1, black arrow), leading to delayed stenosis. The patient’s rhythm was stabilized by tacking the venous cannula away from the vein graft, with good flows down the graft on measurement. The patient had no VT over the next few days. Although rare, ECMO cannulas can cause myocardial ischemia either by malposition [1] or by external compression, and this possibility should be considered in relevant clinical scenarios. Reference

Is emergency and salvage coronary artery bypass grafting justified? The Nordic Emergency/Salvage coronary artery bypass grafting study.

According to the EuroSCORE-II criteria, patients undergoing emergency coronary artery bypass grafting (CABG) are operated on before the beginning of the next working day after decision to operate while salvage CABG patients require cardiopulmonary resuscitation en route to the operating theatre. The objective of this multicentre study was to investigate the efficacy of emergency and salvage CABG. A retrospective analysis of all patients that underwent emergency or salvage CAGB at four North-European university hospitals from 2006 to 2014. A total of 614 patients; 580 emergency and 34 salvage CABG patients (mean age 67 ± 10 years, 56% males) were included. All patients had an acute coronary syndrome: 234 (38%) had an ST segment elevation myocardial infarction (STEMI) and 289 (47%) had a non-STEMI. Haemodynamic instability requiring inotropic drugs and/or intra-aortic balloon pump preoperatively occurred in 87 (14%) and 82 (13%) of the patients, respectively. Three hundred and thirty-one patient (54%) were transferred to the operating room immediately after angiography and 205 (33%) had a failure of an attempted percutaneous coronary intervention. Cardiopulmonary resuscitation within 1 h before the operation was performed in 49 patients (8%), and 9 patients (1%) received cardiac massage during sternotomy. Hospital mortality for emergency and salvage operations was 13 and 41%, respectively. Early complications included reoperation for bleeding (15%), postoperative stroke (6%) and de novo dialysis for acute kidney injury (6%). Overall 5-year survival rate was 79% for emergency operations and 46% for salvage operations. Only one out of 9 patients receiving cardiac massage during sternotomy survived. Early mortality in patients undergoing emergent and salvage CABG is substantial, especially in salvage patients. Long-term survival is acceptable in both emergent and salvage patients. Life-saving emergency and salvage CABG is justified in most patients but salvage patients have dismal prognosis if cardiac massage is needed during sternotomy.

Long-Term Survival and Quality of Life of Patients Undergoing Emergency Coronary Artery Bypass Grafting for Postinfarction Cardiogenic Shock

This study evaluated the long-term outcome of patients undergoing emergency coronary artery bypass grafting (eCABG) for cardiogenic shock after acute myocardial infarction. Sixty-seven consecutive patients underwent eCABG for cardiogenic shock at 2 European institutions during an 11-year period. Preoperative, intraoperative, postoperative, and long-term follow-up data of all patients were prospectively collected. Hospital survival was 86% (58 of 67), with all deaths due to cardiac causes. At a mean follow-up of 78 ± 48 months (range, 1 to 153 months), 43 of the 58 patients (74%) discharged from the hospital were alive. Causes of death in 9 of the 15 follow-up deaths (60%) were noncardiac. Overall survival rate at the end of follow-up was 64% (43 of 67). Of the 43 survivors, 41 (95%) were in New York Heart Association Functional Classification I to II, ischemia free, had a Karnofsky performance status exceeding 80, and an excellent quality of life as assessed by the Seattle Angina Questionnaire. The use of cardiopulmonary bypass and the internal thoracic artery were associated with significantly better long-term survival. The long-term survival and quality of life of patients who undergo eCABG for cardiogenic shock after acute myocardial infarction are good, and eCABG should be considered a valuable therapeutic option in this setting. The use of cardiopulmonary bypass and the internal thoracic artery at the time of the operation are strongly advocated.

The predictive value of fragmented QRS complex for in-hospital and long-term cardiovascular mortality in patients with ST segment elevation myocardial infarction undergoing emergency coronary artery bypass grafting

The predictive value of fragmented QRS complex for in-hospital and long-term cardiovascular mortality in patients with ST segment elevation myocardial infarction undergoing emergency coronary artery bypass grafting

MEDICAL MYOCARDIAL PROTECTION IN PATIENTS WITH ACUTE CORONARY SYNDROME UNDERGOING CORONARY ARTERY BYPASS GRAFTING

In the study 76 patients with acute coronary syndromes (ACS) were included: 52 patients with Q - and 24 patients with non- Q wave myocardial infarction (Ml) who underwent emergency coronary artery bypass graft surgery (CABG) because of early post-infarction angina. Intravenous Corvitin 1% -100,0 ml was added to the standard treatment 3 days before and 3-5 days after CABG. Investigated biochemical and hemostasiological blood analysis, cardio enzyme test, CRP, echocardiography, electrocardiography in 60 leads, ECG-monitoring, coronary angiography (CA). Use of Corvitin helps to improve the systolic and diastolic myocardial function in more earliest terms in patients with ACS with direct revascularization, reduces the effects of ischemic/reperfusion myocardial damages and also decreases risk of developing early postoperative cardiovascular complications: acute heart failure, perioperative Ml, cardiac arrhythmia and can be used for metabolic myocardial protection in case of CABG and

Successful surgical treatment of intravascular ultrasonography catheter entrapment

Coronary angiography (CAG) was performed in a 77-year-old woman who presented with chest discomfort. The CAG showed two diseased vessels. For treatment, the patient underwent angioplasty and stenting. During intravascular ultrasonography (IVUS) following stent deployment, the IVUS catheter became entrapped in the left anterior descending coronary artery, causing ischemic changes in the anterolateral wall, which were apparent on the electrocardiogram. The patient underwent emergency coronary artery bypass grafting and removal of the entrapped IVUS catheter.

Changing trends in emergency coronary bypass surgery

Patients undergoing emergency coronary artery bypass grafting represent a unique and high-risk population that remains challenging for cardiac surgeons. We examined the changing trends in patients undergoing emergency bypass grafting over the past 20 years. We conducted a retrospective review of our database between 1990 and 2009 and patients were divided into 2 groups based on year of operation: 1990-1999, n = 393; 2000-2009, n = 184. The primary outcomes of interest for this study are operative mortality and incidence of low cardiac output syndrome. The percentage of patients undergoing emergency coronary bypass grafting has decreased from 2.7% to 1.7% over time. The percentage of patients with dyslipidemia, hypertension, triple vessel disease, peripheral vascular disease, and left main disease increased over time (P < .05). Operative mortality remained at 8.1% in both year groups. Preoperative hypertension, congestive heart failure, left ventricular ejection fraction less than 20%, and previous cardiac surgery independently predicted operative mortality by logistic regression analysis. Low cardiac output syndrome developed in 25% of the patient population undergoing emergency bypass grafting. The independent predictors of low cardiac output syndrome were small body surface area, congestive heart failure, shock, myocardial infarction, earlier decade (1990-1999) and increased age. Despite a changing preoperative risk profile, the operative mortality of emergency coronary artery bypass grafting has remained stable over the years. However, mortality remains significantly above the observed mortality in elective bypass grafting. Continued improvements in the management of heart failure and the care of the elderly will likely result in reduced risks of emergency coronary artery bypass grafting.

Acute Treatment of ST-Segment-Elevation Myocardial Infarction: Is There a Role for the Cardiac Surgeon?

Several attempts from single institutions to treat acute myocardial infarctions with bypass surgery never reached widespread acceptance in the cardiology and surgical community. Owing to a variety of new surgical techniques, this old dogma has to be reconsidered under the light of patient-adjusted optimal treatment algorithms. Between August 2002 and August 2007, 112 patients, mean age of 66 years (range, 41 to 85 years), underwent emergency coronary artery bypass grafting (untreatable or rejected by the referring cardiologists within 48 hours after onset of symptoms). Thirty-seven patients (33%) exhibited cardiogenic shock, and 18 (16%) had prior cardiopulmonary resuscitation. Preoperative support by intraaortic balloon pump was initiated in only 10%, and 65% had left main stem stenosis. All patients showed a significant elevation of cardiac markers (creatine kinase-MB) and ST-segment elevation. The mean number of grafts was 2.4 (range, 1 to 4). The cardiopulmonary bypass time ranged from 48 to 261 minutes. Intraaortic balloon pump for weaning from extracorporeal circulation was used in 42 patients (38%); 3 patients needed extracorporeal membrane oxygenation support. Postoperative complications included rethoracotomy for bleeding in 4% and stroke in 2%. Thirty-day mortality was 20% in the whole group, 30% in the group with cardiogenic shock, and 15% in those without hemodynamic deterioration (p = 0.044). The multivariate analysis revealed the preoperative need for catecholamines as the only risk factor for 30-day mortality (odds ratio, 6.4; 95% confidence interval, 2 to 21; p = 0.002). Emergency coronary artery bypass grafting in patients with acute myocardial infarction can be performed with acceptable results, especially in those without cardiogenic shock. Therefore, operative revascularization should not be considered only as a rescue therapy.

Meckel's Diverticulum Ischemia Caused by Thromboembolism after Coronary Artery Bypass Grafting

A 75-year-old woman underwent emergency coronary artery bypass surgery after acute anterior wall myocardial infarction. Because of the presence of a local peritonitis, an emergency laparotomy was performed in which necrotizing Meckel's diverticulum was found and resected. Microscopically, sections through the diverticulum revealed a fresh thrombus occluded the arterial lumen of diverticulum. The patient had an uneventful postoperative course. We believe that the cause of Meckel's diverticulum ischemia was the development of atrial fibrillation with left atrium thrombus formation followed by embolic obliteration of Meckel's diverticulum feeding artery.

Implementation of Guidelines for the Treatment of Acute ST-Elevation Myocardial Infarction

Background— The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment–elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention. Methods and Results— The study was performed in Cologne with &gt;1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient’s arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively. Conclusion— The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.