Impact of Expeditious Management of Perioperative Myocardial Ischemia in Patients Undergoing Isolated Coronary Artery Bypass Surgery

Abstract

Background— To analyze the effect of immediate treatment of perioperative myocardial ischemia (PMI) because of early graft failure or incomplete revascularization in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods and Results— Between January 2004 and December 2010, 7461 patients underwent isolated CABG at our institution. All patients showing evidence of PMI (n=399; 5.3% of total) underwent emergent coronary angiography. A total of 900 grafts and 1061 distal anastomoses were examined. Two hundred fifty-five patients had 360 distal anastomoses compromised because of early graft failure or incomplete revascularization (ie, abnormal postoperative coronary angiogram). Revision CABG or percutaneous coronary intervention was performed in 130 (51.0%) and 34 (13.3%) patients with abnormal angiograms, respectively. Nonsurgical therapy was implemented in the remaining 91 patients (35.7%) with abnormal angiograms. One hundred forty-four patients had normal postoperative graft-related angiograms. In-hospital mortality was 7.3% and 2.9% in patients with and without PMI ( P <0.001). In patients with PMI, in-hospital mortality was 9.4% and 3.5% in patients with abnormal and normal postoperative angiograms, respectively ( P =0.03). Significant multivariable predictors of in-hospital mortality were hemodynamic deterioration, preangiography creatine kinase-MB isoenzyme rise >2× normal, and time interval between primary CABG and coronary angiography >30 hours. Five-year survival in patients without PMI (85.7±0.5%) was significantly better than those with PMI and abnormal angiograms (74.9±2.9%; P <0.001 log-rank). When in-hospital mortality was excluded, however, this difference in midterm survival disappeared ( P =0.9). Conclusions— PMI is associated with increased in-hospital mortality in patients undergoing isolated CABG. Expeditious management of bypass graft failure results in similar midterm survival to nonischemic patients in hospital survivors.