Early postoperative balloon coronary angioplasty for failed coronary artery bypass grafting

Outcome of Postcardiac Surgery Acute Myocardial Infarction and Role of Emergency Percutaneous Coronary Interventions

Background. Cardiac surgery carries a well-known risk of perioperative myocardial infarction (MI), which is associated with high morbidity and both in-hospital and late mortality. The rapid haemodynamics deterioration and presence of myocardial ischemia early after cardiac surgical operations is a complex life-threatening condition where rapid diagnosis and management is of fundamental importance. Objective. To analyse the factors associated with mortality of patients with postcardiotomy MI and to study the role of emergency coronary angiography in management and outcome. Methods. We retrospectively enrolled adult patients diagnosed to have postcardiotomy MI and underwent emergency coronary angiography at our tertiary care hospital between January 2016 and August 2019. Results. Sixty-one patients from consecutive 1869 adult patients who underwent cardiac surgeries were enrolled in our study. The studied patients had a mean age of 49 ± 16.2 years with a mean BMI of 29.5 ± 6.6 and 65.6% of them were males. As compared to the survivors group, the nonsurvivors of perioperative MI had significant preoperative CKD, postoperative AKI, longer CPB time, frequent histories of previous PCI, previous cardiotomies, pre and postoperative ECMO use, higher median troponin I levels, higher peak and 24 hours median lactate levels. Regression analysis revealed that reoperation for revascularization (OR: 23; 95% CI: 8.27–217.06; P=0.034) and hyperlactataemia (OR: 3.21; 95% CI: 1.14–9.04; P=0.027) were independent factors associated with hospital mortality after perioperative MI. Hospital mortality occurred in 25.7% vs 86.7% (P<0.001), AKI occurred in 37.1% vs 93.3% (P<0.001), haemodialysis was used in 28.6% vs 80% (P=0.002), and mediastinal exploration for bleeding was performed in 31.4% vs 80% (P=0.006) in the PCI and reoperation groups, respectively, while there were no significant differences regarding gastrointestinal bleeding, cerebral strokes, or intracerebral bleeding. The median peak troponin level was 795 (IQR 630–1200) vs 4190 (IQR 3700–6300) (P<0.001) in the PCI and reoperation groups, respectively. Absence of significant angiographic findings occurred in 18% of patients. Conclusions. Perioperative MI is associated with significant morbidities and hospital mortality. Reoperation for revascularization and progressive hyperlactataemia are independent predictors of hospital mortality. Emergency coronary angiography is helpful in diagnosis and management of perioperative MI.

Outcome of Postcardiac Surgery Acute Myocardial Infarction and Role of Emergency Percutaneous Coronary Interventions

Background. Cardiac surgery carries a well-known risk of perioperative myocardial infarction (MI), which is associated with high morbidity and both in-hospital and late mortality. The rapid haemodynamics deterioration and presence of myocardial ischemia early after cardiac surgical operations is a complex life-threatening condition where rapid diagnosis and management is of fundamental importance. Objective. To analyse the factors associated with mortality of patients with postcardiotomy MI and to study the role of emergency coronary angiography in management and outcome. Methods. We retrospectively enrolled adult patients diagnosed to have postcardiotomy MI and underwent emergency coronary angiography at our tertiary care hospital between January 2016 and August 2019. Results. Sixty-one patients from consecutive 1869 adult patients who underwent cardiac surgeries were enrolled in our study. The studied patients had a mean age of 49 ± 16.2 years with a mean BMI of 29.5 ± 6.6 and 65.6% of them were males. As compared to the survivors group, the nonsurvivors of perioperative MI had significant preoperative CKD, postoperative AKI, longer CPB time, frequent histories of previous PCI, previous cardiotomies, pre and postoperative ECMO use, higher median troponin I levels, higher peak and 24 hours median lactate levels. Regression analysis revealed that reoperation for revascularization (OR: 23; 95% CI: 8.27–217.06; P=0.034) and hyperlactataemia (OR: 3.21; 95% CI: 1.14–9.04; P=0.027) were independent factors associated with hospital mortality after perioperative MI. Hospital mortality occurred in 25.7% vs 86.7% (P<0.001), AKI occurred in 37.1% vs 93.3% (P<0.001), haemodialysis was used in 28.6% vs 80% (P=0.002), and mediastinal exploration for bleeding was performed in 31.4% vs 80% (P=0.006) in the PCI and reoperation groups, respectively, while there were no significant differences regarding gastrointestinal bleeding, cerebral strokes, or intracerebral bleeding. The median peak troponin level was 795 (IQR 630–1200) vs 4190 (IQR 3700–6300) (P<0.001) in the PCI and reoperation groups, respectively. Absence of significant angiographic findings occurred in 18% of patients. Conclusions. Perioperative MI is associated with significant morbidities and hospital mortality. Reoperation for revascularization and progressive hyperlactataemia are independent predictors of hospital mortality. Emergency coronary angiography is helpful in diagnosis and management of perioperative MI.

Distal anastomotic lesions after coronary artery bypass surgery: incidence, pathogenesis, and treatment approach

Distal anastomotic lesions are the most common reason for venous and arterial graft failure. Redo coronary artery bypass surgery carries a higher risk for mortality and non-fatal myocardial infarction. Many operators therefore consider percutaneous coronary intervention as a good alternative for relieving angina symptoms in this subset of patients with anastomotic lesions. However, the best percutaneous method for treating these lesions is still controversial. Here we review reported data on the incidence, pathogenesis, and treatment of distal anastomotic lesions in both venous and arterial bypass grafts.

Clinical significance, angiographic characteristics, and short-term outcomes in 30 patients with early coronary artery graft failure

BACKGROUND

Despite technical advances in coronary artery bypass grafting (CABG), early postoperative myocardial ischaemia still remains a challenging problem. The aim of this study was to determine the incidence, clinical features, angiographic characteristics, and management of early graft failure in the present CABG era.

METHODS

Between January 1997 and December 2002, 1731 patients underwent CABG at our institution. Coronary angiography was performed in patients with clinical evidence of early postoperative ischaemia (</=3 months). Thirty of these patients with graft failure constituted the population of this study.

RESULTS

Off-pump and on-pump CABG were almost evenly performed in these patients [n=16 (53%) and n=14 (47%) respectively]. Acute myocardial infarction and unstable angina were the leading indications for coronary angiography in the majority of patients [n=28 (93%)]. The most common cause of graft failure was occlusion / thrombosis [n=20 (67%)]. Percutaneous coronary intervention (PCI) was offered to the majority of patients [n=22 (73%)]. Of these patients, 14 underwent PCI to native coronary arteries, whereas eight underwent PCI to the culprit vessel. Three patients underwent reoperation, and five received medical management. Four patients (13%) died in hospital (two after redo CABG, one after unsuccessful PCI, and one patient managed medically). Two patients (7%) had nonfatal major complications (one non-ST-elevation myocardial infarction and one stroke).

CONCLUSION

Early graft failure generally presents as acute coronary syndrome. Graft occlusion/ thrombosis is the leading cause of ischaemia. Patients with graft failure can undergo PCI with a relatively low risk, but the need for redo CABG in associated with a high mortality. (Neth Heart J 2009;17:13-7.).

Acute ischemic syndromes following coronary artery bypass graft surgery

Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past--they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The post-operative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre- and intraoperative aspects of peri-CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short- and long-term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.

Feasibility of percutaneous coronary interventions in early postcoronary artery bypass graft occlusion or stenosis

BACKGROUND

With continuing technical advances in percutaneous coronary interventions (PCI) for coronary artery disease (CAD), patients undergoing coronary artery bypass surgery (CABG) often have complex coronary anatomy that is not ideal for PCI. Because of the complex anatomy, these patients have a higher risk of early graft occlusion. The feasibility of PCI in the treatment of early graft occlusion is not well established.

METHODS

A retrospective chart review was performed of patients presenting with recurrent ischemia within three months post-CABG and at one-year follow-up.

RESULTS

Forty-six patients with 156 grafts were identified. Three presented with STEMI, 21 with NSTEMI, 21 with unstable angina, and one with congestive heart failure. Sixty-three grafts were occluded or stenosed (>70%). Twenty-seven grafts (43%) in 17 patients were not amenable to PCI. The other 34 grafts (54%) in 23 patients underwent successful PCI. PCI was performed upon native vessels and occluded grafts with equal frequency. Six patients had patent grafts. At one-year follow-up, six of 23 patients in the PCI group were readmitted with ischemia; five vessels (14%) in four patients had restenosed. There were no deaths. In the group with no PCI, 11 of 23 patients were readmitted with ischemia with one death.

CONCLUSION

PCI for early post-CABG occlusion was safely performed in slightly more than half of target vessels. PCI was performed upon native vessels and occluded grafts with equal frequency. After initial PCI success, the clinical target vessel restenosis rate was 14% at one-year follow-up.

Rescue percutaneous coronary intervention early after coronary artery bypass grafting in the drug-eluting stent era

Ten patients underwent rescue percutaneous coronary intervention for myocardial infarction or ischemia soon after coronary artery bypass grafting, and 6 received drug-eluting stents (DESs). Outcomes were limited primarily by bleeding events. There was 1 episode of DES thrombosis after antiplatelet therapy was discontinued due to gastrointestinal hemorrhage. Rescue percutaneous coronary intervention is a feasible approach to reestablish coronary perfusion in the perioperative period, but DESs should be used only after appropriate risk stratification for potential bleeding complications that may require the withdrawal of antiplatelet therapy.

Treatment of saphenous vein graft lesions with drug-eluting stents

OBJECTIVES

The purpose of the present report was to evaluate clinical and angiographic outcomes of drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions.

BACKGROUND

The safety and efficacy of DES implantation for the treatment SVG lesions remains uncertain.

METHODS

We evaluated in-hospital and six-month outcomes in 61 consecutive patients treated with DES in SVG lesions from March 2002 to March 2004 (DES group), as compared to 89 consecutive patients treated with bare-metal stents (BMS) in the 24 months immediately before the introduction of DES (BMS group). Major adverse cardiac events (MACE) including death, myocardial infarction, target lesion revascularization (TLR), and target vessel revascularization (TVR) were recorded in-hospital and at six-month follow-up.

RESULTS

The rate of in-hospital MACE was similar between the two groups (6.6% vs. 5.6%, p = 1.0). Cumulative MACE at six months was 11.5% in the DES group and 28.1% in the BMS group (p = 0.02). The DES group had a significantly lower incidence of in-segment restenosis (10.0% vs. 26.7%, p = 0.03), TLR (3.3% vs. 19.8%, p = 0.003), and TVR (4.9% vs. 23.1%, p = 0.003). By Cox regression analysis, diabetes (hazard ratio [HR]: 3.03; 95% confidence interval [CI]: 1.33 to 6.90; p = 0.008), usage of BMS (HR: 2.53; 95% CI: 1.07 to 5.97; p = 0.03), and age of SVG (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02) were identified as predictors of MACE at six-month follow-up.

CONCLUSIONS

Compared to BMS implantation, DES implantation in SVG lesions appears safe with favorable and improved mid-term outcomes.

Rescue percutaneous coronary intervention immediately following coronary artery bypass grafting

Perioperative graft failure after coronary artery bypass graft (CABG) can result in acute myocardial infarction with dire clinical consequences. We report a case of rescue percutaneous coronary intervention immediately after unsuccessful CABG. This approach salvaged the patient from cardiogenic shock and should be recognized as a viable alternative to immediate reoperation for certain patients.

Intracoronary thrombolysis in the treatment of graft closure immediately after CABG

A patient with a hypercoagulable state underwent coronary artery bypass grafting and was recovering uneventfully until diffuse electrocardiographic changes and cardiogenic shock developed within hours of the operation. Because of severe hemodynamic compromise on high-dose inotropic drugs and intraaortic balloon pump support, she was taken to the catheterization laboratory, where the patient was discovered to have thrombotic occlusion of all grafts, including the left internal mammary artery to the left anterior descending artery. Multiple graft percutaneous transluminal coronary angioplasty and thrombolysis with urokinase successfully opened the grafts, without bleeding complication. Anastomoses were all free of significant anatomic lesion. She has remained free of cardiac symptoms for 3.5 years after operation.

Balloon angioplasty of the internal mammary artery trunk for early postoperative ischemia: a case report

In this case report kinking of the internal mammary artery graft with possible superimposed spasm is described. Angiographic diagnosis was made 72 hrs following coronary artery bypass surgery and the lesion was successfully dilated with balloon angioplasty.

Clinical markers, management, and long-term follow-up of early ischemia after coronary artery bypass grafting

In summary, the occurrence of angina or myocardial infarction within 1 year after coronary bypass is associated with a high incidence of significant angiographic abnormalities. Early angiography is necessary to identify high-risk patients who could undergo revascularization. Patients with other markers of ischemia should have a noninvasive approach (stress imaging test) as initial evaluation, before coronary angiography is considered. When technically feasible, coronary angioplasty can be performed safely and with a high success rate. Repeat coronary bypass in this group of patients is associated with higher in-hospital complications. Patients with less compromised coronary anatomy can be treated medically with a good long-term outcome.

Use of angioplasty in the management of complicated perioperative infarction following bypass surgery

Ischemic complications in the perioperative period following bypass surgery adversely affect both short- and long-term prognosis. Coronary angioplasty was successfully performed in 2 patients sustaining complicated postoperative myocardial infarctions with resolution of angina and restoration of hemodynamic stability. These cases illustrate that angioplasty can be done safely in such patients and may favorably alter short-term outcome.

Rapid development of left main disease after coronary artery bypass grafting for failed angioplasty: a rare cause of postoperative angina

We report a case of failed coronary angioplasty requiring urgent coronary artery bypass graft surgery. The return of angina pectoris early after surgery led to repeat catheterization, demonstrating a rapidly progressive stenosis of the left main coronary artery. This was treated successfully with coronary angioplasty. In patients with recurrent angina early after bypass surgery in whom angioplasty preceded surgery, acceleration of left main disease should be considered.

Caring for patients after coronary bypass surgery. Follow-up tips for primary care physicians

Primary care physicians are often faced with follow-up care of patients who have had coronary artery bypass graft surgery. Familiarity with possible cardiac, pulmonary, neurologic, and infectious complications is important, and an open line of communication with the consulting cardiologist and the cardiac surgeon is essential. Modification of coronary risk factors is one of the greatest challenges after bypass surgery. The primary care physician plays the major role in directing and monitoring life-style changes that reduce the risk of progressive coronary atherosclerosis. Recurrent myocardial ischemia after bypass surgery should be evaluated fully and is often responsive to nonsurgical therapies, including percutaneous transluminal coronary angioplasty.