Adv. Cardio!., vo!. 20, pp. 79-80 (Karger, Basel 1977)
Emergency Coronary Bypass Surgery for Acute Myocardial Infarction JOHN H. GANJI, RALPH BERG,jr., ROBERT W. KENDALL, LLOYD W. RUDY, and GEORGE E. DUVOISIN
From a total experience of 1,891 cases of direct myocardial revascularization with bypass grafts, there were 450 patients who had unstable angina and 115 ptientsa who were operated in the acute phase of myocardial infarctions. The 30-day hospital mortality for the entire 1,891 cases was 2.1 % with a peri operative infarction rate of 2.5%. The mortality rate of the 450 patients with unstable angina was only 1.1 %. The 115 cases which were classified as acute myocardial infarctions met the following criteria: (1) sustained chest pain unrelieved by coronary dilating drugs; (2) electrocardiographic changes of injury or hyperacute myocardial infarction; (3) left ventriculographic changes in the same location as the area served by the severely diseased coronary artery; (4) consistency between all of the above factors; (5) elevation of the postoperative SGOT to infarction levels (retrospective). Patients who developed myocardial infarction following cardiac catheterization or did not meet all of the above criteria despite the fact that clot was sometimes found in the coronary arteries at the time of surgery, were not included as acute myocardial infarctions. These patients presented to the emergency room with typical clinical syndromes of acute myocardial infarction and underwent emergency cardiac catheterization followed by myocardial revascularization usually within 6-8 h from the onset of sustained chest pain. In our experience, the mortality rate for revascularization after this early phase and within the first month of myocardial infarction rises to 20%. There were 104 male and 11 female patients with an age range from 35 to 74 and a mean age of 55. The average number of grafts inserted in each case was 2. There were 92 grafts to the anterior descending, 20 to the diagonal branch, 39 to the circumflex branch, and 69 to the right coronary artery. The 30-day hospital mortality was 5.2% (6 patients). 15 patients (13%) had pre-
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South Center Medical Building, Spokane, Wash.
GANJr/BERG/KENDALL/RUDY/DuVOISIN
80
J.H. GANJr, MD, South Center Medical Building, Spokane, Wash. (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/18/2019 5:50:51 AM
operative ventricular tachycardia and/or ventricular fibrillation requiring cardioversion; 18 patients (16%) were in cardiogenic shock, and 15 patients (13%) were in acute pulmonary edema prior to surgery. Significant postoperative complications included: (I) pulmonary embolism, 4 patients (3%) ; (2) reoperation for bleeding, 4 patients (3%); (3) sternal dehiscence, 3 patients (2.6%); (4) pneumothorax, 3patients (2.6%). The average hospital stay for all patients undergoing acute revascularization was 7 days. There were 3 late deaths, 1 occurring at 2 months from an unknown cause, 1 occurring at 4 months with a myocardial infarction, and the final patient died 27 months after his operation from a ruptured abdominal aortic aneurysm. Three patients have had a recurrence of their symptoms and have been reoperated. The remaining patients are all alive up to 4 years from the time of their operation. 67 patients were studied up to 37 months postoperatively. The left ventricular ejection fraction had improved in 54% (36 cases) and the ejection fraction was unchanged in 33% (22 patients), and in 9% (6 patients) the ejection fraction had decreased. The graft patency was 92% for this group. We approach the patient with an acute myocardial infarction on the basis that the ischemic myocardium surrounding an area of necrosis can still be preserved. While we do not have a control group for this study, we feel that the risks of acute myocardial revascularization are acceptable and the results promising enough to warrant extensive further investigation.
Emergency Coronary Bypass Surgery for Acute Myocardial Infarction JOHN H. GANJI, RALPH BERG,jr., ROBERT W. KENDALL, LLOYD W. RUDY, and GEORGE E. DUVOISIN
From a total experience of 1,891 cases of direct myocardial revascularization with bypass grafts, there were 450 patients who had unstable angina and 115 ptientsa who were operated in the acute phase of myocardial infarctions. The 30-day hospital mortality for the entire 1,891 cases was 2.1 % with a peri operative infarction rate of 2.5%. The mortality rate of the 450 patients with unstable angina was only 1.1 %. The 115 cases which were classified as acute myocardial infarctions met the following criteria: (1) sustained chest pain unrelieved by coronary dilating drugs; (2) electrocardiographic changes of injury or hyperacute myocardial infarction; (3) left ventriculographic changes in the same location as the area served by the severely diseased coronary artery; (4) consistency between all of the above factors; (5) elevation of the postoperative SGOT to infarction levels (retrospective). Patients who developed myocardial infarction following cardiac catheterization or did not meet all of the above criteria despite the fact that clot was sometimes found in the coronary arteries at the time of surgery, were not included as acute myocardial infarctions. These patients presented to the emergency room with typical clinical syndromes of acute myocardial infarction and underwent emergency cardiac catheterization followed by myocardial revascularization usually within 6-8 h from the onset of sustained chest pain. In our experience, the mortality rate for revascularization after this early phase and within the first month of myocardial infarction rises to 20%. There were 104 male and 11 female patients with an age range from 35 to 74 and a mean age of 55. The average number of grafts inserted in each case was 2. There were 92 grafts to the anterior descending, 20 to the diagonal branch, 39 to the circumflex branch, and 69 to the right coronary artery. The 30-day hospital mortality was 5.2% (6 patients). 15 patients (13%) had pre-
Downloaded by: University of Cambridge 131.111.164.128 - 3/18/2019 5:50:51 AM
South Center Medical Building, Spokane, Wash.
GANJr/BERG/KENDALL/RUDY/DuVOISIN
80
J.H. GANJr, MD, South Center Medical Building, Spokane, Wash. (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 3/18/2019 5:50:51 AM
operative ventricular tachycardia and/or ventricular fibrillation requiring cardioversion; 18 patients (16%) were in cardiogenic shock, and 15 patients (13%) were in acute pulmonary edema prior to surgery. Significant postoperative complications included: (I) pulmonary embolism, 4 patients (3%) ; (2) reoperation for bleeding, 4 patients (3%); (3) sternal dehiscence, 3 patients (2.6%); (4) pneumothorax, 3patients (2.6%). The average hospital stay for all patients undergoing acute revascularization was 7 days. There were 3 late deaths, 1 occurring at 2 months from an unknown cause, 1 occurring at 4 months with a myocardial infarction, and the final patient died 27 months after his operation from a ruptured abdominal aortic aneurysm. Three patients have had a recurrence of their symptoms and have been reoperated. The remaining patients are all alive up to 4 years from the time of their operation. 67 patients were studied up to 37 months postoperatively. The left ventricular ejection fraction had improved in 54% (36 cases) and the ejection fraction was unchanged in 33% (22 patients), and in 9% (6 patients) the ejection fraction had decreased. The graft patency was 92% for this group. We approach the patient with an acute myocardial infarction on the basis that the ischemic myocardium surrounding an area of necrosis can still be preserved. While we do not have a control group for this study, we feel that the risks of acute myocardial revascularization are acceptable and the results promising enough to warrant extensive further investigation.
