Coronary artery bypass graft surgery after acute ST elevation myocardial infarction
- Oz M Shapira, MD
Oz M Shapira, MD
- Professor and Chairman
- Department of Cardiothoracic Surgery
- The Hebrew University, Israel
- John A Bittl, MD
John A Bittl, MD
- Ocala Heart Institute
- Munroe Regional Medical Center
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
In patients with acute ST-elevation myocardial infarction (STEMI), prompt restoration of myocardial blood flow is essential to optimize myocardial salvage and decrease mortality. This is particularly important in the first few hours after symptom onset, when the amount of myocardium salvageable by reperfusion is greatest. Coronary artery reperfusion, if performed in a timely manner, improves clinical outcomes compared to no reperfusion in nearly all groups of patients with an acute STEMI. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Time from hospital arrival (door-to-balloon time)' and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Timing'.)
Both primary percutaneous coronary intervention and fibrinolysis can restore blood flow in an acutely occluded coronary artery in a much shorter time than can coronary artery bypass graft surgery (CABG) and these procedures are preferred to CABG in most cases. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy".)
This topic will address the indications, optimal timing, technical considerations, and outcomes of urgent or emergent CABG in patients with acute STEMI. The role of CABG in patients with non-ST elevation MI or unstable angina is discussed separately. (See "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction".)
In all studies of percutaneous coronary intervention (PCI) or fibrinolysis, outcomes improve as the time from symptom onset to reperfusion decreases. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Time from hospital arrival (door-to-balloon time)' and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Timing'.)
In most cases, PCI or fibrinolysis can usually restore flow to the ischemic myocardium more quickly than coronary artery bypass graft surgery (CABG), largely attributable to delays in getting the patient to the operating room and the time it takes to complete the bypass surgical procedure. Thus, CABG is uncommonly used as the reperfusion strategy of choice in ST elevation myocardial infarction (STEMI); it is estimated that CABG is performed in 5 percent or less of cases [1,2]. CABG may be considered for the following subgroups of patients with STEMI.
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- After unsuccessful or complicated PCI
- Mechanical complications of acute MI
- As the primary reperfusion strategy
- Late presentation or recurrent ischemia
- Cardiogenic shock
- After failed fibrinolysis
- Life-threatening ventricular arrhythmias
- TECHNICAL CONSIDERATIONS
- Minimizing ischemic time
- Intraaortic balloon pump
- Type of graft
- Minimally invasive CABG
- Hybrid procedure
- OUTCOMES AFTER CABG
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS