Coronary artery bypass graft surgery in patients with acute coronary syndromes after primary percutaneous coronary intervention: A current report from the north-rhine westphalia surgical myocardial infarction registry

Abstract

BACKGROUND: Coronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed. METHODS AND RESULTS: We aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North-Rhine-Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in-hospital all-cause mortality and major adverse cardio-cerebral event. Patients were 68±11 years of age, had 3-vessel and left main-stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non–ST-segment–elevation myocardial infarction, and 23.5% in ST-segment–elevation myocardial infarction. A his-tory of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non–ST-segment–elevation myocardial infarction, and 16.1% in ST-segment–elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non–ST-segment–elevation myocardial infarction and 17.2% in ST-segment–elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In-hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI <24 hours, and 14.1% with failed PCI (P<0.003). The in-hospital major adverse cardio-cerebral event rate was 16.4% without PCI, but 17.4% with prior PCI >24 hours, 25.6% with prior PCI <24 hours, and 41.3% with failed PCI (P=0.014). Multivariable logistic regression analysis showed prior PCI (P=0.039), as well as failed PCI (P=0.001) to be predictors for in-hospital all-cause mortality and major adverse cardio-cerebral event. CONCLUSIONS: In the current PCI era, immediately prior or failed PCI before coronary artery bypass grafting in acute coronary syndromes is associated with high perioperative risk, cardiogenic shock, and increased morbidity and mortality.