ABSTRACT
Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P = 0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P = 0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.
Subject(s)
Coronary Artery Bypass/adverse effects , Myocardial Infarction/therapy , Myocardial Ischemia/therapy , Primary Graft Dysfunction/therapy , Aged , Angioplasty, Balloon, Coronary/adverse effects , Angioplasty, Balloon, Coronary/mortality , Biomarkers/blood , Coronary Angiography , Coronary Artery Bypass/mortality , Creatine Kinase, MB Form/blood , Echocardiography, Transesophageal , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/etiology , Myocardial Infarction/mortality , Myocardial Infarction/surgery , Myocardial Ischemia/diagnosis , Myocardial Ischemia/etiology , Myocardial Ischemia/mortality , Myocardial Ischemia/surgery , Primary Graft Dysfunction/diagnosis , Primary Graft Dysfunction/etiology , Primary Graft Dysfunction/mortality , Primary Graft Dysfunction/surgery , Quebec , Reoperation , Retrospective Studies , Time Factors , Treatment Outcome , Troponin T/bloodABSTRACT
OBJECTIVE: To compare real-time (on-line) monitoring of myocardial ischemia with transesophageal echocardiography (TEE) with off-line reviewing during a dobutamine stress test in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective observational study. SETTING: Tertiary care university hospital. PATIENTS: Seventeen patients undergoing CABG. INTERVENTIONS: TEE and electrocardiographic monitoring of myocardial ischemia during dobutamine stress testing. MEASUREMENTS AND MAIN RESULTS: Sixteen of 17 patients developed myocardial ischemia as diagnosed by TEE or electrocardiographic monitoring. On-line and off-line TEE detected myocardial ischemia in 11/17 and 12/17 patients, respectively. In total, 532 myocardial segments were analyzed at baseline and at peak dobutamine dose. The concordance between on-line and off-line assessments of segmental wall motion was poor at baseline and at peak dobutamine dose (κ = 0.28 and 0.29, respectively). The concordance for detecting myocardial ischemia (worsening in regional wall motion by ≥1 class or a biphasic response in any segment) was better between on-line and off-line analysis (κ = 0.60). There was no agreement between ST-segment monitoring and on-line TEE (κ = -0.27) and between 12-lead electrocardiogram and on-line TEE (-0.11). There was no agreement between ST-segment monitoring and off-line TEE (κ = -0.15) and between 12-lead electrocardiogram and off-line TEE (κ = -0.27). CONCLUSIONS: Only a fair agreement exists between on-line and off-line analysis of myocardial ischemia during dobutamine stress testing in patients undergoing CABG. However, TEE misses up to one third of ischemic episodes and the present observations suggest using continuous electrocardiographic methods to complement TEE monitoring.
