WJCS  Vol.3 No.1 , March 2013
Assessing Safety of CABG in the Era Post Primary PCI, an Outcome Analysis of STEMI Population
ABSTRACT

Background: Primary PCI (PPCI) has replaced thrombolysis as the treatment of choice for STEMI. The effect of this change on outcomes of patients referred for subsequent CABG is unknown. Methods: All STEMI patients having thrombolysis or PPCI between 2000 and 2010 were identified. Of these, patients subsequently referred for isolated first time CABG form the cohort for this study. Results: 83 of 2476 (3.4%) patients from the PPCI cohort (median follow-up [FU] 3 years [range 6 m - 7.8 y]) and 49 of 528 (9.2%) from the thrombolysis cohort (median FU 9 y [range 1.5 - 10 y] were referred for subsequent CABG. In this referred group, initial reperfusion success (as defined) was: PPCI = 86%, lysis = 84%, p = 0.69. Surgical waiters with prior PPCI had less post infarct angina (1.2% vs. 25%, p < 0.01) and late re-infarction (6% vs. 20%, p = 0.034) prior to surgery. Timing of CABG was: <6 m (PPCI 82%, lysis 73%), 6 m-1 y (PPCI 8.4%, lysis: 9%), >1 y (PPCI 9.6%, lysis 18%).Other than an increased prevalence of diabetes in the thrombolysis group, there were no differences in demographic details or risk profile. There were no post-operative deaths, MIs or CVAs. There were no significant differences in post-op AF (28% vs. 22% p = 0.5), respiratory failure (8% vs. 18%, p = 0.08), renal failure (5% vs. 6%, p = 0.5) or re-openings (0% vs. 6%, p = 0.8). Mortality at 3 years was 2.4% in the PPCI cohort and 4% in the thrombolysis cohort. Overall mortality during follow-up for the PPCI group was 3.6% (n = 3) (median FU 3 years), and for the lysis group was 24.5% (n = 12) (median FU 9 years). Conclusions: In patients awaiting CABG after STEMI, PPCI reduces the risk of post-infarct angina and re-infarction prior to surgery, but early surgical results were equally favorable in both groups. Additional follow-up is needed in the PPCI cohort to determine whether there are any significantly different longer-term outcomes.


Cite this paper
S. Qureshi, M. Belder and E. Akowuah, "Assessing Safety of CABG in the Era Post Primary PCI, an Outcome Analysis of STEMI Population," World Journal of Cardiovascular Surgery, Vol. 3 No. 1, 2013, pp. 15-22. doi: 10.4236/wjcs.2013.31003.
References
[1]   K. A. Eagle, B. K. Nallamothu, R. H. Mehta, C. B. Granger, P. G. Steg, F. Van de Werf, et al., “Trends in Acute Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction from 1999 to 2006: We Are Getting Better but We Have Got a Long Way to Go,” European Heart Journal, Vol. 29, No. 5, 2008, pp. 609-617. doi:10.1093/eurheartj/ehn069

[2]   C. P. Cannon, C. M. Gibson, C. H. McCabe, A. A. Adgey, M. J. Schweiger, R. F. Sequeira, et al., “TNK-Tissue Plasminogen Activator Compared with Front-Loaded Alteplase in Acute Myocardial Infarction: Results of the TIMI 10B Trial. Thrombolysis in Myocardial Infarction (TIMI) 10B Investigators,” Circulation, Vol. 98, No. 25, 1998, pp. 2805-2814. doi:10.1161/01.CIR.98.25.2805

[3]   E. C. Keeley, J. A. Boura and C. L. Grines, “Primary Angioplasty versus Intravenous Thrombolytic Therapy for Acute Myocardial Infarction: A Quantitative Review of 23 Randomised Trials,” Lancet, Vol. 361, No. 9351, 2003, pp. 13-20. doi:10.1016/S0140-6736(03)12113-7

[4]   The MINAP Steering Group, “Healthcare Quality Improvement Partnership,” Tenth Public Report, 2011. http://www.hqip.org.uk/assets/NCAPOP-Library/MINAP-public-report-2011.pdf

[5]   British Cardiovascular Intervention Society, 2012. http://www.bcis.org.uk

[6]   P. Kolh, W. Wijns, N. Danchin, C. Di Mario, V. Falk, T. Folliguet, et al., “Guidelines on Myocardial Revascularization,” European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for CardioThoracic Surgery, Vol. 38, No. S1, 2010, pp. S1-S52.

[7]   ASCRIBE, 2012. http://www.ascribe.com

[8]   N. Bonaros, D. Vill, D. Wiedemann, K. Fischler, G. Friedrich, O. Pachinger, et al., “Major Risk Stratification Models Do Not Predict Perioperative Outcome after Coronary Artery Bypass Grafting in Patients with Previous Percutaneous Intervention,” European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery, Vol. 39, No. 6, 2011, pp. e164-e169.

[9]   S. Eifert, H. Mair, A. L. Boulesteix, E. Kilian, M. Adamczak, B. Reichart, et al., “Mid-Term Outcomes of Patients with PCI Prior to CABG in Comparison to Patients with Primary CABG,” Vascular Health and Risk Management, Vol. 6, 2010, pp. 495-501. doi:10.2147/VHRM.S8560

[10]   P. Massoudy, M. Thielmann, N. Lehmann, A. Marr, G. Kleikamp, A. Maleszka, et al., “Impact of Prior Percutaneous Coronary Intervention on the Outcome of Coronary Artery Bypass Surgery: A Multicenter Analysis,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 137, No. 4, 2009, pp. 840-845. doi:10.1016/j.jtcvs.2008.09.005

[11]   N. Bonaros, D. Hennerbichler, G. Friedrich, A. Kocher, O. Pachinger, G. Laufer, et al., “Increased Mortality and Perioperative Complications in Patients with Previous Elective Percutaneous Coronary Interventions Undergoing Coronary Artery Bypass Surgery,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 137, No. 4, 2009, pp. 846-852. doi:10.1016/j.jtcvs.2008.09.041

[12]   A. T. Gurbuz, A. Sasmazel, H. Cui, A. A. Zia and A. Aytac, “Previous Percutaneous Coronary Intervention May Increase Symptom Recurrence and Adverse Cardiac Events Following Surgical Revascularization,” Anadolu Kardiyoloji Dergisi: The Anatolian Journal of Cardiology, Vol. 6, No. 2, 2006, pp. 148-152.

[13]   S. Chocron, R. Baillot, J. L. Rouleau, W. J. Warnica, P. Block, D. Johnstone, et al., “Impact of Previous Percutaneous Transluminal Coronary Angioplasty and/or Stenting Revascularization on Outcomes after Surgical Revascularization: Insights from the Imagine Study,” European Heart Journal, Vol. 29, No. 5, 2008, pp. 673-679. doi:10.1093/eurheartj/ehn026

[14]   C. Rao, L. Stanbridge Rde, J. Chikwe, J. Pepper, P. Skapinakis, O. Aziz, et al., “Does Previous Percutaneous Coronary Stenting Compromise the Long-Term Efficacy of Subsequent Coronary Artery Bypass Surgery? A Microsimulation Study,” The Annals of Thoracic Surgery, Vol. 85, No. 2, 2008, pp. 501-507. doi:10.1016/j.athoracsur.2007.09.036

[15]   A. Boening, B. Niemann, A. Wiedemann, P. Roth, R. H. Bodeker, C. Scheibelhut, et al., “Coronary Stenting before Coronary Artery Bypass Graft Surgery in Diabetic Patients Does Not Increase the Perioperative Risk of Surgery,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 142, No. 2, 2011, pp. e53-e57. doi:10.1016/j.jtcvs.2011.04.018

[16]   J. M. van den Brule, L. Noyez and F. W. Verheugt, “Risk of Coronary Surgery for Hospital and Early Morbidity and Mortality after Initially Successful Percutaneous Intervention,” Interactive Cardiovascular and Thoracic Surgery, Vol. 4, No. 2, 2005, pp. 96-100. doi:10.1510/icvts.2004.093104

[17]   C. H. Yap, B. P. Yan, E. Akowuah, D. T. Dinh, J. A. Smith, G. C. Shardey, et al., “Does Prior Percutaneous Coronary Intervention Adversely Affect Early and MidTerm Survival after Coronary Artery Surgery?” JACC Cardiovascular Interventions, Vol. 2, No. 8, 2009, pp. 758-764. doi:10.1016/j.jcin.2009.04.018

[18]   T. Fukui, S. Manabe, T. Shimokawa and S. Takanashi, “The Influence of Previous Percutaneous Coronary Intervention in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting,” Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia, Vol. 16, No. 2, 2010, pp. 99-104.

[19]   P. S. Munk, N. Butt and A. I. Larsen, “Endothelial Dysfunction Predicts Clinical Restenosis after Percutaneous Coronary Intervention,” Scandinavian Cardiovascular Journal, Vol. 45, No. 3, 2011, pp. 139-145. doi:10.3109/14017431.2011.564646

[20]   G. Patti, V. Pasceri, R. Melfi, C. Goffredo, M. Chello, A. D’Ambrosio, et al., “Impaired Flow-Mediated Dilation and Risk of Restenosis in Patients Undergoing Coronary Stent Implantation,” Circulation, Vol. 111, No. 1, 2005, pp. 70-75. doi:10.1161/01.CIR.0000151308.06673.D2

[21]   C. V. Serrano Jr., J. A. Ramires, M. Venturinelli, S. Arie, E. D’Amico, J. L. Zweier, et al., “Coronary Angioplasty Results in Leukocyte and Platelet Activation with Adhesion Molecule Expression. Evidence of Inflammatory Responses in Coronary Angioplasty,” Journal of the American College of Cardiology, Vol. 29, No. 6, 1997, pp. 1276-1283. doi:10.1016/S0735-1097(97)00070-3

[22]   M. Joner, A. V. Finn, A. Farb, E. K. Mont, F. D. Kolodgie, E. Ladich, et al., “Pathology of Drug-Eluting Stents in Humans: Delayed Healing and Late Thrombotic Risk,” Journal of the American College of Cardiology, Vol. 48, No. 1, 2006, pp. 193-202. doi:10.1016/j.jacc.2006.03.042

[23]   S. Fuke, K. Maekawa, K. Kawamoto, H. Saito, T. Sato, T. Hioka, et al., “Impaired Endothelial Vasomotor Function after Sirolimus-Eluting Stent Implantation,” Circulation Journal: Official Journal of the Japanese Circulation Society, Vol. 71, No. 2, 2007, pp. 220-225.

[24]   A. P. Kappetein, T. E. Feldman, M. J. Mack, M. C. Morice, D. R. Holmes, E. St?hle, K. D. Dawkins, F. W. Mohr, P. W. Serruys and A. Colombo, “Comparison of Coronary Bypass Surgery with Drug-Eluting Stenting for the Treatment of Left Main and/or Three-Vessel Disease: 3-Year Follow-Up of the SYNTAX Trial,” European Heart Journal, Vol. 32, No. 17, 2011, pp. 2125-2134. doi:10.1093/eurheartj/ehr213

 
 
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