Emergency surgery in acute coronary syndrome

Transcription

1 Emergency surgery in acute coronary syndrome Teerawoot Jantarawan Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

2 Acute coronary syndrome a spectrum of conditions compatible with acute myocardial ischemia and/or infarction that are usually due to an abrupt reduction in coronary blood flow Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline

3 Acute coronary syndrome Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline

4 Epidemiology Over seven million people every year die from CAD, 12.8% of all deaths (WHO 2011) 1.5 million hospital admissions in the U.S. annually: Approximately 70% NSTE-ACS ; (Heart Disease and Stroke Statistics-2014 Update from AHA) In the Europe (incidence per 100,000/year) : 77 STEMI, 132 non-stemi (ESC guideline 2012)

5 39 participating medical centers.(22 open heart surgery) Between October 2007 and December 2008, 2,007 patients were enrolled. 55% STEMI 33% NSTEMI 12% UA. J Med Assoc Thai Vol. 95 No

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7 J Med Assoc Thai Vol. 95 No

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9 Emergency CABG : % of total CABG

10 The society of thoracic surgeon of Thailand : statistic Siriraj Isolated CABG 842 Total CABG 1,059 Emergency CABG 18 (2.1%) 67 hospitals Isolated CABG 8,628 Total CABG 10,472 Emergency CABG ~ ??

11 What is an emergency? Immediate Within 12 hrs Within 24 hrs Within 48 hrs early strategy Guideline??? Surgeon and Heart team

12 Indication Class I Recommendations (Level of Evidence: B) 1. acute MI in whom 1) primary PCI has failed or cannot be performed 2) coronary anatomy is suitable for CABG, and 3) persistent ischemia of a significant area of myocardium at rest and/or hemodynamic instability refractory to nonsurgical therapy is present Hillis et al 2011 ACCF/AHA CABG Guideline

13 Indication Class I Recommendations (Level of Evidence: B) 2. Patients undergoing surgical repair of a post infarction mechanical complication of MI ventricular septal rupture mitral valve insufficiency because of papillary muscle infarction and/or rupture free wall rupture Hillis et al 2011 ACCF/AHA CABG Guideline

14 Indication Class I Recommendations (Level of Evidence: B) 3. Patients with cardiogenic shock and who are suitable for CABG irrespective of the time interval from MI to onset of shock and time from MI to CABG. Hillis et al 2011 ACCF/AHA CABG Guideline

15 Indication Class I Recommendations (Level of Evidence: C) 4. Patients with life-threatening ventricular arrhythmias (believed to be ischemic in origin) in the presence of left main stenosis greater than or equal to 50% and/or 3-vessel CAD Hillis et al 2011 ACCF/AHA CABG Guideline

16 Indication Class IIa Recommendations (Level of Evidence: B) 1. Patients with multivessel CAD with recurrent angina or MI within the first 48 hours of STEMI presentation as an alternative to a more delayed strategy. Hillis et al 2011 ACCF/AHA CABG Guideline

17 Indication Class III Recommendations (Level of Evidence: C) 1. Emergency CABG should not be performed in patients with persistent angina and a small area of viable myocardium who are stable hemodynamically. 2. Emergency CABG should not be performed in patients with no reflow (successful epicardial reperfusion with unsuccessful microvascular reperfusion). Hillis et al 2011 ACCF/AHA CABG Guideline

18 Emergency CABG After Failed PCI Failed PCI abrupt vessel closure extensive coronary artery dissection incomplete revascularization coronary perforation Unsuccessful dilation other situations resulting in hemodynamic instability and requiring surgical intervention Yang et al JACC Vol. 46, No. 11

19 Emergency CABG After Failed PCI Recommendations Class I level of evidence B 1. Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk. 2. Emergency CABG is recommended after failed PCI for hemodynamic compromise in patients without impairment of the coagulation system and without a previous sternotomy.

20 Emergency CABG After Failed PCI Recommendations Class IIa level of evidence C 1. Emergency CABG is reasonable after failed PCI for retrieval of a foreign body (most likely a fractured guidewire or stent) in a crucial anatomic location. 2. Emergency CABG can be beneficial after failed PCI for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy.

21 Emergency CABG After Failed PCI Recommendation Class IIb Level of Evidence: C 1. Emergency CABG might be considered after failed PCI for hemodynamic compromise in patients with previous sternotomy.

22 Emergency CABG After Failed PCI Recommendation Class III Level of Evidence: C 1. Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion. 2. Emergency CABG should not be performed after failed PCI if revascularization is impossible because of target anatomy or a no-reflow state.

23 Timing NSTE-ACS In a large database analysis of unselected patients admitted for ACS, performance of early CABG(< 48 hrs), even in higher-risk patients, was associated with low in-hospital mortality. STEMI (Monteiro P. Circulation 2006;114), (Parikh SV. JACC Cardiovasc Interv 2010;3(4) When possible, in the absence of persistent pain or haemodynamic deterioration, a waiting period of 3 7 days appears the best compromise. (Weiss ES, J Thorac Cardiovasc Surg 2008;135(3) In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding complications. Class I recommendation (Hillis et al 2011 ACCF/AHA CABG Guideline)

24 Surgical technique Conventional CABG On pump beating heart OPCAB

25 Surgical technique myocardial oxygen demand CPB related inflammatory injury Conventional CABG Global ischemia On pump beating heart - OPCAB - - -

26 638 (3.3%) (stable 531, CS 107) 240 Beating heart operation 124 OPCAB 116 on pump beating heart 398 conventional CPB/CA Rastan et al.beating Heart CABG in Emergency ACS, Circulation July 4, 2006

27 Rastan et al. Beating Heart CABG in Emergency ACS, Circulation July 4, 2006

28 Stable hemodynamic CA is superior in Shorter CPB time More distal anastomoses Cx territory grafting BH is superior in Time to culprit lesion revascularization

29 BH is superior in less Inotrope less bleeding less hospital stay

30 Follow up median 2.78 years (range 0.02 to 5.86 years)

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33 Follow up median 2.78 years (range 0.02 to 5.86 years)

34 Between January 1996 and March patients 44 (7%) OPCAB (acceptable hemodynamics) 570 (83%) CABG/CPB KERENDI ET AL Ann Thorac Surg EMERGENCY OFF-PUMP CORONARY BYPASS 2005;79:801 6

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36 KERENDI ET AL Ann Thorac Surg EMERGENCY OFF-PUMP CORONARY BYPASS 2005;79:801 6

37 KERENDI ET AL Ann Thorac Surg EMERGENCY OFF-PUMP CORONARY BYPASS 2005;79:801 6

38 Conventional CABG Myocardial protection Antegrade Retrograde Graft Adequate vent Optimal revascularization and clamp time Conduit Perioperative care and support

39 Mechanical Hemodynamic support 38% of patients need Intra aortic balloon pump 3%-10% of patients need Extracorporeal Membrane Oxygenator (ECMO) HAGL ET AL. Ann Thorac Surg 2009;88:

40 Results and prognosis 30 days or in hospital Mortality rate : 6.6% - 32% 1- year survival : ~ 70% 3- year survival : ~ 60% 5- year survival : ~ 50% STEMI, PVD, DM, lactate levels >4mmol/l and high preoperative inotrope, and ECMO support predicted late mortality. Piroze M Davierwala et al,nov;2005

41 Conclusion The Incidence of emergency CABG decrease. The mortality rate associated with emergency CABG remains high and unchanged. Beating heart coronary artery bypass graft maybe improve the outcome but maybe not suitable for the instable patients and LM disease. If the ACS patients need CABG and can wait, wait!!!

42 Thank you for your attention