CABG Surgery following STEMI Susana Harrington, MS,APRN-NP Cardio-Thoracic Surgery Nebraska Methodist Hospital February 15, 2018 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force Practice Guidelines Class I CABG in Patients with STEMI: Urgent CABG in patients whose coronary anatomy not amenable to PCI and who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other highrisk features. CABG is recommended in patients with STEMI at time of operative repair of mechanical defects. CABG in Patients with STEMI Class IIa Use of mechanical circulatory support is reasonable in pts with STEMI who are hemodynamically unstable and require urgent CABG. CABG in Patients with STEMI Class IIb Emergency CABG within 6 hrs of symptom onset may be considered in patients with STEMI who do not have cardiogenic shock and are not candidates for PCI or fibrinolytic therapy. 1
Timing of Urgent CABG In Relation to use of antiplatelet Agents Class I ASA should not be withheld before urgent CABG Clopidogrel or Ticagrelor should be discontinued at least 24hrs before urgent on-pump CABG, if possible. Short-acting intravenous GP IIb/IIIa receptor antagonists (Eptifibatide, Tirofiban) should be discontinued at least 2-4hrs before urgent CABG. Abciximab should be discontinued at least 12 hrs before urgent CABG. Class IIb Urgent off-pump CABG within 24hrs of Clopidogrel or Ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding. Urgent CABG within 5 days of Clodipogrel or Ticagrelor administration or within 7 days or Prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding. Brilanta Time is Muscle Black box warning: Specifically states not to start Brilinta in patients who may undergo urgent CABG. Patient will need to wait 5-7 days post administration due to high risks of bleeding/coagulopathy. Timing of CABG in stable patients after acute MI Mortality is higher in the early stages post- MI and progressively decreases with time post-mi Case Study Situation: RB is a 60 yo gentleman, with hx of CAD (3 stents to RCA). He experienced approximate one-hour of substernal chest pain. He did take 3 SLN and ASA at home. Had syncopal episode and sudden cardiac arrest. OFD was called and pt was found in Vtach and was defibrillated x2. He was brought to the ED and was found to be experiencing a STEMI. Pt was taken to cath lab and was found to have 3VCAD. Background Pt has History of : COPD, HTN, Dyslipidemia, OSA, Tobacco Abuse, GERD, Gout, Depression Pt initiated on Nitro gtt and Amiodarone gtt after cardiac cath Troponin Level 0.04 2
Findings Emergent Cardiac Cath: CX: Complex ulcerated plaque in the mid 2 nd OM branch (50-75%) RCA: 100% occluded proximally. LAD: Calcified. Mid-LAD: 75%, Distal 50-75%. EF = 35% Unsuccessful attempt made to do a PCI to the RCA Operative Procedure 1. Endoscopic vein harvest from left leg using greater saphenous vein. 2. Coronary bypass grafting x3: left internal mammary artery to distal left anterior descending artery reverse saphenous vein aorta to obtuse marginal artery reverse saphenous vein aorta to right posterior descending artery Recovery ECHO revealed EF of 45% Right ventricular hypokinesia secondary to right ventricular infarction. Liver enzymes were elevated (Amiodarone and Atorvastatin were discontinued --?secondary to hepatic congestion). Discharged to home 5 days post-operatively. Follow-up with cardiac rehab. Miscellaneous ECHO (2/8/17): Technically difficult study due to poor acoustic windows, even with contrast agent enhancement. The left ventricle is not well visualized. Qualitatively, the left ventricular ejection fraction is 30-35%. Echocardiographic images are suboptimal, unable to quantitatively evaluate right ventricular systolic function. There is no pericardial effusion. There is no comparison study available. ECHO: (2/13/17) The left ventricular diastolic diameter is normal (4.2-5.8) cm. Qualitatively, the left ventricular ejection fraction is 35-40%. The left ventricular wall thickness is mildly increased (1.1-1.3) cm. There is moderate global hypokinesis of the left ventricle. Abnormal septal motion. Qualitatively, the right ventricle is severely dilated. Qualitatively the right ventricular systolic function is severely decreased. Qualitatively, the right atrium is severely dilated. February 8 th 1:59 am February 8 th 6:25 am 3
February 9 th 5:53 am Question Which Anti-platelet should NOT be taken if a patient with ACS is a possible candidate for CABG? Question What EKG leads would indicate the patient has an inferior myocardial infarction? Question: Blockage in what artery would most likely result in a patient having cardiac surgery? Questions Which of the following situations does NOT require an urgent CABG in a STEMI patient? References O Gara, Patrick T., Kushner, Fredrick G., Ascheim, Deborah D., et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012. Nichols, Elizabeth L., McCullough, Jock N., Ross, Cathy S., et al. Optimal Timing From Myocardial Infarction to Coronary Artery Bypass Grafting on Hospital Mortality. Annals of Thoracic Surgery 2017; 103:162-71. Raghavan, Ramya, Benzaquen, Bruno S., Rudski, Lawrence. Timing of bypass surgery in stable patients after acute myocardial infarction. The Canadian Journal of Cardiology. 2007 Oct; 23 (12): 976-982. 4
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