Skip to main content
Top
Published in: General Thoracic and Cardiovascular Surgery 6/2014

01-06-2014 | Original Article

Optimal coronary artery bypass grafting strategy for acute coronary syndrome

Authors: Hiroyuki Nishi, Taichi Sakaguchi, Shigeru Miyagawa, Yasushi Yoshikawa, Satsuki Fukushima, Daisuke Yoshioka, Tetsuya Saito, Koichi Toda, Yoshiki Sawa

Published in: General Thoracic and Cardiovascular Surgery | Issue 6/2014

Login to get access

Abstract

Objective

Conventional coronary artery bypass grafting (CABG) using cardiopulmonary bypass and cardiac arrest is associated with higher mortality and morbidity rates in acute coronary syndrome (ACS) patients undergoing surgery. Although off-pump CABG (OPCAB) is beneficial for high-risk patients, its efficacy for ACS is unknown, with on-pump beating CABG an adjunctive method. We investigated the effects of OPCAB and on-pump beating CABG for ACS.

Methods

We evaluated 121 consecutive patients with ACS (91 males, 30 females; mean age 69.5 ± 10.3 years) who underwent CABG since 2000. Seventy-five had unstable angina (UA) and 46 acute myocardial infarction (AMI) [non-ST elevation (NSTEMI): 22, ST elevation (STEMI): 24]. We assessed CABG for acute coronary syndrome under our primary OPCAB strategy, and compared perioperative status between UA and AMI patients.

Results

(1) Sixty-five (87 %) with UA underwent OPCAB, 8 on-pump beating CABG, and 2 conventional CABG. Conversion from OPCAB was seen in 4 patients. In-hospital mortality was 1.3 %. (2) All UA patients who had intra-aortic balloon pumping (IABP) underwent OPCAB. No patients with preoperative IABP experienced conversion from OPCAB. (3) In AMI patients, hospital mortality was higher (8.9 %) and the ratios for OPCAB, on-pump beating CABG, and conventional CABG were 39, 57, and 4 %, respectively. Mortality was exclusively seen in patients with STEMI who underwent conventional CABG.

Conclusions

OPCAB might have beneficial effects for ACS patients with UA, while IABP was found essential for completing OPCAB. In AMI patients, on-pump beating CABG might be reasonable for avoiding conversion from OPCAB and ischemic perfusion injury.
Literature
1.
go back to reference Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol. 2008;52:1693–701.PubMedCrossRef Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol. 2008;52:1693–701.PubMedCrossRef
2.
go back to reference Ben-Gal Y, Moses JW, Mehran R, Lansky AJ, Weisz G, Nikolsky E, et al. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. JACC Cardiovasc Interv. 2010;3:1059–67.PubMedCrossRef Ben-Gal Y, Moses JW, Mehran R, Lansky AJ, Weisz G, Nikolsky E, et al. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. JACC Cardiovasc Interv. 2010;3:1059–67.PubMedCrossRef
3.
go back to reference Zembala M, Trzeciak P, Gąsior M, Gierlotka M, Hudzik B, Tajstra M, et al. Optimal timing for surgical revascularization in survivors of acute coronary syndromes eligible for elective coronary artery bypass graft surgery. Int J Cardiol. 2011;153:173–8.PubMedCrossRef Zembala M, Trzeciak P, Gąsior M, Gierlotka M, Hudzik B, Tajstra M, et al. Optimal timing for surgical revascularization in survivors of acute coronary syndromes eligible for elective coronary artery bypass graft surgery. Int J Cardiol. 2011;153:173–8.PubMedCrossRef
4.
go back to reference Hirose H, Amano A, Takahashi A, Takanashi S. Urgent off-pump coronary artery bypass grafting. Jpn J Thorac Cardiovasc Surg. 2002;50:330–7.PubMedCrossRef Hirose H, Amano A, Takahashi A, Takanashi S. Urgent off-pump coronary artery bypass grafting. Jpn J Thorac Cardiovasc Surg. 2002;50:330–7.PubMedCrossRef
5.
go back to reference Ochi M, Hatori N, Saji Y, Sakamoto S, Nishina D, Tanaka S. Application of off-pump coronary artery bypass grafting for patients with acute coronary syndrome requiring emergency surgery. Ann Thorac Cardiovasc Surg. 2003;9:29–35.PubMed Ochi M, Hatori N, Saji Y, Sakamoto S, Nishina D, Tanaka S. Application of off-pump coronary artery bypass grafting for patients with acute coronary syndrome requiring emergency surgery. Ann Thorac Cardiovasc Surg. 2003;9:29–35.PubMed
6.
go back to reference Rastan AJ, Eckenstein JI, Hentschel B, Funkat AK, Gummert JF, Doll N, et al. Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies. Circulation. 2006;114(1 Suppl):I477–85.PubMed Rastan AJ, Eckenstein JI, Hentschel B, Funkat AK, Gummert JF, Doll N, et al. Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic cardiac arrest strategies. Circulation. 2006;114(1 Suppl):I477–85.PubMed
7.
go back to reference Kaya K, Cavolli R, Telli A, Soyal MF, Aslan A, Gokaslan G, et al. Off-pump versus on-pump coronary artery bypass grafting in acute coronary syndrome: a clinical analysis. J Cardiothorac Surg. 2010;27(5):31. Kaya K, Cavolli R, Telli A, Soyal MF, Aslan A, Gokaslan G, et al. Off-pump versus on-pump coronary artery bypass grafting in acute coronary syndrome: a clinical analysis. J Cardiothorac Surg. 2010;27(5):31.
8.
go back to reference Polonski L, Gasior M, Gierlotka M, Osadnik T, Kalarus Z, Trusz-Gluza M, et al. A comparison of ST elevation versus non-ST elevation myocardial infarction outcomes in a large registry database: are non-ST myocardial infarctions associated with worse long-term prognoses? Int J Cardiol. 2011;152:70–7.PubMedCrossRef Polonski L, Gasior M, Gierlotka M, Osadnik T, Kalarus Z, Trusz-Gluza M, et al. A comparison of ST elevation versus non-ST elevation myocardial infarction outcomes in a large registry database: are non-ST myocardial infarctions associated with worse long-term prognoses? Int J Cardiol. 2011;152:70–7.PubMedCrossRef
9.
go back to reference Hagl C, Khaladj N, Peterss S, Martens A, Kutschka I, Goerler H, et al. Acute treatment of ST-segment-elevation myocardial infarction: is there a role for the cardiac surgeon? Ann Thorac Surg. 2009;88:1786–92.PubMedCrossRef Hagl C, Khaladj N, Peterss S, Martens A, Kutschka I, Goerler H, et al. Acute treatment of ST-segment-elevation myocardial infarction: is there a role for the cardiac surgeon? Ann Thorac Surg. 2009;88:1786–92.PubMedCrossRef
10.
go back to reference Zaroff JG, diTommaso DG, Barron HV. A risk model derived from the National Registry of Myocardial Infarction 2 database for predicting mortality after coronary artery bypass grafting during acute myocardial infarction. Am J Cardiol. 2002;90:1–4.PubMedCrossRef Zaroff JG, diTommaso DG, Barron HV. A risk model derived from the National Registry of Myocardial Infarction 2 database for predicting mortality after coronary artery bypass grafting during acute myocardial infarction. Am J Cardiol. 2002;90:1–4.PubMedCrossRef
11.
go back to reference Lee DC, Oz MC, Weinberg AD, Ting W. Appropriate timing of surgical intervention after transmural acute myocardial infarction. J Thorac Cardiovasc Surg. 2003;125:115–9.PubMedCrossRef Lee DC, Oz MC, Weinberg AD, Ting W. Appropriate timing of surgical intervention after transmural acute myocardial infarction. J Thorac Cardiovasc Surg. 2003;125:115–9.PubMedCrossRef
12.
go back to reference Hirose H, Amano A, Takahashi A. Off-pump coronary artery bypass grafting for patients with three-vessel disease. Surgery. 2002;132:57–65.PubMedCrossRef Hirose H, Amano A, Takahashi A. Off-pump coronary artery bypass grafting for patients with three-vessel disease. Surgery. 2002;132:57–65.PubMedCrossRef
13.
go back to reference Kawamura M, Nakajima H, Kobayashi J, Funatsu T, Otsuka Y, Yagihara T, et al. Patency rate of the internal thoracic artery to the left anterior descending artery bypass is reduced by competitive flow from the concomitant saphenous vein graft in the left coronary artery. Eur J Cardiothorac Surg. 2008;34:833–8.PubMedCrossRef Kawamura M, Nakajima H, Kobayashi J, Funatsu T, Otsuka Y, Yagihara T, et al. Patency rate of the internal thoracic artery to the left anterior descending artery bypass is reduced by competitive flow from the concomitant saphenous vein graft in the left coronary artery. Eur J Cardiothorac Surg. 2008;34:833–8.PubMedCrossRef
14.
go back to reference Li Z, Amsterdam EA, Yeo KK, Hoegh H, Mahendra G, Boyd WD, et al. Coronary artery bypass operations for elderly patients in California, 2003 to 2008. Ann Thorac Surg. 2012;93:1167–72.PubMedCrossRef Li Z, Amsterdam EA, Yeo KK, Hoegh H, Mahendra G, Boyd WD, et al. Coronary artery bypass operations for elderly patients in California, 2003 to 2008. Ann Thorac Surg. 2012;93:1167–72.PubMedCrossRef
15.
go back to reference Abu-Omar Y, Taghavi FJ, Navaratnarajah M, Ali A, Shahir A, Yu LM, et al. The impact of off-pump coronary artery bypass surgery on postoperative renal function. Perfusion. 2012;27:127–31.PubMedCrossRef Abu-Omar Y, Taghavi FJ, Navaratnarajah M, Ali A, Shahir A, Yu LM, et al. The impact of off-pump coronary artery bypass surgery on postoperative renal function. Perfusion. 2012;27:127–31.PubMedCrossRef
16.
go back to reference Jin R, Hiratzka LF, Grunkemeier GL, Krause A, Page US 3rd. Aborted off-pump coronary artery bypass patients have much worse outcomes than on-pump or successful off-pump patients. Circulation. 2005;112(9 Suppl):I332–7.PubMed Jin R, Hiratzka LF, Grunkemeier GL, Krause A, Page US 3rd. Aborted off-pump coronary artery bypass patients have much worse outcomes than on-pump or successful off-pump patients. Circulation. 2005;112(9 Suppl):I332–7.PubMed
17.
go back to reference Miyahara K, Matsuura A, Takemura H, Saito S, Sawaki S, Yoshioka T, et al. On-pump beating-heart coronary artery bypass grafting after acute myocardial infarction has lower mortality and morbidity. J Thorac Cardiovasc Surg. 2008;135:521–6.PubMedCrossRef Miyahara K, Matsuura A, Takemura H, Saito S, Sawaki S, Yoshioka T, et al. On-pump beating-heart coronary artery bypass grafting after acute myocardial infarction has lower mortality and morbidity. J Thorac Cardiovasc Surg. 2008;135:521–6.PubMedCrossRef
18.
go back to reference Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1–157.PubMedCrossRef Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1–157.PubMedCrossRef
19.
go back to reference Funkat AK, Beckmann A, Lewandowski J, Frie M, Schiller W, Ernst M, Hekmat K, et al. Cardiac surgery in Germany during 2011: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2012;60:371–82.PubMedCrossRef Funkat AK, Beckmann A, Lewandowski J, Frie M, Schiller W, Ernst M, Hekmat K, et al. Cardiac surgery in Germany during 2011: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2012;60:371–82.PubMedCrossRef
20.
go back to reference Shroyer AL, Coombs LP, Peterson ED, Eiken MC, DeLong ER, Chen A, et al. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003;75:1856–64.PubMedCrossRef Shroyer AL, Coombs LP, Peterson ED, Eiken MC, DeLong ER, Chen A, et al. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003;75:1856–64.PubMedCrossRef
21.
go back to reference Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366(16):1489–97.PubMedCrossRef Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366(16):1489–97.PubMedCrossRef
22.
go back to reference Niranjan G, Asimakopoulos G, Karagounis A, Cockerill G, Thompson M, Chandrasekaran V. Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial. Eur J Cardiothorac Surg. 2006;30:271–7.PubMedCrossRef Niranjan G, Asimakopoulos G, Karagounis A, Cockerill G, Thompson M, Chandrasekaran V. Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial. Eur J Cardiothorac Surg. 2006;30:271–7.PubMedCrossRef
23.
go back to reference Wan S, Izzat MB, Lee TW, Wan IY, Tang NL, Yim AP. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg. 1999;68:52–6.PubMedCrossRef Wan S, Izzat MB, Lee TW, Wan IY, Tang NL, Yim AP. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury. Ann Thorac Surg. 1999;68:52–6.PubMedCrossRef
24.
go back to reference Marui A, Kimura T, Tanaka S, Okabayashi H, Komiya T, Furukawa Y, et al. Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention. Am J Cardiol. 2012;110:1773–8.PubMedCrossRef Marui A, Kimura T, Tanaka S, Okabayashi H, Komiya T, Furukawa Y, et al. Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention. Am J Cardiol. 2012;110:1773–8.PubMedCrossRef
25.
go back to reference Golding LA, Loop FD, Peter M, Cosgrove DM, Taylor PC, Phillips DF. Late survival following use of intraaortic balloon pump in revascularization operations. Ann Thorac Surg. 1980;30:48–51.PubMedCrossRef Golding LA, Loop FD, Peter M, Cosgrove DM, Taylor PC, Phillips DF. Late survival following use of intraaortic balloon pump in revascularization operations. Ann Thorac Surg. 1980;30:48–51.PubMedCrossRef
26.
go back to reference Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308–20.PubMedCrossRef Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308–20.PubMedCrossRef
27.
go back to reference Tomasco B, Cappiello A, Fiorilli R, Leccese A, Lupino R, Romiti A, et al. Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality. Ann Thorac Surg. 1997;64:678–83.PubMedCrossRef Tomasco B, Cappiello A, Fiorilli R, Leccese A, Lupino R, Romiti A, et al. Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality. Ann Thorac Surg. 1997;64:678–83.PubMedCrossRef
28.
go back to reference Sergeant P, Blackstone E, Meyns B. Early and late outcome after CABG in patients with evolving myocardial infarction. Eur J Cardiothorac Surg. 1997;11:848–56.PubMedCrossRef Sergeant P, Blackstone E, Meyns B. Early and late outcome after CABG in patients with evolving myocardial infarction. Eur J Cardiothorac Surg. 1997;11:848–56.PubMedCrossRef
29.
go back to reference Thompson CR, Buller CE, Sleeper LA, Antonelli TA, Webb JG, Jaber WA, et al. Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we use emergently revascularize Occluded Coronaries in cardiogenic shocK? J Am Coll Cardiol. 2000;36(3 Suppl A):1104–9.PubMedCrossRef Thompson CR, Buller CE, Sleeper LA, Antonelli TA, Webb JG, Jaber WA, et al. Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we use emergently revascularize Occluded Coronaries in cardiogenic shocK? J Am Coll Cardiol. 2000;36(3 Suppl A):1104–9.PubMedCrossRef
30.
go back to reference Perrault LP, Menasché P, Peynet J, Faris B, Bel A, de Chaumaray T, et al. On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off? Ann Thorac Surg. 1997;64:1368–73.PubMedCrossRef Perrault LP, Menasché P, Peynet J, Faris B, Bel A, de Chaumaray T, et al. On-pump, beating-heart coronary artery operations in high-risk patients: an acceptable trade-off? Ann Thorac Surg. 1997;64:1368–73.PubMedCrossRef
Metadata
Title
Optimal coronary artery bypass grafting strategy for acute coronary syndrome
Authors
Hiroyuki Nishi
Taichi Sakaguchi
Shigeru Miyagawa
Yasushi Yoshikawa
Satsuki Fukushima
Daisuke Yoshioka
Tetsuya Saito
Koichi Toda
Yoshiki Sawa
Publication date
01-06-2014
Publisher
Springer Japan
Published in
General Thoracic and Cardiovascular Surgery / Issue 6/2014
Print ISSN: 1863-6705
Electronic ISSN: 1863-6713
DOI
https://doi.org/10.1007/s11748-013-0358-6

Other articles of this Issue 6/2014

General Thoracic and Cardiovascular Surgery 6/2014 Go to the issue