Coronary Artery Bypass Grafting in Patients with Acute Myocardial Infarction and Cardiogenic Shock

Abstract

Objective: Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) remains associated with a high rate of mortality and disabling morbidity. Coronary artery bypass grafting (CABG) is seldom considered in this setting due to the fear of peri-operative complications. Here, we analysed the outcome of CS patients undergoing CABG within 48 hours after diagnosed with AMI.

Methods: A single-center, retrospective data analysis was performed in 220 AMI patients with CS that underwent CABG within 48 hours between 01/2001 and 01/2018.

Results: 141 patients were diagnosed with ST-elevation myocardial infarction (STEMI), 79 with non-STEMI (NSTEMI). Median age was 67 (60; 72) for STEMI, and 68 (60.8; 75.0) years for NSTEMI patients (p = 0.190). 52.5% of STEMI patients and 39.2% of NSTEMI patients had suffered from cardiac arrest (CA) pre-operatively (p = 0.049). Coronary 3-vessel disease was present in most patients (78.0% STEMI vs 83.5% NSTEMI; p = 0.381). Percutaneous coronary interventions (PCI) were performed in 32.6% STEMI and 27.8% NSTEMI patients (p = 0.543) prior to surgery. Time from diagnosis to surgery was shorter in STEMI patients (3.92 (2.67; 5.98) vs 7.50 (4.78; 16.74) hours; p $<$ 0.001). A complete revascularization was achieved in 82.3% of STEMI and 73.4% of NSTEMI cases (p = 0.116). Post-operative low cardiac output occurred in 14.2% of STEMI vs 8.9% of NSTEMI patients (p = 0.289). The rate of cerebrovascular injury-including hypoxic brain damage was 12.1% for STEMI and 10.1% among NSTEMI patients. (p = 0.825). 30-day mortality was 32.6% after STEMI vs 31.6% in NSTEMI cases (p = 0.285).

Conclusions: In contrast to the discouraging data concerning the role of PCI in AMI patients with CS and complex coronary artery disease, CABG may represent a treatment option worth considering.

Keywords: CABG; acute myocardial infarction; cardiogenic shock.

Fig. 1.

Study design. AMI, acute myocardial infarction; STEMI, ST-elevation myocardial infarction; NSTEMI, non-STEMI.

Fig. 2.

Survival of patients with cardiogenic shock. (A) Overall survival of all patients with cardiogenic shock. 10-year Kaplan-Meier survival curves after acute myocardial infarction and coronary artery bypass grafting in patients with cardiogenic shock. (B) Survival after cardiopulmonary resuscitation. 10-year survival of patients with pre-operative cardiopulmonary resuscitation (CPR) or without (w/o) CPR. Kaplan-Meier survival curves showed no significant differences between the groups (p = 0.962).

Fig. 3.

10-year survival of STEMI and NSTEMI patients with cardiogenic shock. Kaplan-Meier survival curves for STEMI and NSTEMI patients showed no differences between the groups (p = 0.844).