Meta-Analytic Review of Coronary Angiography in Peri-Procedural Myocardial Injury and Infarction After Cardiac Surgery

Abstract

Introduction: Peri-procedural myocardial infarction (PMI) after cardiac surgery is a significant yet often under-recognised complication, sometimes necessitating urgent coronary angiography (PMI-rCA). This meta-analysis evaluates its prevalence, angiographic findings, management strategies, and associated mortality. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. Data from nine studies comprising 104,445 post-cardiac surgery patients were analysed. Among them, those undergoing PMI-rCA were categorised by treatment strategy: conservative management, percutaneous coronary intervention (PCI), or reperform surgery. A network meta-analysis compared mortality risks across these groups, with findings visualised using forest plots, network diagrams, and SUCRA rankings. Results: PMI-rCA was performed in 1205 patients (2%). Of these, 34.3% had no significant angiographic abnormalities, 53.7% exhibited graft failure, and 10.4% had native vessel ischemia. Management strategies included conservative treatment (55.5%), PCI (23.5%), and reperforming surgery (21%). Network meta-analysis indicated that conservative management was associated with the lowest mortality risk, followed by PCI, while reperforming surgery had the highest risk. Discussion: These findings highlight the complexity of PMI diagnosis and treatment. The high proportion of patients without significant angiographic abnormalities raises concerns about potential overuse of invasive procedures. Meanwhile, PCI appears to be a more favourable interventional strategy than reperforming surgery in terms of mortality outcomes. Conclusions: PMI requiring coronary angiography is uncommon but clinically significant, with a 16% mortality rate. A tailored, risk-based approach is essential to optimise management, balancing conservative therapy, PCI, and reperforming surgery based on individual patient profiles.

Keywords: cardiac surgery complications; graft failure; percutaneous coronary intervention (PCI); peri-procedural myocardial infarction requiring coronary angiography; surgical mortality and outcomes.

Figure A1

Search strategy and keywords (left), meta-analytic flow diagram (right).

Figure A2

Study bias analysis with ROBINS-E.

Figure A3

Summary forest plot of NMA.

Figure A4

(top): meta-regression for PMI-rCA prevalence and mortality. (bellow): meta-regression for PMI-rCA prevalence and mortality.

Figure 1

Flowchart of the meta-analysis.

Figure 2

PMI-rCA prevalence displayed with forest plot (left), Q–Q plot (top right), and funnel plot (bottom right).

Figure 3

PMI-rCA mortality displayed with forest plot (left), Q–Q plot (top right), and funnel plot (bottom right).

Figure 4

Pie chart showing PMI-rCA prevalence (yellow) and mortality (red).

Figure 5

Network plot (left) and individual study results compared by treatment (right).

Figure 6

Comparison by treatment (left) and graphical representation of the ranking with Litmus Rank-O-Gram (top right) and Radial SUCRA (bottom right).

Figure 7

Evidence-informed algorithm for the management of peri-operative myocardial injury-related coronary angiography (PMI-rCA), based on the findings of our systematic review.