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Postoperative myocardial
infarction
An article from the e-journal of the ESC Council for
Cardiology Practice
05 Oct 2011
Prof. Nawwar Al-Attar
Biomarker values above five times the 99th percentile of the normal reference
range during the first 72 hrs following coronary artery bypass graft
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Table of contents
I - CLINICAL CLASSIFICATION OF MYOCARDIAL INFARCTION
II - DIAGNOSIS
III - MANAGEMENT
REFERENCES
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new LBBB, angiographically documented new graft or native coronary artery occlusion, or
imaging evidence of new loss of viable myocardium, should be considered as diagnostic
of CABG-related myocardial infarction (4).
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Preoperative MI
II - DIAGNOSIS
Establishing a definite diagnosis of postoperative MI can be difficult. A large spectrum of
lesions ranging from transient myocardial ischemia to complete necrosis can occur. The
classical clinical approach using elements such as chest pain, ECG changes and increased
cardiac enzymes (CK-MB, troponin) can be misleading and inadequate, missing numerous
coronary events albeit less severe but frequent enough to call for therapeutic
intervention. Classical signs are often masked by postoperative analgesia that can make
ischemia silent. Q waves are frequently absent and non-specific ECG modifications
following cardiac surgery can blur clinical presentation. Finally, elevation of enzymes
especially post- surgery CK-MB can further complicate the interpretation of biomarkers
in the diagnosis of MI. Current recommendations suggest that biomarker values above
five times the 99th percentile of the normal reference range during the initial 72 hrs
following CABG, when associated with the appears of new pathological Q-waves or new
LBBB, or angiographically documented new graft or native coronary artery occlusion, or
imaging evidence of new loss of viable myocardium, should be considered as diagnostic
of CABG-related myocardial infarction (4).
III - MANAGEMENT
Specific treatment of myocardial ischemia after CABG depends primarily on findings
obtained by imaging techniques, namely, coronary angiography.
In symptomatic patients, early graft occlusion has been identified as the cause of
ischemia in 75% of cases. Perioperative coronary angiography has shown up to 8% of
early occlusions of venous grafts following CABG (8). Emergency PCI with
desobstruction/stenting of the occluded graft is an alternative to emergency surgical
reintervention and is associated with acceptable results and fewer complications. It is
advised that the target for PCI should be the body of the native vessel while freshly
occluded venous grafts or the anastomosis itself should not be targeted due to the risk of
embolisation or perforation. Surgery should be favored if the graft or native artery
appears unsuitable for PCI, or if several important grafts are occluded.
In asymptomatic patients, re-operation or PCI should only be considered if the artery is a
good size, severely narrowed and supplies a large territory of myocardium. Redo CABG or
PCI should be decided by the Heart Team (9).
REFERENCES
1. Chen JC, Kaul P, Levy JH, Haverich A, Menasche P, Smith PK, Carrier M, Verrier ED, Van de Werf F, Burge R,
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The content of this article reflects the personal opinion of the author/s and is
not necessarily the official position of the European Society of Cardiology.
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