Acute Myocardial Infarction after CABG

Jeffrey Wirianta Friday, May 3rd 2002 ICU/Post Op

Indications for CABG in Unstable Angina/Non-Q-Wave MI Class I 1. Significant LM coronary artery stenosis 2. Left main equivalent: significant ( > 70%) stenosis of proximal LAD and proximal LCx artery 3. Ongoing ischemia not responsive to max. nonsurgical th/.
ACC/AHA Guideline for CABG

Indications for CABG in Stable Angina Class I

1. Significant LM coronary artery stenosis 2. LM equivalent 3. 3-VD 4. 2-VD with significant proximal LAD st. & either LVEF < 0.50 or demonstrable ischemia 5. 1- or 2-VD w/o significant proximal LAD st. but with a large area of viable myocardium & high-risk criteria 6. Disabling angina despite max medical th/, when surgery can be performed with acceptable risk

Antiplatelet and anticoagulation th/

Class I 5. Pts taking clopidogrel CABG is planned withheld for at least 5 days, preferably for 7 days
ACC/AHA Guideline for UA-non STEMI

Aspirin & other antiplatelet drugs discontinued 7 days before CABG

ACC/AHA Guideline for CABG

247 pts undergoing CABG Clopidogrel recipients : > incidence of reexploration for bleeding > percentage receiving PRC, cryoprecipitate U, platelet U, FFP
Yende S, Crit Care Med 2001; 29 : 2271-5

Mr. MA ( 57 y.o ) came to NCCHK on April 15th 2002 short of breath and chest pain 3 1/2 hr before adm , history of UAP, hypertension & DM in 1996
12/3/96 PTCA on LAD with good result. 28/3/96 Thallium scanning , good perfusion, only mild

reversible defect on ant. wall normal LV function 17/4/96 TMR , no more chest discomfort 26/7/99 AMI, primary PTCA & stent on RCA RCA 95 % st, LAD total occlusion after D2, LCx 80 % st, OM1 70 % st, OM2 70 % st. 5/8/99 PTCA on OM1 and OM2, res. st. 5 % no intervention on LAD He took medicine regularly, seloken 1 x 50 mg and mixtart aspirin (-) , history of severe gastric bleeding on Sept. 2000

BP = 130/83 mmHg, HR = 76 x/1, RR = 24 x/1, other physical findings (n) , CTR = 55% Lab. cardiac enzymes (n) on serial, renal function (n), electrolytes (n), lipid profile (n), > blood glucose

D/. UAP, DM, history of PTCA and TMR

th/. lovenox, ISDN, seloken, plavix , mixtart.
17/4/02 Cath : RCA (n), short LM with 90 % st,

LAD 99 % st. prox, LCx 90 % st. before OM1 18/4/02 Echo : dilated LA, no thrombus, concentric LVH, LVEF = 45 %, hypokinetic on ant. wall, no scar tissue, sclerotic aorta, valves (n), E/A > 1 He was discharged, persantin 1 x 1 tab, plavix 1 x 1 tab, lipitor 1 x 10 mg

SR, LAD, 72 x/1, PR 0.18 QRS 0.06 QS V1-V4 rS II, III, AVF Inv. T V5-V6

24/4/02 ( 15.10 23.30 )

Off pump CABG 2 grafts, LIMA-LAD, SVG-Cx

Op. : dilated heart, all surface of the heart was sticked to the pericardium. Some epicardium was peeled off on the apikolateral part. LIMA was good, small coronary vessels, small saphenous vein
Complications : after SVG to Cx and proximal was done, bleeding ( oozing ), VT ( DC 2 x 10 J SR ), BP = 85/45, HR = 145, PA = 12, adrenalin bolus, drip, and IABP was inserted

Input

: cristalloid = 1000 cc, colloid = 2000 cc, TC = 90 cc, FFP = 560 cc, fresh blood = 550 cc, pump blood = 1000 cc, PC = 970 cc

Output : urine = 700 cc, blood loss = 2500 cc

Pra op : Hb = 15,0, L = 5600, Ht = 45, Tr = 180,

Ur = 34, Cr = 1,0, Na = 138, K = 3,9, Ca = 2,2, Cl = 106, Mg = 2,0, Glucose = 138

21.29 : Hb = 8,5, Ht = 25, Glucose = 410,

astrup = metab. acidosis partly compensated

00.30 : in ICU, BP = 105/65, HR = 80, CVP = 8, PA = 12

ECG showed ST elevation on anterior leads

00.56 : Hb = 11,8, L = 21.000, Ht = 35, Tr = 141, Fibr = 170,

CK = 1434, CKMB = 164, Ur = 42, Cr = 1,8, Glucose = 377, astrup = uncompen. metab. acidosis, lactat = 10,8

01.55 :
VT, BP = 80/40 DC 100 J SR 140 x/1

cordaron 150 mg bolus, 750 mg/24 hr, tracrium drip 0,5, levophed & adrenalin titrated, lasix 20 mg/hr, GIK non DM 40 cc/hr, meronem, NTG 0,25 ug/kg/1, electrolytes deficit were corrected

On follow up

On arrival in ICU

02.25 : VT, BP = 50/20 mmHg DC 100 J SR 135 x/1,

BP = 125/70 mmHg, urine = 50 cc.

06.00 : BP = 60-110/40-60, HR = 115-120,

CVP = 15-18, PA = 25-34, CVVH was put on

Problem : bleeding drain 2-3 cc/kg/hr & from the feet, no urine

Hb = 8,7, L = 10.800, Ht = 26, Tr = 69, Fibr. = 150, CK = 4515, CKMB = 322, Ur = 51, Cr = 2,7, Glocuse = 630 Echo : << global contraction, LVEF = 17 %, PE = 200 cc, akinetic on apical and anterior wall, hypokinetic on other segments, no tamponade Tranfusioned TC 120 cc, FFP = 1520 cc, PC = 380 cc

13.58 : Hb = 6,8, L = 13,900, Ht = 31, Tr = 79

23.39 : Hb = 7,4, Ht = 22, Tr = 48

04.37 : Hb = 10,8, L = 13.900, Ht = 31, Tr = 84,

CK = 5349, CKMB = 409, Ur = 46, Cr = 2,3, Glucose = 62, Astrup = normal.

06.00 : BP = 70-90/30-40, HR = 100-115 x/1,

drain = minimal bleeding, subserous, no urine

09.00 : BP <<, dobutamine titrated 14.00 : BP = 48-86/27-42, HR = 58-96, CVP = 17-26, PA = 18-28 16.15 : BP <<, HR <<, passed away at 16.55

PROBLEMS . . . . .
widespread cicatrix small & diffuse calcification on coronary vessels small saphenous vein unstable hemodynamic during op perioperative AMI profuse bleeding during & post op low out put syndrome & ARF Off pump CABG . . . . . On pump CABG ?

Most consistent predictors of mortality after CABG urgency of operation prior heart surgery age sex ( female : increased risk ) LVEF percent stenosis of the LM cor. artery number of major cor. artery with >70% stenosis
ACC/AHA Guideline for CABG

Women have > perioperative mortality after CABG compared with men
Hogue CW Jr, Anesthesiology 2001; 95 : 1074-8

Patient or Disease Characteristic

Age 60-69
Age 70-79 Age > 80 Female sex EF<40% Urgent surgery Emergency surgery Prior CABG PVD Diabetes Dialysis or creatinin > 2 COPD Obesity (BMI 31-36) Severe obesity ( BMI > 37 )

Mortality Score

Total Score

Mortality %

2
3 5 1.5 1.5 2 5 5 2

0
1 2 3 4 5 6 7 8 9

0.4
0.5 0.7 0.9 1.3 1.7 2.2 3.3 3.9 6.1

ACC/AHA Guideline for CABG

4
1.5

10
11 12 13

7.7
10.6 13.7 17.7

Total Score

14

> 28.3

CPB was independent factor : > mortality, > incidence of AMI / early major events
Calafiore AM, Ann Thorac Surg 2001; 72 : 456-63

Off pump CABG : CPB is not employed the beating heart cant be stopped aorta cant be clamped pt isnt fully heparinized surgical is more difficult

OP-CABG is safe and effective for LM CAD

Meharzal ZS, Indian Heart J 2001; 53 : 314-8

Possible advantages :
pt recover more quickly less post op neurologic deficiencies blood is not damaged provides a more physiologic state offer a better renal protection extremely sick pt

OP-CABG

Possible disadvantages : more difficult emergency CPB 25% of all OP-CABG distal anastomosis may not be as good as experience ?
perfusion.com

Candidates for OP-CABG : suitable anatomy ( epicardial vessels > 1.2 mm, not calcified ) high risk for peri / post op. organ dysfunction

Contraindication : unfavorable anatomy ( small, intramyocardial or diffuse calcifications vessel )

Calafiore AM, Ann Thorac Surg 2001 ; 72 : 456-63

Diagnosis perioperative MI ?
the appearance of new Q waves on the ECG, but non Q wave perioperative MI may occur & may be significant clinically different treshold for identifying a myocardial infarct CKMB level: > 2 times ULN > 3 times ULN > 5-10 times ULN

Spontaneous MI Coronary artery interventions Bypass surgery

MI redefined 2000

Troponin T 3 ug/L
Holmvang L, Chest 2002; 121.

aggressive treatment to reduce myocardial oxygen demand and maintain perfussion pressure is essential to lower the risk of perioperative MI

In operation room: If myocardial ischemia/ dysfunction is noted reevaluated suplemental grafts/ graft revision IABP

In ICU If ECG changes upon arrival in the ICU IV nitroglycerin / calcium channel blockers IABP graft revision optimized cardiac output avoid excessive volume infusions

Repeat angiography shortly after CABG :

new localized changes in ST segment CKMB > 80 u/L new Q waves in the ECG recurrent/sustained ventricular tachyarrhythmia VF hemodynamic deterioration with LV failure despite inotropic support
Holmvang L, Chest 2002;121.

Preoperative Period: Risk vs Benefit 1. Establish the indication 2. Assess perioperative risk 3. Assess expected long-term outcome
ACC/AHA Guideline for CABG

Perioperative Period: Steps to Reduce Risks

Potential Complication Low-output syndrome Steps to Consider in Certain Cohorts blood cardioplegia for acute ischemia/ LV dysfunction prophylactic intra-aortic balloon pump delay if acute right ventricular MI Beta-blockers or alternate consider discontinuing aspirin autodonation of blood

Postoperative arrhythmias Bleeding and transfusion risk

Predisposing factors :

LM or 3 VD UAP ( especially following a failed PTCA ) poor LV function ( LVEDP > 15 mmHg, low EF ) LVH coronary endarterectomy long aortic crossclamp period

Consideration before concluding perioperatif MI

new Q wave are noted in 5% patient after surgery 20% of newQ wave are considered to be false positive CKMB is unreliable determinant of perioperative infarction. ( CKMB can be elevated over 100 u/cc by trauma, reperfusion injury, reperfusion VF ) new regional /wall movement abnormality is more consistent with the perioperative MI

MECHANISM of PERIOPERATIVE MI

undetected preoperative myocardial necrosis prolonged ischemia inadequate myocardial protection reperfusion injury following cardioplegic arrest incomplete revascularization anastomotic stenosis graft thrombosis intracoronary air embolism

Prognosis :

uncomplicated infarction no influence on op. mortality / long term survival hemodinamically significant MI >> mortality determined by adeqacy of revascularization & residual EF prognosis of MI with EF > 40% and complete revascularization = no periop. MI
Force T, Circulation 1990; 82 : 903-12