Predictors of perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Background Perioperative myocardial infarction (PMI) increases morbidity and mortality after off-pump coronary artery bypass grafting (CABG). The objective of the current study was to characterize patients with PMI after off-pump CABG and identify its predictors. Results We included 1181 patients who had off-pump CABG from 2010 to 2020; 59 patients (5%) had PMI. We compared patients with PMI to those without PMI. Patients with PMI were older (57 (25th–75th percentiles: 51–63) vs. 54 (48–60) years; P = 0.01) and had higher NYHA class (28 (47.46%) vs. 326 (29.06%): P = 0.01). The distal anastomosis time was longer in patients with PMI (28 (23–35) vs. 24 (16–30) min; P ˂ 0.001). Patients with PMI had higher postoperative low cardiac output (10 (18.18%) vs. 1 (0.1%): P ˂ 0.001), prolonged ventilation (12 (8–39) vs. 8 (6–10) h, P ˂ 0.001), ICU (71 (46–138) vs. 24 (23–42) h; P ˂ 0.001), and hospital stay (9 (6–15) vs. 7 (6–8) days; P ˂ 0.001). Mortality was significantly higher in patients with PMI (20 (33.9%) vs. 6 (0.53%); P ˂ 0.001). Older age (OR: 1.05 (95% CI: 1.01–1.1); P = 0.02), increased number of distal anastomoses (OR: 1.74 (95% CI: 1.20–2.50); P = 0.003), preoperative congestive heart failure (OR: 10.27 (95% CI: 2.58–40.95); P = 0.001), and thrombolysis within 24 h of surgery (OR: 15.34 (1.93–121.9); P = 0.01) were associated with increased PMI, while PMI was lower in male patients (OR: 0.42 (95% CI: 0.19–0.93); P = 0.03) and with higher body surface area (BSA) (OR: 0.08 (95% CI: 0.07–0.86); P = 0.04). Conclusions Post-off-pump CABG PMI was associated with increased morbidity and mortality. Risk factors for PMI were older age, lower BSA, females, increased distal anastomoses, preoperative heart failure, and thrombolysis.

Myocardial Infarction Complications After Surgery in Vietnam: Estimates of Incremental Cost, Readmission Risk, and Length of Hospital Stay

Myocardial infarction is a considerable burden on public health. However, there is a lack of information about its economic impact on both the individual and national levels. This study aims to estimate the incremental cost, readmission risk, and length of hospital stay due to myocardial infarction as a post-operative complication. We used data from a standardized national system managed by the Vietnam Social Insurance database. The original sample size was 1,241,893 surgical patients who had undergone one of seven types of surgery. A propensity score matching method was applied to create a matched sample for cost analysis. A generalized linear model was used to estimate direct treatment costs, the length of stay, and the effect of the complication on the readmission of surgical patients. Myocardial infarction occurs most frequently after vascular surgery. Patients with a myocardial infarction complication were more likely to experience readmission within 30 and 90 days, with an OR of 3.45 (95%CI: 2.92–4.08) and 4.39 (95%CI: 3.78–5.10), respectively. The increments of total costs at 30 and 90 days due to post-operative myocardial infarction were 4,490.9 USD (95%CI: 3882.3–5099.5) and 4,724.6 USD (95%CI: 4111.5–5337.8) per case, while the increases in length of stay were 4.9 (95%CI: 3.6–6.2) and 5.7 (95%CI: 4.2–7.2) per case, respectively. Perioperative myocardial infarction contributes significantly to medical costs for the individual and the national economy. Patients with perioperative myocardial infarction are more likely to be readmitted and face a longer treatment duration.

Cardiovascular Imaging Following Perioperative Myocardial Infarction/Injury

Background: Patients developing perioperative myocardial infarction/injury(PMI) have high mortality. PMI work-up and therapy remain poorly defined.Methods: In a prospective multicenter study enrolling high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program, the frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction(T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/ cardiologist on service, who determined selection/timing of cardiovascular imaging. In transthoracic echocardiography(TTE) a new wall motion abnormality within 30days, in myocardial perfusion imaging(MPI) a new scar or ischemia within 90days, and in coronary angiography(CA) Ambrose-Type II or complex lesions within 7days of PMI detection were considered indicative of T1MI. Results: In patients with PMI, 21%(268/1269) underwent at least one cardiac imaging modality. TTE was used in 13%(163/1269), MPI in 3%(37/1269), and CA in 5%(68/1269). Consultation by a cardiologist, was associated with higher use of cardiaovascular imaging(27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and in 63% of CA. Conclusion: Most patients with PMI did not receive any cardiovascular imaging within their PMI work-up. If performed, MPI and CA have high yield for signs indicative of T1MI. Study registration: https://clinicaltrials.gov/ct2/show/NCT02573532

Coronary endarterectomy in myocardial revascularization

Aim. To compare the immediate outcomes of combined coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) and isolated CABG.Material and methods. This retrospective study included 192 patients with stable angina who underwent myocardial revascularization in the period from January 2016 to August 2018. The patients were divided into 2 groups. Group 1 included patients who underwent combined CABG and CE, while group 2 — patients who underwent isolated CABG. Patients in both groups did not differ in the main preoperative characteristics, with the exception of the incidence of obesity and right coronary artery disease.Results. In-hospital mortality in group 1 was 2,2% (n=2), in group 2 — 2% (n=2). The incidence of perioperative myocardial infarction in group 1 was 1% (n=1) and in group 2 — 0%. There were no significant differences between groups in the following postoperative parameters: in-hospital mortality, perioperative myocardial infarction, need and duration of inotropic support, duration of mechanical ventilation (MV) and need for long-term mechanical ventilation, stroke, arrhythmias, resternotomy for bleeding. In group 1, encephalopathy (11,8%) and respiratory failure (12,9%) were significantly more common.Conclusion. Combined CABG and CE is a safe technique for achieving complete myocardial revascularization in diffuse coronary artery disease, since, in comparison with isolated CABG, there is no increase in the incidence of death and perioperative myocardial infarction. However, in this category of patients, an increase in the incidence of non-lethal, non-disabling cerebral and pulmonary complications should be expected.

Obstructive Sleep Apnea Increases the Risk of Perioperative Myocardial Infarction Following Off-Pump Coronary Artery Bypass Grafting

Background and Aims: The impact of obstructive sleep apnea (OSA) on perioperative myocardial infarction (PMI) following coronary artery bypass grafting (CABG) remains unclear. Off-pump CABG (OPCABG) has become a common practice for CABG in China. The present study investigated mainly the correlation between OSA and PMI following OPCABG.Methods: In this prospective observational single-center study, consecutive eligible patients listed for elective OPCABG underwent cardiorespiratory polygraphy before surgery between January 2019 and June 2020. OSA was defined as an apnea-hypopnea index (AHI) ≥15 events/h. The primary end point was perioperative myocardial infarction (PMI) following OPCABG (type 5 MI).Results: Patients with OSA accounted for 42.2% (62/147) of the cohort. Twenty-four patients (16.3%) met the protocol criteria for PMI: 17 (27.4%) in the OSA group and 7 (8.2%) in the non-OSA group (P = 0.002). Multivariate logistic regression analysis revealed that AHI (OR = 1.115, 95% CI 1.066 to 1.166, P < 0.001), high-sensitivity c-reactive protein (hs-CRP) (OR = 1.080, 95% CI 1.025 to 1.138, P = 0.004), and SYNTAX score (OR = 1.098, 95% CI 1.056 to 1.141, P < 0.001) were associated with PMI incidence. Furthermore, ROC analysis revealed that the AHI (AUC = 0.766, 95% CI 0.689 to 0.832, P < 0.001) and SYNTAX score (AUC = 0.789, 95% CI 0.715 to 0.852, P < 0.001) had predictive value for PMI. In addition, multiple linear regression analysis showed that the AHI was an independent influencing factor of hs-CRP (B = 0.176, 95% CI 0.090 to 0.263, P < 0.001) and the SYNTAX score (B = 0.553, 95% CI 0.397 to 0.709, P < 0.001).Conclusions: OSA was independently associated with a higher incidence of PMI following OPCABG, and the formation of severe coronary atherosclerotic lesions aggravated by an enhanced inflammatory response might be the potential mechanism. The efficacy of CPAP treatment for improving prognosis after CABG remains to be further investigated.