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Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention.

ABSTRACT: Background:Coronary ostial stenosis is an uncommon but potentially lethal complication following aortic root replacement with or without aortic valve replacement (including Bentall and David procedures). This manifests clinically as acute myocardial ischaemia in the early or late post-operative period. Traditionally, this might be managed with redo open-heart surgery. Case summary:This case series describes two presentations where urgent percutaneous coronary intervention was used to manage myocardial infarction complicating aortic root surgery with coronary reimplantation. Discussion:This series highlights the risk of acute myocardial infarction after cardiac surgery involving coronary reimplantation. Emergency percutaneous coronary intervention is feasible and illustrates the importance of shared post-operative care involving the cardiac surgeons and the cardiology team.

SUBMITTER: Adamson C

PROVIDER: S-EPMC7042144 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention.

Adamson Carly C Rocchiccioli Paul P Brogan Richard R Berry Colin C Ford Thomas J TJ

European heart journal. Case reports 20191022 4

<h4>Background</h4>Coronary ostial stenosis is an uncommon but potentially lethal complication following aortic root replacement with or without aortic valve replacement (including Bentall and David procedures). This manifests clinically as acute myocardial ischaemia in the early or late post-operative period. Traditionally, this might be managed with redo open-heart surgery.<h4>Case summary</h4>This case series describes two presentations where urgent percutaneous coronary intervention was used ...[more]

PMID: 32123801

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Project description:Preinfarction angina may act as a clinical surrogate of ischemic preconditioning that may reduce infarct size and improve mortality in the setting of thrombolytic therapy for ST-elevation myocardial infarction. However, the benefits of preinfarction angina in the setting of primary percutaneous coronary intervention with stenting is inconclusive because of the greater achievement of infarct artery patency and speed of reperfusion.To identify a homogeneous population, we performed a retrospective analysis of 1031 patients admitted with a first ST-elevation myocardial infarction with ischemic times between 1 and 6 hours who received primary percutaneous coronary intervention. We identified 245 patients who had occluded arteries on presentation, of which 79 patients had documented preinfarction angina defined as chest pain within 24 hours of infarction. Infarct size was measured as the peak creatine kinase level, a metric supported in a subgroup by late enhancement on cardiac magnetic resonance imaging. Patients with preinfarction angina (n=79) had a 50% reduction in infarct size compared with those patients without preinfarction angina (n=166) by both peak creatine kinase (1094±75 IU/L versus 2270±102 IU/L; P<0.0001) and creatine kinase area under curve (18 420±18 941 versus 36 810±21 741 IU/h per liter; P<0.0001) despite having identical ischemic times (185±8 minutes versus 181±5 minutes; P=0.67) and angiographic area at risk (24.1±1.2% versus 25.3±0.9%; P=0.43). There was an absolute 4% improvement in left ventricular ejection fraction before discharge in those patients with preinfarction angina (P<0.02).The occurrence of preinfarction angina is associated with significant myocardial protection in the setting of primary percutaneous coronary intervention with stenting during ST-elevation myocardial infarction. Because preinfarction angina is relatively common, it is important that these patients be identified in clinical trials investigating therapies designed to reduce reperfusion injury and infarct size.

Project description:BACKGROUND:Patients with ST elevation myocardial infarction have traditionally been hospitalized for five to seven days to monitor for serious complications such as heart failure, arrhythmias, reinfarction and death. The Zwolle primary percutaneous coronary intervention (PCI) index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h. METHODS:The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between April 2004 and February 2006 at a large Canadian teaching hospital. The goal was to characterize length of stay (LOS) in low-risk patients and to identify variables that correlate with patients who were hospitalized longer than expected. RESULTS:Data were collected on 255 patients. The mean LOS was 7.2+/-7.7 days (median 5.0 days [interquartile range 3.5 days]). A total of 179 patients (70%) had a Zwolle score of 3 or lower, identifying them as low risk. There was one death in the low-risk group (0.6% 30-day mortality) and 15 deaths in the higher-risk group (19.7% 30-day mortality), validating the Zwolle score in the population. A contraindication to early discharge was identified in 34 of the low-risk patients. Among the 144 remaining low-risk patients, the mean LOS was 5.1+/-3.3 days (median 4.0 days [interquartile range 3.0 days]). Only 8% were discharged within 48 h and only 28% within 72 h. It was determined that fewer patients were discharged on weekends and Wednesdays (when medical residents were away for teaching) than on other weekdays. LOS was longer among patients who were discharged on warfarin (7.6 days versus 4.6 days, P=0.006), and among patients who were transferred back to their presenting hospital rather than being discharged directly from the hospital where PCI was performed (5.6 days versus 4.0 days, P<0.001). CONCLUSIONS:Seventy-two per cent of low-risk primary PCI patients were hospitalized longer than 72 h. The following three factors were identified as correlating with prolonged LOS in this population: fewer discharges on days when there was less resident staffing; the use of warfarin at discharge; and transfer of patients back to their presenting hospital rather than discharging them directly from the PCI-performing hospital. A programmed approach to the identification and early discharge of low-risk patients could have significant cost savings and should be investigated prospectively.

Dataset Information

Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention.

Publications

Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention.

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