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
PTCA on LAD with good result.
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
12/3/96
28/3/96

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.
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
17/4/02

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

: 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

Pra op

21.29

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

astrup = metab. acidosis partly compensated

00.30 :

00.56

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

ECG showed ST elevation on anterior leads

: 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

Mortality
Score

Total
Score

Mortality
%

Age 60-69

0.4

Age 70-79

0.5

Age > 80

0.7

Female sex

1.5

0.9

EF<40%

1.5

1.3

Urgent surgery

1.7

Emergency surgery

2.2

Prior CABG

3.3

PVD

3.9

6.1

10

7.7

1.5

11

10.6

Obesity (BMI 31-36)

12

13.7

Severe obesity ( BMI > 37 )

13

17.7

Total Score

14

> 28.3

Diabetes
Dialysis or creatinin > 2
COPD

ACC/AHA
Guideline
for CABG

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 :

OP-CABG

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

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

Steps to Consider in Certain Cohorts

Low-output
syndrome

blood cardioplegia for acute ischemia/

LV dysfunction
prophylactic intra-aortic balloon
pump
delay if acute right ventricular MI

Postoperative
arrhythmias

Beta-blockers or alternate

Bleeding and
transfusion risk

consider discontinuing aspirin

autodonation of blood

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