Role of cardiac surgery in the hospital phase management of patients treated with primary angioplasty for acute myocardial infarction

Although cardiac surgery is performed in similar to 10% of acute myocardial infarction (AMI) patients undergoing a primary percutaneous transluminal c oronary angioplasty (PTCA) reperfusion strategy before discharge, the indic ations for and timing of operative revascularization, and the short- and lo ng-term outcomes after surgery have not been characterized. In the prospect ive, controlled Primary Angioplasty in Myocardial Infarction-2 trial, cardi ac catheterization was performed in 1,100 patients within 12 hours of onset of AMI at 34 centers, followed by primary PTCA when appropriate, Cardiac s urgery was performed before hospital discharge in 120 patients (10.9%), ele ctively in 42.6%, and on an urgent or emergent basis in 57.4%, Surgery was performed in 6.1% of 982 patients after primary PTCA (although emergently f or failed PTCA in only 4 cases [0.4%]), and in 53 of 118 patients (44.9%) n ot undergoing primary PTCA, Patients requiring surgery were older, and more frequently had diabetes and 3-vessel disease than those managed nonoperati vely. Internal mammary artery grafts were placed in only 31% of patients. I n-hospital mortality was 6.4% in patients undergoing urgent/emergent surger y, 2.0% after elective surgery, and 2.6% in patients not undergoing surgery (p = NS), After multivariate correction for baseline risk factors, early a nd late survival free of reinfarction were similar in patients undergoing v ersus not undergoing in-hospital cardiac surgery. Thus, the appropriate use of coronary artery bypass graft surgery in the peri-infarction period is a n integral component of the primary PTCA approach, and is frequently used t o optimize the prognosis of a highrisk AMI cohort with unfavorable baseline features. The implications for the performance of primary PTCA in AMI at c enters without on-site surgical facilities are discussed. (C) 2000 by Excer pta Medica, Inc.