Myocardial infarction after cardiac surgery: When to intervene?

Central MessageSuspicion of myocardial ischemia right after cardiac surgery requires prompt clinical evaluation and transfer to the catheterization laboratory or operating room, if deemed necessary.See Commentaries on pages 1202 1203.Feature Editor's Introduction—Diagnosing infarction following can be challenging. Hospitals have different activation protocols when is suspected, which ultimately aim preserve myocardium from further cellular loss by timely restoration coronary blood flow. Individual signs such as physical examination, biomarkers, electrocardiographic changes are rather nonspecific common often perioperative teams unsure about appropriate management. This Invited Expert Opinion article Dangas colleagues explores underlying etiologies, evaluation, management strategies postoperative surgery. The authors focus 2 specific etiologies for (coronary artery bypass graft failure injury during valvular surgery), they center their in-depth discussion assessment these serious adverse events.Mariya Geube, MD Suspicion necessary. See 1203. Over past decades, (CS) has undergone a rapid remarkable development that significantly decreased complications improved surgical outcomes. Nonetheless, (MI) remains an important complication. actual incidence MI varies across studies (2%-10%) highly dependent definition used (ie, Third Universal Definition MI, Fourth Society Cardiovascular Angiography Intervention definition, etc).1Thielmann M. Sharma V. Al-Attar N. Bulluck H. Bisleri G. Bunge J.J.H. et al.ESC joint working groups cardiovascular biology heart position paper: peri-operative in patients undergoing surgery.Eur Heart J. 2017; 38: 2392-2407Crossref PubMed Scopus (98) Google Scholar,2Thygesen K. Alpert J.S. Jaffe A.S. Chaitman B.R. Bax J.J. Morrow D.A. al.Fourth universal (2018).J Am Coll Cardiol. 2018; 72: 2231-2264Crossref (1825) Scholar Whereas criteria nonprocedure-related well defined, reaching consensus single procedure-related been challenging.2Thygesen As rarely capable reporting classic ischemic symptoms shortly CS, clinicians intensive care (ICU) step-down units rely mostly diagnostic tests establish diagnosis MI. In addition, high-level evidence-driven guidance lacking, most findings based observational expert documents (rather than any randomized study). Therefore, context CS topic ongoing debate. Hereafter, we provide setting mainly valve surgeries. Although post-CS aforementioned operations, overall approach similar. Various factors lead CS. Many them related extent tissue damage, potential injury, technical aspects inclusive cardioplegia applied.3Whittaker A. Aboughdir Mahbub S. Ahmed Harky Myocardial protection surgery: how limited options? A comprehensive literature review.Perfusion. 2021; 36: 338-351Crossref (13) this review, Graft dysfunction complex phenomenon may occur early period. harvesting approaches, vessel selection venous vs arterial), myocardial-preservation solutions normal saline, heparinized blood, crystalloid solution, etc.), anastomosis techniques all play role determining outcome. usually due thrombotic occlusion, anastomotic stenosis, kinking, overstretching, vasoconstriction. Radial conduits particularly prone spasm adrenergic receptors' dominance vascular smooth muscle endothelial nitric oxide synthase expression. Moreover, vasopressor use extend several days ICU/step-down unit affect flow (CABG) Another essential factor consider used, on-pump off-pump bypass. Several reveal greater patency more complete revascularization bypass.4Alberti K.G.M.M. Eckel R.H. Grundy S.M. Zimmet P.Z. Cleeman J.I. Donato K.A. al.Harmonizing metabolic syndrome: interim statement International Diabetes Federation task force epidemiology prevention; National Heart, Lung, Blood Institute; American Association; World Federation; Atherosclerosis Society; Association Study Obesity.Circulation. 2009; 120: 1640-1645Crossref (10478) However, surgeon experience, conduit selection, anticoagulation allow safe selected patients.5Lamy Devereaux P.J. Prabhakaran D. Taggart D.P. Hu Paolasso E. al.Off-pump coronary-artery grafting at 30 days.N Engl J Med. 2012; 366: 1489-1497Crossref (549) Scholar,6Puskas J.D. Williams W.H. Mahoney E.M. Huber P.R. Block P.C. Duke P.G. conventional grafting: 1-year patency, cost, quality-of-life outcomes: trial.JAMA. 2004; 291: 1841-1849Crossref (491) Coronary stenosis/occlusion resulting acute rare but well-reported complication surgery.7Coutinho G.F. Leite F. Antunes M.J. Circumflex mitral repair: not known, perhaps so infrequent-lessons learned 6-case experience.J Thorac Cardiovasc Surg. 154: 1613-1620Abstract Full Text PDF (23) mechanisms numerous distortion, twisting, laceration artery), stitch placement. For example, stenosis left circumflex artery, especially left-dominant circulation, occurs repair its proximity annulus where suture fixed. 5 mm less (Figure 1) frequently visualized advanced intraoperative echocardiography. setting, significant hemodynamic compromise. Similarly, injured occluded tricuspid with both ring annuloplasty. closely approximates annulus, cavotricuspid isthmus lower atrium 2). thorough understanding anatomic relationship between anatomy critical minimizing types CS.8Caruso Sabry Birdi I. Dramatic resolution immediate distortion surgery.J Card 2020; 35: 1135-1137Crossref (2) ScholarFigure 2Tricuspid (RCA). encircled area (in red) represents region closest annulus. APc, Anteroposterior commissure; AL, anterior leaflet; PL, posterior ASc, anteroseptal SL, septal PSc, posteroseptal commissure.Figure adapted Calafiore AM, Iacò Bartoloni G, Di Mauro Right occlusion band 2009;138:1443-4.View Large Image Figure ViewerDownload Hi-res image Download (PPT) An uncommon cause ostial combined valve–graft replacement aortic root (also known Bentall procedure). Extrinsic compression replanted neo-ostium result subsequent Cabrol grafts proximal main arteries another option allows perfusion very high plane relative valve, thereby facilitating future procedures also avoiding stretching/kinking native arteries.9Cabrol C. Pavie Gandjbakhch Villemot J.P. Guiraudon Laughlin L. al.Complete ascending aorta reimplantation arteries: new approach.J 1981; 81: 309-315Abstract Common symptoms, angina shortness breath, typically evaluable intubated sedated ICU. patient's status should serve starting point suspected. Whenever possible, invasive monitoring pulmonary catheter considered, increased filling pressures suggestive Other Swan-Ganz (Edwards Lifesciences, Irvine, Calif)–derived data, output measurement, indicate viable impairment global function. interpreted caution, given many coexisting conditions. persistent hypotension requiring vasopressors vasoplegia induced prolonged cardiopulmonary cardiogenic shock exacerbated reduced preload anesthetic medications. elevated lactate levels ICU represent oxygen supply–consumption mismatch impaired clearance. secondary hypoxemia, hyperglycolysis, hypovolemia, anemia, liver injury) ischemia.10O'Connor Fraser interpretation abnormalities surgery.Anaesth Intensive Care. 40: 598-603Crossref Cardiac biomarkers detecting become diagnosing elevation cTn finding direct myocardium. result, identifying clinically increases necessitate investigation According type CABG-related MI) defined level increase least 10 times 99th percentile upper reference limit baseline values.2Thygesen those whom stable decreasing, postprocedure must 20%. absolute postprocedural value still limit. Creatine kinase isoenzyme makes steeper upstroke/decline over 24 hours (than curve) therefore easier assess re-elevation. no cut-off values established, mentioned could taken evaluating patients.11Cubero-Gallego Lorenzo Heredia Gómez Tamayo Diagnosis high-sensitivity troponin T electrocardiogram echocardiogram changes.J 895-903Abstract (15) conditions met, (ECG) noninvasive imaging parallel sensitivity specificity Prolonged isolated unaccompanied findings, indicates reperfusion amenable management.1Thielmann additional testing patient condition. All ECG followed serial tracings. While frequent associated ischemia, benign. ST-segment T-wave because pericardial epicardial thus indicators postoperatively. patterns, reciprocal ST-depression, reliable require echocardiography) before transferring back room.2Thygesen contrast, pathologic Q waves coupled rise (not necessarily limit) strongest evidence prompts angiographic rule out occlusion.2Thygesen appearance bundle branch block (LBBB) strong marker event. surgery, recommend LBBB commonly develops surgery.12Généreux P. Piazza Alu M.C. Nazif T. Hahn R.T. al.VARC-3 Writing CommitteeValve academic research consortium 3: updated endpoint definitions research.Eur 42: 1825-1857Crossref (202) Ventricular arrhythmias electrolyte abnormalities, catecholaminergic medications, scar tissue, ventricular tachycardia/ventricular fibrillation, priority urgent resuscitation, including defibrillation correction reversible causes arrhythmia hyperkalemia, hypomagnesemia, acidosis). gravity instability coexist. Echocardiography powerful tool enables function detection caused regional ischemia. It performed results biomarker inconclusive, occurrence cases. Regional wall motion detected echocardiography correlation territory. They depict decreases amplitude rate contractility, thickening local remodeling. alone do previous infarction, myocarditis, LBBB, cardiomyopathy. pacing, inflammation, stunning, hibernation post-CS.1Thielmann To localize quantify infarct, contrast recommended it enhances visualization segments perfused grafts.13Cerqueira M.D. Weissman N.J. Dilsizian Jacobs A.K. Kaul Laskey W.K. al.Standardized segmentation nomenclature tomographic heart: healthcare professionals committee council cardiology Association.Circulation. 2002; 105: 539-542Crossref (5450) Notwithstanding, echocardiographic biventricular dysfunction, without variation, detected. Such observations multiple large territories. attributed other surgery-related physiologic occlusion. decision intervene under among teams, maintenance vital utmost importance. suspected delivery optimized increasing supply decreasing demand. supplemental reduce mortality supplied 90% saturation. pressure maintained ahead consideration unloading support device; tachycardia minimized sympathetic stimulation providing analgesia. Review bedside done nonischemic considering percutaneous intervention 3). absence besides increases, watchful waiting repeated measures re-evaluation electrocardiography preferred whenever shows improvement parameters. Conversely, suspicion intertwined factors, options possible: room re-exploration clear workup angiography. former mandatory hemorrhagic emergencies severe compromise despite measures. permits, warranted. angiography gold standard (whether implementation optimal corrective injury. bedside, laboratory, difficult dangerous critically ill patients. risk contrast-associated nephropathy weighed against benefits procedure.14Mehran R. G.D. Weisbord S.D. Contrast-associated kidney injury.N 2019; 380: 2146-2155Crossref (289) Following angiography, indication repeat undergo (PCI) stenting.15Alqahtani Ziada K.M. Badhwar Sandhu Rihal C.S. Alkhouli Incidence, predictors, outcomes in-hospital grafting.J 73: 415-423Crossref Besides logistical reasons faster perform while already laboratory), optimal, since who develop high-risk candidates Long-term prognosis dramatic guarded regardless treatment approaches.16Parasca C.A. Head S.J. Milojevic Mack Serruys P.W. Morice M.-C. al.Incidence, characteristics, SYNTAX trial years.JACC Interv. 2016; 9: 2493-2507Crossref (72) case failure, PCI first considered vessels supplying grafts.17Levine G.N. Bates E.R. Blankenship J.C. Bailey S.R. Bittl J.A. Cercek B. al.2011 ACCF/AHA/SCAI guideline intervention: report College Cardiology Foundation/American practice guidelines Interventions.J 2011; 58: e44-e122Crossref (1988) When postoperatively, valid arterial kinking noted total extrinsic obstruction, emergent reoperation preferred. procedure, managed reintervention identify mechanical obstruction reposition button grafting. Shared decision-making involving intensivists, surgeons, interventional cardiologists paramount importance evaluations decisions. Antithrombotic therapy initiated bleeding acceptable medical team. Assessment individual basis accounting various factors: old age, low body mass index, active primarily through chest tubes pericardium), major bleeding, volumes salvaged cells transfused, anastomoses, hepatic (international normalized ratio >1.5), renal (creatinine clearance <30 mL/min), thrombocytopenia, uncontrolled systemic hypertension.18Vuylsteke Pagel Gerrard Reddy Nashef Aldam al.The Papworth score: stratification scheme excessive bleeding.Eur Cardiothorac 39: 924-930Crossref (106) antithrombotic strategy beyond scope paper; nonetheless, entire team ICU, doctors detailed key available (Table able select beneficial flexible tenuous period post-CS. summarize, oral antiplatelet consisting aspirin P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) CABG yet swallow absorb bridging heparin vitamin K antagonist being (again few delay, previously). time initiation agents influence whether (surgical percutaneous). If likelihood event high, avoid lethal complications. certain circumstances, only option, risks outweigh risks. agent administered, risk. agents, inhibitors heparin, avoided until established. intravenous infusion reversal hemorrhage.Table 1Pharmacologic considerations agentsRouteMechanism actionTime onsetHalf-lifeActivity delayed MI/shockTime effect reversalReversible activity?AspirinOralPlatelet COX-1 enzyme inhibitor20 min (when chewed)20 (3-10 hours—dose-dependent metabolite)Yes4 dYesClopidogrelOralPlatelet receptor inhibitor2 h30 min∗Half-life metabolite.Yes5 dYesTicagrelorOralPlatelet inhibitor30 min-1 h9 h∗Half-life metabolite.Yes4-5 dNoPrasugrelOralPlatelet min7 metabolite.Yes5-9 dYesCangrelorIntravenousPlatelet min3-6 minNo30 min–1 hourN/A†Reversal platelet transfusion insignificant action drug discontinuation.EptifibatideIntravenousPlatelet GP IIb/IIIa inhibitor<1 h2.5 hNo3-4 hNoTirofibanIntravenousPlatelet min2.5 hNo4-8 hNoUnfractionated heparin‡Many compounds variable molecular chains included formulations.IntravenousBlocks thrombin generation activity2-4 h‡Many formulations.30 min-2 formulations.No (inactive clot-bound thrombin)2-4 formulations.YesBivalirudinIntravenousDirect inhibitorImmediate30 minNo1.5 hNoThe pharmacokinetic/pharmacodynamic data vary commercial formulations each drug. infarction; N/A, available.∗ Half-life metabolite.† Reversal discontinuation.‡ formulations. Open table tab available. Gastrointestinal narrow administration.19Chaudhry Zaki Wegner Pednekar Tse Sheinbaum al.Gastrointestinal nationwide population-based analysis morbidity predictors.J Vasc Anesth. 31: 1268-1274Abstract (43) Indeed, anticoagulant intraoperatively formulation. Cangrelor, potent onset fast body, useful population. drug's unique pharmacokinetic properties offer advantages tube drain, fresh wound, etc) inability reverse latter options. Improvements last decades resulted increasingly diseases. manage guidelines. Clinical focused ECG, warranted decide proceed reoperation. Additional needed investigate utility technologies assays