post CABG Myocardial Infarction : Latest Diagnostic and Therapeutic Approach
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Transcript of post CABG Myocardial Infarction : Latest Diagnostic and Therapeutic Approach
POST CABG MYOCARDIAL INFARCTION : LATEST
DIAGNOSTIC AND THERAPEUTIC APPROACH
Susana G. Garcia MD
NO DISCLOSURE
Objectives Review the current definition, risk factors,
clinical impact and incidence of PMI Describe the different clinical
presentation of PMI and how this dictate the goal and approach to diagnosis and treatment of PMI
Describe the use and limitation of different diagnostic tools in the evaluation of perioperative ischemia and infarction
Present current data on novel diagnostic tools and therapies used in PMI
Objectives Present algorithmic approach to post
CABG patients with signs of ongoing ischemia
Discuss the recent guideline on: Resuscitation of cardiac arrest after cardiac
surgery Mechanical Circulatory Support Mgt of Early Graft Failure
Universal Definition of Perioperative Myocardial
Infarction“ an increase in biomarker values to > 5x the
URL during the first 72 h ff CABG, when associated with:
the appearance of new pathological Q-waves or new LBBB or
angiographically documented new graft or native coronary artery occlusion
or imaging evidence of new loss of viable
myocardium”ESC-ACCF-AHA-WHF UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION
Pre-op Risk factors of PMI Age >70 years
(ESC) Female gender Renal Failure Diabetes Peripheral artery
disease Emergency CABG Repeat CABG Preop MI
Preop Ischemia Cardiomegaly Diastolic dysfunction Prior MI Use of nsaid No bb , no statin, no
asa Severe
LVdysfsn(EF<35%) or cardiogenic shock
Intraoperative Risk factors of PMI
Long CPB time CABG combined with other surgery Intraop ischemia Surgical technique Inadequate protection
Post-op Risk factors of PMI High Hct (Spiess B. D. et al.; J Thorac Cardiovasc Surg
1998;116:460-46) Rapid arrhythmias Hypertension Hypotension Tachycardia from
Volume depletion Blood loss Inotropes. Pressores Pain
Significance of PMI PMI is associated
with adverse outcome
Available data suggests a direct correlation between : the amount of
myonecrosis the likelihood of
reduced survival
Incidence of PMI Because of the wide variability in the
definitions used, the incidence of reported MI is highly variable
Incidence= of 2–40%
Diagnosis of PMI
is not straightforward
In the early period the critical issue is : to determine whether
there is acute severe ischemia/infarction due to Early Graft Failure Acute Native Coronary
Thrombosis that warrants urgent
intervention.
Subclinical Enzyme Leak
Persistent Signs of Ischemia --Hemodynamically Sable
Persistent Signs of Ischemia-- Hemodynamically Unstable
Cardiogenic Shock /Cardiac Arrest
Some degree of myocardial injury virtually always occurs after CABG
At one end of the spectrum, the myocardial injury is manifested as a small troponin release with no clinical sequelae Troponin release may be
from: Myocardial trauma Imperfect myocardial
protection
Diagnosis of PMI
Subclinical Enzyme Leak
Persistent Signs of Ischemia --Hemodynamically Sable
Persistent Signs of Ischemia-- Hemodynamically Unstable
Cardiogenic Shock /Cardiac Arrest
Diagnosis of PMI At the other end of the
spectrum, is severe myocardial ischemia or infarction that is associated with hypotension, LCOS and ventricular arrhythmias
This latter situation demands urgent investigation because it may represent an acute obstruction of a coronary graft or native coronary vessel
Timely intervention may be life saving
Initial Goal in theEvaluation of PMI To search for signs
of ischemia/infarction which may be due to Early Graft
Failure Acute Native
Coronary Thrombosis
that warrants urgent intervention.
Clinical Assessment of PMI Angina (not reliable):
Pain from myocardial ischemia is very difficult to distinguish from wound pain
Most are sedated and ventilated during the early post op period Cannot report symptoms
Hemodynamic Instability: Has many causes But one important to consider is ischemia
Clinical Assessment of PMI Hemodynamic Instability
Acute ischemia of severity sufficient to cause hypotension or low cardiac output state : implies a large region of threatened
myocardium warrants urgent intervention and treatment
Swan Ganz Catheter Measurements suggestive of LCOS
Increased in PA pressure Increased PCWP Low CO
Signs of Ongoing Ischemia
39 patients with post op suspicion of graft failure
ECG Diagnosis New significant Q waves
≥ 0.04 second duration in any two leads except III and aVR
may be indicative of full-thickness MI but they take 24 to 48 hours to
develop therefore not useful in the
assessment of suspected ischemia ST segment depression
≥ 1 mm, measured 0.06 sec after the J point
if it occurs, develops concurrently with myocardial ischemia.
ST segment elevation, with the subsequent new Q waves after CABG surgery may provide a useful marker of
acute ischemia.
ECG Diagnosis Diffuse upsloping ST elevation
Pericarditis do not mply ischemia.
New LBBB or AV block may indicate acute ischemia, but they too are common following cardiac
surgery. Recurrent Ventricular Tachycardia
strongly suggestive of severe acute ischemia.
ECG Diagnosis Despite the limitations of ECG analysis, the finding of ST segment depression or
elevation that is limited to a specific coronary territory + hemodynamic instability / ventricular
arrhythmias is strongly suggestive of acute ischemia.
Echocardiography All patients with suspected myocardial
ischemia after CABG surgery should undergo urgent echocardiograms
—preferably a transesophageal echocardiogram examination looking SWMAs
SWMAs are more sensitive and specific for myocardial
ischemia than ECG changes but they can be difficult to interpret in
postoperative patients.
Biochemical Markers Troponin I
a value > 20 μg/l is associated with prolonged hospital stay
indicative of early graft failure Salamonsen RF,. Clin Chem
2005; 51:40-46. Troponin T
a value > 1.58 μg/l at 18 to 24 hours after surgery is predictive of adverse outcome, including death.
Januzzi JL. J Am Coll Cardiol 2002; 39:1518-1523.
Biochemical Markers
A limitation of making judgments based on troponins is that peak levels occur at about 24 hours after an ischemic event
Troponin T peaks a little later than troponin I Thus, these markers are not ideal for the
evaluation of acute ischemia soon after surgery.
Biochemical Markers
CKMB is less sensitive and specific than the troponins takes nearly 24 hours to reach peak levels.
Myoglobin levels peak within 6 to 12 hours of ischemic injury but are poorly predictive of outcome.
Costa MA(ARTS trial). Circulation 2001; 104:2689-2693.
cTnI elevation after CABG discriminates patients: with graft-related PMI non-graft-related PMI without PMI
however, not earlier than 12 h after surgery. This detection window is far too long to enable
timely rescue strategies
New Biomarkers for Ischemia
Reported to detect ischemia within the first 30 minutes: Heart type fatty acid
binding protein(hFABP) Ischemia Modified
Albumin
May enable early intervention aimed at restoring myocardial flow
Interventions for Suspected Postoperative Myocardial Ischemia
Approach to Diagnosis and Treatment PMI
If ischemia is suspected on the basis of hemodynamic instability or ECG changes
urgent transesophageal
Hypotensive: / Signs of Ongoing Ischemia by ECG
TEE
Tamponade /Hemodynamic Deterioration +/- Ischemia
Re-exploration
:Revision of
Graft / Evacuation
of Clot or Hematoma; Ligation of Bleeders
No Tamponade: +Acute
IschemiaIntensify Tx of Spasm +
Optimize Filling
Pressure; Inotropic Support;
IABPNo responseUrgent Coron
ary Angiograph
y
PCI vs
Surgical
depending on anatomy
Initiate Mgt for Arrhythmia,Ischemia. LCOS
2010 ESC Guideline in Myocardial Revasc
Approach to Diagnosis and Treatment PMI
If ischemia is suspected on the basis of hemodynamic instability or ECG changes
urgent transesophageal
Hypotensive: / Signs of Ongoing Ischemia by ECG
TEE
Tamponade /Hemodynamic Deterioration +/- Ischemia
Re-exploration
:Revision of
Graft / Evacuation
of Clot or Hematoma; Ligation of Bleeders
No Tamponade: +Acute
IschemiaIntensify Tx of Spasm +
Optimize Filling
Pressure; Inotropic Support;
IABPNo responseUrgent Coron
ary Angiograph
y
PCI vs
Surgical
depending on anatomy
Initiate Mgt for Arrhythmia,Ischemia. LCOS
Management of MyocardialIschemia:
Class I Recommendations to reduce the risk of perioperative myocardial
ischemia and infarction, management targeted at optimizing the determinants of coronary arterial perfusion heart rate diastolic or mean arterial pressure, and right ventricular or LV end-diastolic pressure
is recommended (Level of Evidence: B)
2011 ACC AHA CABG Guideline
INTRAOPERATIVE EVALUATION OF
MYOCARDIAL ISCHEMIAIntraoperative TEE
PA CathECG
Intraoperative Graft Assessment
TEE vs PA Cath TEE : useful for evaluation
of LVEDA/LVEDV EF and CO LVEDP Valve Function PHTN Shunts Complications Ischemia ( New RWMA)
guide surgical therapy lead to
revison of failed conduit placement of additional grafts
not originally planned
Potentially superiority over Swan PCWP or PADP in assessment of LVEDP in the early post op period
Fontes ML, Bellows W, Ngo L, et al.
Assessment of ventricular function in critically ill patients: limitations of PAC
J Cardiothorac Vasc Anesth. 1999;13:521–7.
Live 3DTEE Time to minimal
regional volumes normal subject
synchronous in a heart failure
patient dispersed
Translational Research Volume 159, Number 3
New TEE Technologies for Detection of Ischemia
Doppler Tissue Imaging
Real Time 3D TEE Speckle Tracking
Cost effectiveness has not been determined
Too complex for routine use
Intraoperative Graft Assessment
Graft patency strongly influences early and late outcomes after CABG.
Transit Time Flow Measurement quantitative volume flow technique, cannot
define the degree of graft stenosis
Indocyanine Green Angiography
Diagnostic accuracy for detecting clinically significant graft failure
ICG > Transit-time US flow measurement.
LAD
LIMAAnastomosis
A randomized comparison of intraoperative ICG angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts Journal of Thoracic and Cardiovascular Surgery,Volume 132, Issue 3, September 2006, Pages 585-594Nimesh D. Desai
Indocyanine Green Angiography
High inter-rater reliability for graft patency between surgeons.
For graft stenosis >50% Sn=100% Sp=100%
LAD
LIMA Anastomosis
Desai JACC Vol 46, Issue 8, 18 Oct 2005, pp 1521-25
The Hybrid Suite
has the capability of serving both as: a complete surgical OR a cath laboratory.
It allows for routine completion
angiogram following CABG surgery
identifies abnormal grafts, providing the opportunity to revise them with PCI surgery before leaving the OR.
Semin Thorac Cardiovasc Surg 21:207-212
Is Routine intraoperative graft assessment safe?
Does it lead to a marked reduction in graft occlusion 1 year after CABG?
Yes
No
The Graft Imaging to Improve Patency (GRIIP) clinical trial resultsThe Journal of Thoracic and Cardiovascular Surgery, Volume 139, Issue 2, February 2010, Pages 294-301.e1 * Steve K. Singh, MD, MS
Subclinical Enzyme Leak
Persistent Signs of Ischemia --Hemodynamically Sable
✓✓Persistent Signs of Ischemia-- Hemodynamically Unstable
Cardiogenic Shock /Cardiac Arrest
Interventions for Suspected Postoperative Myocardial Ischemia
CARDIAC ARREST / SHOCK FROM PMI
2010 European Resuscitation Council Guideline: Cardiac Arrest Following
Cardiac Surgery Incidence 0.7-2.9% Potentially reversible If treated promptly has a high survival rate
54-79% Key to successful resuscitation
Early resternotomy esp if + tamponade (external chest compression
not effective)
Cardiac Arrest
Activate Surgical Team for Emergency Resternotomy
Resuscitation based on 2010 ACC AHA or ESC CPR Guideline following Cardiac
SurgeryHemodynamically UnstableEarly Resternotomy
+ Resumption of
CPB
Initial Stabilizati
onTEE: + tamponade
TEE :
No Tamponade+ new Ischemia
Coronary Angiography
PCI vs Resternotomy depending on findings
DURING WITNESSED ARREST OF POST CARDIAC SURGERY
PATIENTS, CAN I START CHEST COMPRESSION?
2010 ESC CPR Guideline: External chest compression should be
started immediately in all patients who collapse without a pulse
Correct reversible cause (K, volume, bleeding, O2, acidosis, ischemia)
During CPR… IABP changed to pressure trigger If unable to attain SBP of at least 80mmHg with
effective compression: may indicate tamponade Do early resternotomy
Witnessed and Monitored VF/VT Arrest
3 quick defibrillation
3 failed shocks
Emergency Resternotomy
Further defibrillation as indicated should be performed with internal paddles at 20 joules after
resternotomy
Amiodarone 300mg after 3rd failed defibrillation attempt (but don’t delay resternotomy)
“AN IRRITABLE MYOCARDIUM FF CABG IS CAUSED MOST
COMMONLY BY MYOCARDIAL ISCHEMIA
Correction of Ischemia, rather than giving
Amiodarone, is more likely to achieve myocardial
stability”
Emergency Resternotomy
An integral part of resuscitation after cardiac surgery
Improved survival and QOL are well documented with rapid sternotomy
Should be standard part of resuscitaton within 10 days after cardiac surgery
Reinstitution of Emergency CPB
Survival to discharge 32-56%when CPB is reinstituted in the ICU
Survival rates decline rapidly when procedure delayed for >24 hrs
Indications:correct surgical bleeding Repair graft occlusionRest myocardium
Cardiac Arrest
Activate Surgical Team for Emergency Resternotomy
Resuscitation based on 2010 ACC AHA or ESC CPR Guideline following Cardiac
SurgeryHemodynamically UnstableEarly Resternotomy
+ Resumption of
CPB
Graft Revision / Evacuation of
Effusion
Unstable
Hemodynamic Stability
Initial Stabilizati
onTEE: + tamponade
TEE :
No Tamponade/Hypovolemia+
Acute Ischemia
Coronary Angiography
PCI vs Resternotomy depending on findings
Persistent Cardiogenic Shock After Graft Revision
Optimal treatment demands the ff to prevent end organ failure and death: Hemodynamic support (improve systemic
perfusion) Pharmacologic Mechanical
Invasive hemodynamic monitoring Early Reperfusion
2010 ESC/EACTS Myocardial Revascularization Guideline2009 ACC/AHA Guideline focused update on Heart Failure
Mechanical Circulatory Support ECMO
Used for cardiac arrest refractory to standard resuscitation measures
9 case series have reported improved survival after cardiac surgery
Recommendation: “In post cardiac surgery patients who are refractory to standard resuscitation procedure, mechanical circulatory support ( ECMO and CPB) may be effective in improving outcome” (Class IIb,LOE B)
2010 AHA Guideline for CPR and ECC
Mechanical Circulatory Support IABP in Perioperative Myocardial
Dysfunction 2011 ACCF AHA CABG Guideline:
Class II a (LOE B) In the absence of severe PAD, the insertion of
IABP is reasonable to reduce mortality in CABG patients who are considered to be at high risk Undergoing reoperation LVEF<30% Left Main Disease
Cardiac Arrest Activate Surgical Team
for Emergency Resternotomy
Resuscitation based on 2010 ACC AHA or ESC CPR Guideline following Cardiac
SurgeryHemodynamically UnstableEarly Resternotomy
+ Resumption of
CPB
Graft Revision / Evacuation of
Effusion
Unstable
Consider ECMO
Hemodynamic Stability
Initial Stabilizati
onTEE: + tamponade
TEE :
No Tamponade/Hypovolemia+
Acute Ischemia
Coronary Angiography
PCI vs Resternotomy depending on findings
Asymptomatic Enzyme Leak
Usually have uneventful postoperative course but are at increased risk for adverse events
and should be kept in a highly monitored environment (ICU) during their early postoperative periods.
Prior to discharge to the ward, such patients should be medically optimized with: β blockers ACE inhibitors antiplatelet agents (aspirin ± clopidogrel), statins.
Asymptomatic Enzyme Leak
Prevention of Perioperative Myocardial Injury BB should not be stopped to avoid acute ischemia Avoid NSAIDS Resumption of ASA 6 hours post op Complete Revasc Arterial Grafting to LAD Graft flow measurement /evaluation (Class 1C)
Graft flow <20mL/min and PI >5 mandate graft revision
Volatile Anesthetics protective in the setting of myocardial ischemia and
reperfusion2010 ESC/ EACTS Myocardial Revasc Guideline
✓✓Subclinical Enzyme Leak
Persistent Signs of Ischemia --Hemodynamically Sable
✓✓Persistent Signs of Ischemia-- Hemodynamically Unstable
✓✓Cardiogenic Shock /Cardiac Arrest
Interventions for Suspected Postoperative Myocardial Ischemia
PERSISTENT SIGNS OF ISCHEMIA --HEMODYNAMICALLY SABLE
Mechanism Hemodynamically Stable PMI During CABG
Usually non-graft related Poor Myocardial Protection
Inadequate cardioplegic perfusion Coronary Air Incomplete revascularization Global Ischemic Reperfusion Injury (IRI) induced by:
Aortic cross-clamping and de-clamping SIRS from CPB Distal microembolization Surgical Manipulation of the Heart Genetic susceptibility to acute IRI
Sometimes Graft Related Suboptimal graft flow Spasm Failure
HEMODYNAMICALLY STABLE WITH ECG CHANGES
SUGGESTING ISCHEMIA OR PMIGoals:
1. Is there recent infarction?2. If yes, Risk stratification to
determine need for early vs conservative mgt • Cardiac Enzymes• ECG• Non-invasive Imaging• Role of MRI
Troponins T and I used to detect, characterize, and quantify
PMI during CABG surgery. Helps in risk stratification in
hemodynamically stable patients
Limitation of Current Diagnostic Screening for PMI
Electrocardiograms changes are difficult to interpret following surgery
unless there is the appearance of a new Q-wave MI
Echocardiography New RWMA
which represent myocardial stunning rather PMI To predict graft failure :Sn=20% Sp=25%
Myocardial nuclear scanning only detect obvious perfusion defects arising from
graft or native coronary artery occlusion will not detect diffuse PMI
Cardiac magnetic resonance imaging (MRI)
Can be used to detect new loss of viable myocardium post-CABG surgery
can therefore be used to detect peri-operative MI.
Delayed gadolinium contrast enhancement by cardiac MRI (DE-CMR) gold-standard imaging technique for visualizing
myocardial fibrosis or infarction.Can also characterize, and quantify
PMI.
CMRI: Mechanism of PMI provide clues to the underlying aetiology of
myocardial injury. three patterns of DE-MRI have been
described: (i) a transmural MI in a coronary artery territory:
early graft or native coronary artery occlusion (ii) a sub-endocardial MI:
distal coronary embolization (iii) diffuse patchy areas of myocardial necrosis:
acute global IRI or other causes.
Pegg TJ, et al. A randomized trial of on-pump beating heart and conventional cardioplegic arrest inCABG patients with impaired LV function using CMRI and biochemical markers. Circulation2008;118:2130–2138.
“Is the presence of MI on DE-CMR in patients undergoing CABG surgery associated with worse clinical outcomes?”
“the presence of ne PMI on CMR following either CABG or PCI
was associated with a 3.1-fold increase
MACE Reduced event free
survivalRahimi K et al Prognostic value of coronary revascularisation-related myocardial injury: a cardiac MRI study. Heart 2009;95:1937–1943.
Detection of PMI after CABG
Preoperative MRI scan in short axis plane in a 76yo DM patient with dyspnoea. underwent CABG for 3VD
Postoperative MRI short axis (B) Showed new inferior and infero-septal hyperenhancement (white
arrow). He died of heart failure 12 months after
Rahimi K et al Prognostic value of coronary revascularisation-related myocardial injury: a cardiac MRI study. Heart 2009;95:1937–1943.
AHA Scientific StatementSafety of MRI in Patients With
Cardiovascular Devices
“MR examination of patients with sternal wires is generally considered to be safe.”
Circulation. 2007; 116: 2878-2891 From the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovascular Radiology and Intervention:
Glenn N. Levine MD, FAHA;
AcadesineP - post CABG PMI
ptsI - Acadesine
infusion O - reduced
Severity of PMI from IRI
mortality rate after 2 yrs of ff up
M - RCTPost-Reperfusion MI Long-Term Survival ImprovementUsing Adenosine Regulation With AcadesineDennis T. Mangano, etal ,J Am Coll Cardiol 2006;48:206 –14
Hemodynamically Stable: with ECG changes suggest Ischemia or Infarct (new LBBB or Q wave)
Biomarker Rise >/= 5x the URL (use rapid assay point of care test)
TTE
Equivocal
Cardiac MR or
Nuclear MPICo
nfirms acute
global IRI
Consider Acadesine Infusion
confirms
early graft
or native coronary artery occlusion
Confirmed Ongoing Ischemia: New wall motion
abnormality with large
area of myocardium
at risk+ worse LV fxnCoronary
Angiography
PCI vs Resternotomy for graft
revision
depending on
findings
Biomarker Rise <5x the URL (use rapid assay, point of care test)
Repeat after 8 hours
Biomarker rise <5x URL
Repeat in 4 hours
Biomarker <5x URLMaximize Ischemic nd Post
MI Regimen:
+Early Antiplatel
et and Statin
Therapy
PCI VS SURGICAL REPAIR OF GRAFT
CLOSUREFactors to Consider
CABG >PCI Hemodynamically unstable Concomittant tamponade or bleeder Unsuitable Vessels for PCI (High Syntax
Score) Number of Occluded Bypass Grafts Available IMA for grafting totally occluded
vessels Good Distal Targets
2011 ACCF AHA SCAI PCI Guideline
PCI>CABG Hemodynamically stable Limited areas of Ischemia Patent graft to LAD
Suitable PCI targets (low syntax score) Mechanism of graft closure can be fixed by PCI
Kinking Thrombosis Anastomotic stenosis
Co-morbid conditions (High Euro or STS score)
SVG PCI Increased risk of distal embolization MI
and no reflow PCI of de novo SVG stenosis
High risk bec: Atheroma is friable embolization
GPI- less effective for SVG than native arteries Combined data support use of distal embolic
protective device during SVG PCI (Class I-A)
2011ACCF AHA SCAI PCI Guideline
Class II a ; LOE B Hybrid coronary revascularization (defined as
the planned combination of LIMA-LAD artery grafting and PCI of >/=1 non LAD coronary arteries) is reasonable in patients with 1 or more of the ff: Limitation to traditional CABG
Heavily calcified prox aorta Poor target vessels for CABG (but amenable for PCI)
Lack of suitable graft conduits Unfavorable LAD artery for PCI
excessive vessel tortuosity or CTO
2010 ESC EACTS MYOCARDIAL REVASCULARIZATION GUIDELINE
What Stent To Use for SVG PCI
2011 ACCF AHA SCAI PCI Guideline
Summary Perioperative MI is associated with adverse short
and long term clinical outcome PMI may present as asymptomatic enzyme leak
to cardiogenic shock Goals of therapy depends on clinical presentation Early detection and intervention of graft failure is
key to restore myocardial flow and prevent consequences of PMI
Latest guideline recommends : PCI > Redo CABG in the mgt of graft failure heart team approach in the determining the optimal
definitive mgt of graft failure
THANK YOU
Clinical Spectrum of PMI
Post CABG with Signs of Ongoing Ischemia
Hymodynamically
Unstable: Cardia
c Arrest/Shock
VT/VF,New Q/LBBB,
ST, LCOS
Hemodynamically Stable:With
Signs of
Ongoing
Ischemia
Without
Signs of
Ongoing
Ischemia
DiagnosticApproach and Therapeutic Approach Vary depending on initial presentation the critical issue is :
to determine whether there is acute severe ischemia/infarction due to Early Graft Failure Acute Native Coronary Thrombosis
that warrants urgent intervention. Patients presenting with hemodynamic
instability or signs of ischemia are more likely to have graft failure and warrant early intervention to save viable myocardium and reduce post op mortality risk
Clinical Spectrum of PMI
Post CABG with Signs of Ongoing Ischemia
Hymodynamically
Unstable: Cardia
c Arrest /Shock
VT/VF, ST, LCOS
Hemodynamically Stable:With
Signs of
Ongoing
Ischemia
Without
Signs of
Ongoing
Ischemia
Clinical Spectrum of PMI
Post CABG with Signs of Ongoing Ischemia
Hymodynamically
Unstable: Cardia
c Arrest/Shock
VT/VF, ST, New Q wave/
LBBB LCOS
Hemodynamically Stable:With
Signs of
Ongoing
Ischemia
Without
Signs of
Ongoing
Ischemia
Recurrent VT, ST, new Q wave/LBBB, LCOS :Hypotensive not in Shock
Urgent TEE to : Confirm ongoing
ischemia Rule out Tamponade
Mgt of ischemia
Nitrates Optimize O2 Transfusion
arrhythmia LCOS
Optimiize filling pressures Inotropic support IABP
Hypotensive: with Signs of Ongoing Ischemia
TEE
Tamponade /Hemodynamic DeteriorationRe-exploration
:Revision fo
Graft / Evacuation
of Clot or Hematoma; Ligation of Bleeders
No Tamponade: Large area of
myocardium at Risk/ Some
Response to Conservative
MgtAggressive Tx of Spasm
+ Urgent Coronary
AngiographyPCI vs
Surgical vs
Hybrid depending on
anatomy
Mgt of Arrhythmia Ischemia and LCOS
2011 ACC AHAF CABG GUIDELINE TEE
CLASS I Intraoperative TEE should be performed for
evaluation of acute, persistent and life-threatening hemodynamic disturbances that have not responded to treatment
LOE B CLASS II
Intraoperative TEE is reasonable for monitoring of hemodynamic status, ventricular fxn and RWMA and valvular fxn in patients undergoing cabg
LOE B
INTRAOPERATIVE EVALUATION OF GRAFT
FLOW
PERSISTENT CARDIOMYOPATHY INSPITE SURGICAL REPAIR OF
GRAFT FAILUREWhat’s the role of Hybrid
Revascularization?
Hybrid Coronary Revascularization
Defined as planned combination of LIMA-to –LAD artery grafting and PCI of >/=1 non LAD coronary arteries
Intended to combine the advantages of CABG ( durability of LIMA graft) and PCI
May be performed in a hybrid suite in one operative setting or as a staged procedure
2011ACCF AHA SCAI PCI Guideline
Class II a ; LOE B Hybrid coronary revascularization (defined as
the planned combination of LIMA-LAD artery grafting and PCI of >/=1 non LAD coronary arteries) is reasonable in patients with 1 or more of the ff: Limitation to traditional CABG
Heavily calcified prox aorta Poor target vessels for CABG (but amenable for PCI)
Lack of suitable graft conduits Unfavorable LAD artery for PCI
excessive vessel tortuosity or CTO