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