Emergency coronary artery bypass surgery in the era of the FITT-STEMI project

Objectives: Time to the onset of treatment in ST-segment elevated myocardial infarction (STEMI) is crucial for the survival of myocardial tissue. The FITT-STEMI project (“Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction”), started in 2008, aims to reduce this time span in order to ameliorate outcome of patients. We assessed the effect on emergency coronary artery bypass surgery after implementation of FITT-STEMI.

Methods: Since 2008, 28 consecutive patients (FITT-STEMI group) from two FITT-STEMI sites were operated on for STEMI immediately after cardiac angiography. The outcome of this group was compared to the results of STEMI-patients from the same sites being operated in a 3 years' time period before the onset of the FITT-STEMI project (STEMI-group). The mean age of the FITT-STEMI group was 66±13 years, (43–86), 78% were male. A three-vessel disease was obvious in 82%, 57% presented with left main stem stenosis. Ten patients (36%) exhibited cardiogenic shock and 14% (4 pts) had cardiopulmonary resuscitation prior to surgery. An intraaortic balloon pump (IABP) was implanted preoperatively in the catheterization laboratory in 46%. Mean time from onset of symptoms to surgery was 8.3±6.4 hours.

Results: All patients were operated on cardiopulmonary bypass and cardioplegic arrest using intermittent cold blood cardioplegia. Mean number of distal anastomoses was 3.7±1.0, with use of the left internal mammary artery (LIMA) in 27 out of 28 patients (96.4%). Complete revascularization was achieved in 96%. Postoperative complications included one rethoracotomy for bleeding (3.6%) and secondary chest closure for initial thorax apertum in one patient. IABP was used in 57% (16 pts). Thirty-day and in-hospital mortality for the FITT-STEMI group were 7.1% (2 pts) and 10.7% (3 pts). The STEMI-group comprised 35 patients (mean age 66±9 years) with similar rate of cardiogenic shock (31%) and support by IABP (60%). Mean time from onset of symptoms was in the STEMI-group significantly higher (14.7±12.6 hours) and 30-day mortality was 25.7%.

Conclusion: Emergency coronary artery bypass grafting in patients with STEMI offers an option for otherwise untreatable coronary artery disease with acceptable results. Implementation of FITT-STEMI further improves the results with reduction of time span from onset of symptoms to surgery. Complete revascularisation and use of LIMA should be standard of care even in this high risk subset of patients.