Emergency Coronary Artery Bypass Grafting in Patients with Acute Coronary Syndromes following Primary PCI: A Current Report of the North–Rhine–Westphalia Surgical Myocardial Infarction Registry

Objectives: Although surgical revascularization for primary reperfusion therapy in acute coronary syndromes (ACS) has largely been superseded since the advent of PCI, the indication for coronary artery bypass grafting (CABG) has remained an important treatment option, particular in those were PCI was not sufficient, and/or has failed. We aimed to evaluate the current state of the art and clinical outcomes of emergency CABG following primary PCI in ACS patients in the contemporary stent era on a multicentric basis.

Methods: Multicentric data were obtained from “The North-Rhine-Westphalia Surgical Myocardial Infarction Registry” with > 120 patients characteristics and outcome variables. Patients undergoing CABG surgery with unstable angina (UAP) non-ST elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI) were enrolled.

Results: Between January 2010 and December 2017, a total of 2,432 patients (age: 68 ± 11 years, male: 78%) were admitted to CABG surgery with UAP (25%), NSTEMI (50%), or STEMI (25%). Logistic EuroSCORE was 20 ± 20% in NSTEMI and 24 ± 20% in STEMI. A total of 36% of the patients had a history of prior PCI (27.8% NSTEMI and 38.8% STEMI). PCI was acutely performed within 24 hours before surgery in 8.9% for NSTEMI and 19.0% for STEMI and within the last 6h in 5.2% for NSTEMI and 17.3% for STEMI. In 6.8% of NSTEMI and 17.2% of STEMI patients, PCI failed and 18.2% of them presented with cardiogenic shock (CS). Multivariate regression analysis revealed PCI within 24 hours to be an independent and strong predictor for CS (p < 0.001; OR = 2.53, CI: 1.53–4.18). In patients without prior PCI < 24 hours, in-hospital mortality and MACCE occurred in 6.9 and 15.8% in NSTEMI and 11.9 and 15.5% in STEMI. In patients with prior PCI < 24 hours in-hospital mortality and MACCE rate occurred in 5.5 and 19.4% in NSTEMI and rose to 15.0 and 25.5% in STEMI. In patients with failed PCI, in-hospital mortality and MACCE was 1.8 and 20% in NSTEMI, but increased to 15.5 and 31% in STEMI (p < 0.001) and 33 and 86% (p < 0.0001) in failed PCI with CS.

Conclusion: In the current PCI era, “The North-Rhine-Westphalia Surgical Myocardial Infarction Registry” showed that emergency CABG still remains an important treatment option, particularly in patients where PCI was not sufficient or has failed. Acute PCI before surgery is an important predictor for cardiogenic shock, which in turn is clearly associated with increased morbidity and mortality following emergency CABG.