Coronary Artery Bypass Grafting Following Myocardial Infarction
Coronary artery bypass grafting (CABG) following myocardial infarction (MI) includes a subset of patients with variable presentations as well as comorbid conditions related to or as a sequela from the cardiac event. Patients may present after an isolated episode in an acute fashion or after attempted percutaneous intervention with further injury necessitating surgical evaluation. Special consideration should be given to the patient who presents with cardiogenic shock after an infarction as the timing of intervention affects outcome. This, however, may be influenced by concurrent patient pathophysiology, which should lead the surgeon to consider alternative support options before definitive surgical revascularization. At times, patients will present with postinfarct structural complications that will prompt urgent surgical planning because of the potential for poor outcomes. Many challenging aspects of care surrounding surgical revascularization relate to the optimal timing of surgical intervention. Numerous patient characteristics and presenting factors play a role in determining whether emergent CABG is indicated or whether an urgent or delayed intervention is more prudent. Alternative challenges exist in the patient population with ischemic heart disease and a known prior MI. Finally, the subset of patients with preexisting comorbidities needing coronary revascularization requires careful deliberation as surgical intervention may at times present risks that do not outweigh benefits. This chapter will address each of these presenting patient groups, review the indications for surgical intervention and discuss timing of intervention that optimizes surgical outcomes after MI.
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