Top Things to Know: Considerations on the Management of Acute Postoperative Ischemia Following Cardiac Surgery
Published: June 22, 2023
Prepared by Mario Gaudino, MD; Writing Group Chair
- This Statement describes the incidence, etiology, clinical presentation, diagnosis, treatment, and outcomes for patients who experience postoperative ischemia following cardiac surgery.
- The incidence of postoperative myocardial infarction after cardiac surgery has been reported to range from 0.3% to 9.8% after isolated coronary bypass surgery, 0.7% to 11.8% when bypass surgery is combined with concomitant valvular surgery, and 1.7%-2.2% after isolated mitral valve surgery.
- Graft-related factors are the most common cause of postoperative ischemia after coronary artery bypass graft (CABG), but other factors may contribute including technical issues, competitive flow, suture entrapment or coronary artery distortion, and non-graft related factors.
- There is no consensus definition of postoperative myocardial ischemia, as elevations in cardiac biomarkers may not be reliable for diagnosis postoperatively, and pain management regimens may mask ischemic symptoms.
- Due to the difficulty with diagnosis, clinicians must maintain a high level of suspicion for diagnosing postoperative ischemia, and use of modalities such as ECG, and echocardiogram, are encouraged early.
- Delay in urgent angiography has been associated with higher mortality, thus a low threshold for action is encouraged in patients with suspected acute postoperative myocardial ischemia.
- Indications for urgent angiography include new ECG changes, chest pain with ongoing signs of ischemia, cardiac imaging abnormalities, cardiac rhythm abnormalities, significant elevations in cardiac biomarkers, and low cardiac output syndrome despite postoperative pressor support.
- Patients with acute postoperative myocardial ischemia and low cardiac output syndrome may require mechanical support when first line treatment has failed.
- The key to successful clinical outcomes is fast and effective reperfusion of the ischemic zone that is generally achieved by percutaneous intervention and, less often, by repeat surgery.
- Short-term mortality is elevated in patients with acute postoperative myocardial ischemia, irrespective of the treatment modality, with reported mortality rates ranging from 5.1% to 24%, while the evidence on long-term mortality has been mixed.
Citation
Gaudino M, Dangas GD, Angiolillo DJ, Brodt J, Chikwe J, DeAnda A, Hameed I, Rodgers ML, Sandner S, Sun LY, Yong CM; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Considerations on the management of acute postoperative ischemia after cardiac surgery: a scientific statement from the American Heart Association [published online ahead of print June 22, 2023]. Circulation. doi: 10.1161/CIR.0000000000001154