Salvage coronary artery bypass grafting (CABG) is often performed for cardiogenic shock on compassionate basis without clinical data justifying this aggressive approach. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European cardiac surgery centers. Salvage CABG was defined according to the EuroSCORE criteria, that is, a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. A percutaneous coronary intervention procedure preceded salvage CABG in 55 patients (64.7%). Thirty patients (35.3%) died during the inhospital stay. The mean EuroSCORE II was 32.0% and the observed-to-expected ratio was 1.08. Salvage CABG was associated with high rates of postoperative stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%). Survival at 1, 3, and 5 years was 58.6%, 49.8%, and 40.9%, respectively. Twenty patients (23.5%) were postoperatively treated with extracorporeal membrane oxygenation (ECMO). The rates of adverse events after ECMO were particularly high (stroke 40%, resternotomy for bleeding 60%, dialysis 35%, gastrointestinal complications 30%, and deep sternal wound infection 30%). Of patients treated with ECMO, 8 (40%) survived to discharge, and 1-year survival was 29.2%. Salvage CABG is associated with high risk of immediate mortality and severe adverse events. However, the observed immediate and intermediate outcome justify coronary surgery in these critically ill patients. A number of these patients are currently treated by ECMO, and its results are encouraging.
Emergency coronary revascularization in patients with cardiogenic shock is burdened by an early mortality rate of about 42% to 44% after either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). In patients referred for emergency CABG, there is a subset of patients who require cardiopulmonary resuscitation by external cardiac massage en route to the operating theater or before the induction of anesthesia. In a recent multicenter study assessing the outcome of emergency CABG, a salvage procedure was performed in 4% of patients with an early mortality rate of 23%. In this setting, salvage operation represent one of the most controversial areas of cardiac surgery in terms of risk–benefit ratio, health care resources, and, not least, ethical implications. Furthermore, conditions leading to salvage operation and the poor early outcome after salvage CABG may be a topic of medicolegal litigation, which cannot be settled without data on the outcome of this particular subset of patients. Notwithstanding this, the efficacy of CABG in these patients remains unclear because of the heterogeneity and limited number of patients requiring salvage coronary surgery. The aim of this study was to analyze early and intermediate outcomes after salvage CABG.
Methods
We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European centers of cardiac surgery (Paracelsus Medical University Nuremberg, Germany, n = 11; University Hospital Pontchaillou, Rennes, France, n = 11; Varese University Hospital, Varese, Italy, n = 2; Verona University Hospital, Verona, Italy, n = 25; Ospedali Riuniti, Trieste, Italy, n = 15; Monaldi Hospital, Naples, Italy, n = 5; University Hospital Jean Minjoz, Besançon, France, n = 5; Karolinska University Hospital, Stockholm, Sweden, n = 3; Catania University Hospital, Catania, Italy, n = 2; S. Camillo Hospital, Rome, Italy, n = 2; Oulu University Hospital, Oulu, Finland, n = 4) from 2005 to 2015. Permission to perform this study was granted by institutional review boards. Baseline characteristics were defined according to the EuroSCORE definition criteria. Salvage CABG was defined as a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. This does not include cardiopulmonary resuscitation after induction of anesthesia. Preoperative and intraoperative characteristics of this study population were collected in a dedicated datasheet and are reported in Table 1 .
| Variable | Overall (n=85) | Survived to discharge (n=55) | In-hospital death (n=30) | p-value |
|---|---|---|---|---|
| Age (years) | 64.6±10.3 | 63.9±9.8 | 66.5±10.1 | 0.262 |
| Octogenarians | 6 (6.5%) | 3 (4.8%) | 3 (10%) | 0.383 |
| Women | 23 (27%) | 13 (24%) | 10 (33%) | 0.336 |
| Diabetes mellitus | 25 (29%) | 18 (33%) | 7 (23%) | 0.364 |
| Hypertension | 61 (72%) | 40 (73%) | 21 (70%) | 0.790 |
| eGFR (ml/min/1.73 m 2 ) | 68±28 | 72±28 | 63±30 | 0.151 |
| Dialysis | 3 (3.5%) | 2 (3.6%) | 1 (3.3%) | 1.000 |
| Peripheral arterial disease | 23 (27%) | 18 (33%) | 5 (6.7%) | 0.111 |
| Pulmonary disease | 10 (12%) | 7 (13%) | 3 (10%) | 1.000 |
| Poor mobility | 17 (20%) | 14 (25%) | 3 (10%) | 0.154 |
| Stroke | 7 (8.2%) | 5 (9.1%) | 2 (6.7%) | 1.000 |
| Current neurological status | 0.329 | |||
| Acute stroke | 2 (2.4%) | 1 (1.8%) | 1 (3.3%) | |
| Unconsciousness | 20 (23%) | 11 (20%) | 9 (30%) | |
| Unconsciousness and stroke | 1 (1.2%) | 0 | 1 (3.3%) | |
| Acute neurological impairment | 23 (27%) | 12 (22%) | 11 (37%) | 0.141 |
| Prior cardiac surgery | 3 (3.5%) | 1 (1.8%) | 2 (6.7%) | 0.283 |
| Previous PCI | 26 (31%) | 14 (26%) | 12 (41%) | 0.148 |
| Recent MI (≤90 days) | 73 (86%) | 46 (84%) | 27 (90%) | 0.527 |
| STEMI | 57 (67%) | 35 (64%) | 22 (73%) | 0.363 |
| LVEF≤30% | 38 (45%) | 22 (40%) | 16 (55%) | 0.184 |
| No. diseased vessels | 0.895 | |||
| Left main disease | 35 (41%) | 20 (36%) | 15 (50%) | 0.222 |
| Delay from onset of symptoms to operation (hours) | 10.2±10.1 | 8.9±10.4 | 12.6±9.5 | 0.006 |
| Ventricular arrhythmia | 0.262 | |||
| Ventric. Tachycardia | 13 (15%) | 6 (11%) | 7 (23%) | |
| Ventric. Fibrillation | 19 (22%) | 15 (27%) | 4 (13%) | |
| Asystole | 7 (8.2%) | 3 (5.5%) | 4 (13%) | |
| Unspecified arrhythmia | 3 (3.5%) | 2 (3.6%) | 1 (3.3%) | |
| PCI-related complication | 24 (24%) | 13 (24%) | 11 (37%) | 0.202 |
| Failed PCI attempt | 31 (33%) | 18 (33%) | 13 (43%) | 0.332 |
| Ischemia despite PCI | 26 (35%) | 19 (40%) | 7 (25%) | 0.175 |
| Direct transfer from cathlab | 56 (66%) | 36 (65%) | 20 (67%) | 0.910 |
| CPR within 1 hour from start of operation | 61 (72%) | 39 (71%) | 22 (73%) | 0.812 |
| CPR at the time sternotomy | 27 (32%) | 16 (29%) | 22 (37%) | 0.473 |
| Heart rhythm at sternotomy | 0.207 | |||
| Sinus rhythm | 48 (63%) | 34 (69%) | 14 (52%) | |
| Nodal rhythm | 2 (2.6%) | 1 (2.0%) | 1 (3.7%) | |
| Ventricular tachycardia | 5 (6.6%) | 4 (8.2%) | 1 (3.7%) | |
| Ventricular fibrillation | 5 (6.6%) | 2 (4.1%) | 3 (11%) | |
| Asystole | 5 (6.6%) | 1 (2.0%) | 4 (15%) | |
| Atrial fibrillation/flutter | 11 (14%) | 7 (14%) | 4 (15%) | |
| Preop. IABP | 58 (68%) | 38 (69%) | 20 (67%) | 0.819 |
| EuroSCORE II (%) | 32.0±16.7 | 30.3±17.4 | 35.2±15.1 | 0.082 |
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