Will emergency coronary bypass grafting after failed elective percutaneous transluminal coronary angioplasty prevent myocardial infarction?

An emergency aorto-coronary bypass grafting operation was performed within 12 hours after the development of acute myocardial ischemia due to partial or complete vascular occlusion in 34 of 950 (3.6%) patients who had received elective percutaneous transluminal coronary angioplasty (PTCA). Of the 34 patients, three (= 8.8%) died postoperatively in irreversible cardiogenic shock. Half of the surviving patients developed a Q-wave infarction after the operation, whereas the other half remained without transmural infarct. With comparable clinical data and times of operation up to placement of the aorto-coronary bypass vessel, an adequate residual perfusion must still have been present in the cases with non Q-wave infarction. Since in many cases a myocardial necrosis is unavoidable despite relatively early operative revascularization, the decisive role will be played by the remaining perfusion of the vessel concerned and any collaterals. It follows that treatment of an early PTCA complication, occurring in the catheter laboratory, ought to be the earliest possible aorto-coronary bypass operation unless available cardiological methods can reliably assure reperfusion. Treatment of a PTCA complication occurring later, however, e.g. after hours in the intensive-care unit, should be a repeat PTCA attempt: surgery at this stage will not prevent the transmural infarction but will increase risk of lethal complications.