Primary PCI is great for STEMI but “Primary CABG ” is not why ?
Posted Jun 28 2009 9:44pm
No one can deny , there is a huge revascularisation dilemma between CABG and PCI in patients with CAD. This is especially prevalent in multivessel disease in chronic coronary syndromes.
In acute STEMI , CABG is never considered as a primary revascularisation procedure.There should be strong reason for this ! Few studies , suggested a role for CABG in acute MI if it is done within3- 6 hours .But it became very clear , by and large CABG for acute STEMI is contraindicated . This especially applicable when q waves are formed.
Performing a complex surgery on a blood vessel subtending a dead , irritable ,myocardium is dangerous. Even a graft for non IRA vessel has no great benefit in the acute setting. The mortality of CABG in the first 48hours of MI can be up to 15%. Primary PCI opens up the IRA without the hazards of major surgery
Issues for CABG in STEMI
Failed thrombolysis : Rescue PCI could be useful provided it is also performed within the same time window . In most situations there is nothing called “rescue CABG “
Some would believe Left main and critical TVD is an indication for an emergency CABG. Yes , CABG may be indicated in this setting , but even here it may be delayed for a week if there is no ongoing ischemia , angina or hemodynamic instability.
Still , there is a definite role for CABG in STEMI in the following situations.
Mechanical complication- VSR/MR/Free wall rupture
Failed and complicated primary PCI.( Note : Simple failure to open a IRA is not an indication for CABG , there need to be a life threatening situation ! )
Routine CABG is generally dangerous and contraindicated for STEMI , while it is a great , life saving surgery in most of the refractory NSTEMI : How ?