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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
  • Cardiogenic shock
  • 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 ! )

 Coming soon

Routine  CABG  is  generally  dangerous and contraindicated   for STEMI ,  while it  is  a great ,  life saving surgery  in  most of  the  refractory  NSTEMI : How ?

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