tailieunhanh - THE ROLE OF SURGERY IN HEART FAILURE - part 7

Nong đầu sau khi AMI, ngay cả sau khi điều trị reperfusion thành công mạnh mẽ dự đoán tỷ lệ tử vong sớm và muộn. Thời điểm tối ưu của revascularization phẫu thuật sau khi AMI là gây tranh cãi. Trong lịch sử, bắc cầu chủ vành cấp cứu sau khi AMI đã cao hơn 5% đến 30% tỷ lệ tử vong, | SURGERY FOR MYOCARDIAL SALVAGE 195 31 P .05 . Migrino and colleagues 159 investigated the outcomes of the Global Use of SK and TPA for Occluded Coronary Arteries-1 trial and showed that even with early opening of the IRA within 3 hours a significant number of patients 17 had elevated Lv ESV LVESVIO40 mL m2 . Early dilatation after AMI even after successful reperfusion therapy strongly predicted early and late mortality. The optimal timing of surgical revascularization after AMI is controversial. Historically emergent CABG after AMI had higher mortality 5 to 30 with especially poor prognosis in patients who had transmural TM infarcts 160 161 . However early studies comparing CABG to medical treatment showed that surgical revascularization within 6 hours of symptom onset improved mortality over medically treated nonrevascularized patients. DeWood and colleagues 162 retrospectively studied 440 patients who had TM AMI. Starting CPB within 6 hours of AMI decreased short-term and long-term mortality and improved late event free survival. Hospital mortality for non-TM MI was and for TM MI was . Mortality for CABG within 6 hours was versus for CABG after 6 hours. However the average patient age was 54 with mostly single and double vessel disease exposing the study to criticism of selection bias. Main predictors of death were age prior CABG and shock. Today s environment is different. The population is older multivessel disease is prevalent and safe alternatives such as thrombolysis and PTCA exist. The capabilities of PCI are improving. A recent study of the New York State cardiac surgery registry investigated the effect of timing in CABG after TM AMI with the goal of delineating the optimal timing in this population as part of a strategy to improve outcome after AMI. This was a retrospective multicenter analysis of 32 099 patients after CABG after TM AMI from 1991 to 1996 by 179 surgeons at 33 hospitals in New York State 163 . The average age was 65 with EF