[Surgical revascularization in acute coronary insufficiency: an analysis of the risk factors for hospital mortality in urgencies and emergencies].
OBJECTIVE
A retrospective analysis of 444 patients (Pts) with acute coronary insufficiency (A.C.I.) submitted to coronary artery bypass grafting between January '85 and December '92 was performed in order to identify incremental risk factors associated with perioperative mortality and to evaluate whether prediction of mortality can be accomplished utilizing risk models specifically linked to the severity of myocardial ischemia.


METHODS
Based on clinical and ECGraphic standpoints three different groups were identified: urgent group, comprehensive of 257 Pts. in whom, because of full medically controlled ischemia, myocardial revascularization could be delayed until to 24-48 hours. Emergency-A group, comprehensive of 127 Pts with recurrent ischemia despite medical therapy, but with no signs of coronary insufficiency at the time of institution of cardiopulmonary bypass (CPB). Emergency-B group, comprehensive of 60 Pts operated on after a mean preoperative ischemic interval of 3.9 +/- 2.4 hours who presented unrelenting signs of ischemia, either persisting since the inception of the clinical picture or lasting for over 30 minutes at the time of institution of CPB; among those, 27 Pts were in cardiogenic shock.


RESULTS
Mortality rate in the three groups was respectively: 7.4%, 13.4%, 31.7%. Multivariate analysis identified the following risk factors of in-hospital mortality: urgent group: aortic cross-clamping time (A.C.C.T.) (p = 0.10) and ejection fraction (E.F.) (p = 0.023). Emergency-A group: A.C.C.T. (p = 0.017), E.F. (p = 0.023) and non-use of blood cardioplegia (B.C.) (p = 0.04). Emergency-B group: cardiogenic shock (p = 0.00), preoperative ischemic interval > 6 hours (p = 0.00), A.C.C.T. (p = 0.018) and non-use of B.C. (p = 0.012).


CONCLUSIONS
A useful stratification of Pts with A.C.I. in three different groups, each with its own risk model, can be obtained by means of clinical-ECGraphic criteria alone. Different prognostic weights can be attributed to the variables A.C.C.T., E.F. and non-use of B.C. depending on clinical status. A significant reduction of mortality rate in Pts with cardiogenic shock can be achieved by the utilization of individually-tailored surgical management.
Tomasco
B
B
Divisione di Cardiochirurgia, Ospedale San Carlo, Potenza.
Cappiello
A
A
Fiorilli
R
R
Leccese
A
A
Lupino
R
R
Romiti
A
A
Tesler
U F
UF
D000208:Acute Disease; D016009:Chi-Square Distribution; D003327:Coronary Disease / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D004562:Electrocardiography; D004630:Emergencies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors
Rivascolarizzazione chirurgica dell'insufficienza coronarica acuta: analisi dei fattori di rischio di mortalitaà ospedaliera in urgenza ed emergenza.