Effects of Previous Percutaneous Coronary Artery Interventions (PCI) on Myocardial Functions Post Coronary Artery Bypass Grafting, Should Previous PCI be Included in the Euroscore?

Abstract

Background: Previous reports indicated that patients who underwent CABG operation after previous stenting had a higher incidence of early death and major adverse cardiac events.Aim of the work: In our study, we tried to evaluate the effects of previous PCI on the myocardial function as estimated by echocardiography. As improvements in myocardial functions are a necessary argument for undergoing revascularization, it is critical to conclude preoperatively all the risk factors that might hinder this improvement. By doing such evaluation, we tried to conclude if it is necessary to include previous coronary artery stenting as a part of the EUROSCORE for risk evaluation before coronary artery bypass surgery if it really had a negative impact on postoperative myocardial function following CABG revascularization surgery.Patients and methods: After approval of the ethical committee of Ain Shams University, a prospective comparative randomized study on a cohort of 100 consecutive patients who underwent CABG in the period between January 2015 and December 2017 in Ain Shams University Hospitals, Cairo, Egypt. The patients were randomly assigned to the groups according to the specified inclusion and exclusion criteria. Patients were divided into two groups, GROUP I (number=50) patients who underwent CABG without previous left anterior descending artery stenting, and GROUPII (number=50) patients who underwent CABG with previous single or multiple LAD stenting. ECHO WITH 2D STAIN (speckle tracking) was used to evaluate the cardiac functions. Echocardiography was done pre-operatively, after one week, three months and six months postoperatively in both groups.Results: The results revealed that there is no statistically significant difference between both groups in the Preoperative risk factors: age, smoking, DM, HTN, family history, dyslipidemia, liver function, renal function, and hemoglobin levels. EuroSCORE values were comparable between the two groups. However, there was a statistically significant difference in preoperative MI, as there were 78% in group II that have history of preoperative MI in the 3-months period before surgery while in group I there were only 22%. Moreover, there is a statistically significant difference in the LADcalcification and atheroma severity between the two groups as 78% in group II vs. 22% in group I had extensive LAD disease with poor vessel quality. There was a statistically significant difference between both groups regarding the incidence of postoperative arrhythmia and bleeding postoperatively with higher values in group II. More importantly, the results revealed that there was a statistically significant difference between both groups in ECHO dimensions, EF and FS which are higher and better in group I vs. group II. Also, there is a statistically significant difference between both groups in ECHO wall motion values in most of the segments especially apical anterior septum segment and apex which reflect the viability of these segments. These motion values were better in group I vs. group II indicating better revascularization.Conclusion: Previous PCI has a negative impact on the outcome of subsequent CABG. This effect was independent of any preoperative risk variables. Myocardial functions estimated by echocardiography measured dimensions such as EDD, ESD, EF, and RSWMA have been shown to improve better in the group having CABG without previous PCI. So, the decision to use Percutaneous Coronary Interventions should be carefully weighed against the higher risk it provides for subsequent CABG. The guidelines for intervention should be strictly followed especially in patients with complex coronary lesions who have higher incidence to be referred for CABG. We also advise inclusion of the PCI proceduresas an independent risk category to be added to the risk factors already measured in the current EuroSCORE system.