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J Thorac Cardiovasc Surg 2008;135:509-511
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Mitruka (Rancho Mirage, Calif). I think there is little question that early revascularization confers a survival advantage in patients with AMI. This has been demonstrated by the cardiologists performing PCI in this patient population. Indeed, the door to balloon time is now a benchmark for programmatic success. This early intervention has resulted, however, in many surgeons being cajoled or even coerced into performing high-risk operations earlier than may be beneficial. The optimal timing of surgical revascularization after AMI remains somewhat controversial, although it is generally accepted that waiting is better. This was demonstrated by the Columbia group evaluating New York State databases, and they showed that waiting to operate, especially in patients with transmural infarcts, results in better outcomes.

This retrospective study performed by the Johns Hopkins group using California discharge data adds to the growing body of literature that attempts to objectify the optimal timing of CABG after AMI. This group is to be congratulated for a statistical tour de force that overcame many of the inherent limitations and biases of a retrospective study in drawing meaningful conclusions. By using multiple logistic and linear regression, as well as propensity-adjusted multivariate analysis, the risk of adverse events could be assessed while controlling for factors associated with high preoperative clinical acuity. With this methodology, they were able to conclude that early CABG less than 3 days after an AMI was an independent predictor of mortality after controlling for clinical acuity and surgical propensity. Identifying the optimal timing of CABG after AMI to be 3 to 5 days to reduce postoperative mortality will be of clear clinical benefit. Furthermore, outlining that patients with higher acuity undergoing operation sooner will have higher morbidity will be beneficial in aligning outcome expectations between surgeons and our referring physicians. With that long-winded preamble, I . . . [Full Text of this Article]