As a result of significant technologic improvements over the past 30 years, percutaneous coronary intervention (PCI) has become an increasingly safe and effective procedure. Along with this maturation, the indications for emergency cardiac surgery for failed PCI have been reduced. Nevertheless, some type of surgical backup strategy continues to be a standard of practice for the optimal performance of PCI. To understand this evolution, it is appropriate to start this chapter with an historical perspective.
On September 16, 1977, Andreas Gruentzig performed the first percutaneous transluminal coronary angioplasty (PTCA) in Zurich, Switzerland. Elaborate precautions were taken in the event that emergency coronary bypass surgery was necessary to rescue an unstable patient following a failed PTCA attempt. These provisions included a roller pump coronary perfusion device, an open ready operating room, and the physical presence of a cardiac surgeon and an anesthesiologist in the catheterization laboratory room.1 Fortunately, the procedure was successful, and the rest is history. Ironically, the birth of angioplasty would not have been possible without the support and interaction of cardiovascular surgeons with cardiologists. Gruentzig freely credited Ake Senning and Marko Turina, his cardiovascular surgeons in Zurich, with allowing him to develop the PTCA technique.
Of Gruentzig’s first 50 patients, 7 (14%) needed emergency bypass operations, but surgery was accomplished with no major mortality or morbidity.2 In June 1979, a PTCA workshop was convened in Bethesda, Maryland, sponsored by the National Institutes of Health National Heart, Lung, and Blood Institute (NIH-NHLBI), at which the initial clinical experience in the technique was discussed. Out of this pivotal meeting, the founding fathers of PTCA took the unprecedented step to commit a fledging procedure and themselves to a comprehensive multicenter registry that would fairly assess safety and efficacy. As a result, the NIH-NHLBI PTCA Registry3 was formed, setting the standards for the rigorous analysis of PCI that continues to this day in various registries, institutional databases, and multicenter randomized trials. It is with this tradition of open granularity that the evolution of PCI and the role of emergency surgery can be best assessed.
Different degrees and complexity of coronary artery bypass graft (CABG) surgery may be necessary following a failed PCI. The most appropriate definitions of urgency are provided by the National Cardiovascular Data Registry (NCDR) CathPCI Registry version 4.4 data elements.4
Elective: The patient’s cardiac function has been stable in the days prior to the operation. Cardiac surgery could be deferred without risk of compromised cardiac outcome.
Urgent: Procedure required during same hospitalization in order to minimize chance of further clinical deterioration. Examples include, but are not limited to, worsening sudden chest pain, congestive heart failure, acute myocardial infarction, anatomy, intra-aortic balloon pump (IABP), unstable angina with intravenous nitroglycerin, or rest angina.
Emergency: Patients requiring emergency operation will have ongoing refractory (difficulty, complicated, and unmanageable) unrelenting cardiac compromise, ...