Outcome in Patients Having Salvage Coronary Artery Bypass ...

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Salvage coronary artery bypass grafting (CABG) is often performed for ... retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 Eu ...
Outcome in Patients Having Salvage Coronary Artery Bypass Grafting Giuseppe Santarpino, MD, PhDa,*, Vito G. Ruggieri, MD, PhDb, Giovanni Mariscalco, MD, PhDc, Karl Bounader, MDb, Cesare Beghi, MDd, Theodor Fischlein, MD, PhDa, Francesco Onorati, MD, PhDe, Giuseppe Faggian, MDe, Giuseppe Gatti, MDf, Aniello Pappalardo, MDf, Marisa De Feo, MDg, Ciro Bancone, MD, PhDg, Andrea Perrotti, MDh, Sidney Chocron, MD, PhDh, Magnus Dalen, MDi,j, Peter Svenarud, MD, PhDi,j, Antonino S. Rubino, MDk, Carmelo Mignosa, MDk, Riccardo Gherli, MDl, Francesco Musumeci, MDl, Angelo M. Dell’Aquila, MDm, Eeva-Maija Kinnunen, MDn, and Fausto Biancari, MD, PhDn Salvage coronary artery bypass grafting (CABG) is often performed for cardiogenic shock on compassionate basis without clinical data justifying this aggressive approach. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European cardiac surgery centers. Salvage CABG was defined according to the EuroSCORE criteria, that is, a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. A percutaneous coronary intervention procedure preceded salvage CABG in 55 patients (64.7%). Thirty patients (35.3%) died during the inhospital stay. The mean EuroSCORE II was 32.0% and the observed-to-expected ratio was 1.08. Salvage CABG was associated with high rates of postoperative stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%). Survival at 1, 3, and 5 years was 58.6%, 49.8%, and 40.9%, respectively. Twenty patients (23.5%) were postoperatively treated with extracorporeal membrane oxygenation (ECMO). The rates of adverse events after ECMO were particularly high (stroke 40%, resternotomy for bleeding 60%, dialysis 35%, gastrointestinal complications 30%, and deep sternal wound infection 30%). Of patients treated with ECMO, 8 (40%) survived to discharge, and 1-year survival was 29.2%. Salvage CABG is associated with high risk of immediate mortality and severe adverse events. However, the observed immediate and intermediate outcome justify coronary surgery in these critically ill patients. A number of these patients are currently treated by ECMO, and its results are encouraging. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;116:1193e1198) Emergency coronary revascularization in patients with cardiogenic shock is burdened by an early mortality rate of about 42% to 44% after either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).1 In patients referred for emergency CABG, there is a subset of patients who require cardiopulmonary resuscitation by external cardiac massage en route to the operating theater or before the induction of anesthesia. In a recent multicenter study assessing the outcome of emergency CABG, a salvage

procedure was performed in 4% of patients with an early mortality rate of 23%.2 In this setting, salvage operation represent one of the most controversial areas of cardiac surgery in terms of riskebenefit ratio, health care resources, and, not least, ethical implications. Furthermore, conditions leading to salvage operation and the poor early outcome after salvage CABG may be a topic of medicolegal litigation, which cannot be settled without data on the outcome of this particular subset of patients. Notwithstanding this, the

a Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany; bDepartment of Thoracic and Cardiovascular Surgery, University Hospital Pontchaillou, Rennes, France; c Cardiac Surgery, University of Leicester, Glenfield Hospital, Leicester, United Kingdom; dDepartment of Heart and Vessels, Cardiac Surgery Unit, Ospedale di Circolo, Varese, Italy; eDivision of Cardiac Surgery, University of Verona, Verona, Italy; fDivision of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy; gDepartment of Cardiothoracic and Respiratory Sciences, V. Monaldi Hospital, Naples, Italy; hDepartment of Thoracic and CardioVascular Surgery, University Hospital Jean Minjoz, Besançon, France; Departments of iCardiothoracic Surgery and Anesthesia, and jMolecular

Medicine and Surgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden; kCardiac Surgery Unit, A.O.U. Policlinico Vittorio Emanuele, University of Catania, Catania, Italy; lDepartment of Cardiac Surgery, S.Camillo Hospital, Rome, Italy; mDepartment of Cardiac Surgery, University Hospital Münster, Münster, Germany; and nDepartment of Surgery, University of Oulu, Oulu, Finland. Manuscript received May 17, 2015; revised manuscript received and accepted July 12, 2015. See page 1198 for disclosure information. *Corresponding author: Tel: (þ49) 09113985441; fax: (þ49) 09113985443. E-mail address: [email protected] (G. Santarpino).

0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.07.034

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Table 1 Distribution of baseline characteristics of patients who underwent salvage coronary artery bypass grafting. Prevalence of these covariates among survivors and operative deaths is shown Variable Age (years) Octogenarians Women Diabetes mellitus Hypertension eGFR (ml/min/1.73 m2) Dialysis Peripheral arterial disease Pulmonary disease Poor mobility Stroke Current neurological status Acute stroke Unconsciousness Unconsciousness and stroke Acute neurological impairment Prior cardiac surgery Previous PCI Recent MI (90 days) STEMI LVEF30% No. diseased vessels Left main disease Delay from onset of symptoms to operation (hours) Ventricular arrhythmia Ventric. Tachycardia Ventric. Fibrillation Asystole Unspecified arrhythmia PCI-related complication Failed PCI attempt Ischemia despite PCI Direct transfer from cathlab CPR within 1 hour from start of operation CPR at the time sternotomy Heart rhythm at sternotomy Sinus rhythm Nodal rhythm Ventricular tachycardia Ventricular fibrillation Asystole Atrial fibrillation/flutter Preop. IABP EuroSCORE II (%)

Overall (n¼85)

Survived to discharge (n¼55)

In-hospital death (n¼30)

p-value

64.610.3 6 (6.5%) 23 (27%) 25 (29%) 61 (72%) 6828 3 (3.5%) 23 (27%) 10 (12%) 17 (20%) 7 (8.2%)

63.99.8 3 (4.8%) 13 (24%) 18 (33%) 40 (73%) 7228 2 (3.6%) 18 (33%) 7 (13%) 14 (25%) 5 (9.1%)

66.510.1 3 (10%) 10 (33%) 7 (23%) 21 (70%) 6330 1 (3.3%) 5 (6.7%) 3 (10%) 3 (10%) 2 (6.7%)

0.262 0.383 0.336 0.364 0.790 0.151 1.000 0.111 1.000 0.154 1.000 0.329

2 20 1 23 3 26 73 57 38

(2.4%) (23%) (1.2%) (27%) (3.5%) (31%) (86%) (67%) (45%)

1 (1.8%) 11 (20%) 0 12 (22%) 1 (1.8%) 14 (26%) 46 (84%) 35 (64%) 22 (40%)

1 9 1 11 2 12 27 22 16

35 (41%) 10.210.1

20 (36%) 8.910.4

15 (50%) 12.69.5

13 19 7 3 24 31 26 56 61 27

6 15 3 2 13 18 19 36 39 16

7 4 4 1 11 13 7 20 22 22

(3.3%) (30%) (3.3%) (37%) (6.7%) (41%) (90%) (73%) (55%)

0.141 0.283 0.148 0.527 0.363 0.184 0.895 0.222 0.006 0.262

(15%) (22%) (8.2%) (3.5%) (24%) (33%) (35%) (66%) (72%) (32%)

48 (63%) 2 (2.6%) 5 (6.6%) 5 (6.6%) 5 (6.6%) 11 (14%) 58 (68%) 32.016.7

(11%) (27%) (5.5%) (3.6%) (24%) (33%) (40%) (65%) (71%) (29%)

34 (69%) 1 (2.0%) 4 (8.2%) 2 (4.1%) 1 (2.0%) 7 (14%) 38 (69%) 30.317.4

(23%) (13%) (13%) (3.3%) (37%) (43%) (25%) (67%) (73%) (37%)

14 (52%) 1 (3.7%) 1 (3.7%) 3 (11%) 4 (15%) 4 (15%) 20 (67%) 35.215.1

0.202 0.332 0.175 0.910 0.812 0.473 0.207

0.819 0.082

Nominal variables are reported as counts and percentages; continuous variables are reported as mean and standard deviation. CPR ¼ cardiopulmonary resuscitation; eGFR ¼ estimated glomerular filtration rate; IABP ¼ intra-aortic balloon pump; LVEF ¼ left ventricular ejection fraction; MI ¼ myocardial infarction; PCI ¼ percutaneous coronary intervention; STEMI ¼ ST-elevation myocardial infarction.

efficacy of CABG in these patients remains unclear because of the heterogeneity and limited number of patients requiring salvage coronary surgery. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. Methods We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European centers of cardiac

surgery (Paracelsus Medical University Nuremberg, Germany, n ¼ 11; University Hospital Pontchaillou, Rennes, France, n ¼ 11; Varese University Hospital, Varese, Italy, n ¼ 2; Verona University Hospital, Verona, Italy, n ¼ 25; Ospedali Riuniti, Trieste, Italy, n ¼ 15; Monaldi Hospital, Naples, Italy, n ¼ 5; University Hospital Jean Minjoz, Besançon, France, n ¼ 5; Karolinska University Hospital, Stockholm, Sweden, n ¼ 3; Catania University Hospital, Catania, Italy, n ¼ 2; S. Camillo Hospital, Rome, Italy, n ¼ 2; Oulu University Hospital, Oulu, Finland, n ¼ 4) from

Coronary Artery Disease/Salvage Coronary Surgery

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Table 2 Operative data on patients who underwent salvage coronary artery bypass grafting. Prevalence of these covariates among survivors and operative deaths is shown

Table 3 Postoperative complications after salvage coronary artery bypass grafting

Variable

In-hospital mortality 30-day mortality Stroke Inotropic support>12 hours Pre- and postoperative IABP IABP inserted postoperatively ECMO ECMO and IABP Resternotomy for bleeding Resternotomy for hemodynamic instability Red blood cell transfusion Fresh frozen plasma/Octaplas transfusion Platelet transfusion Atrial fibrillation De novo dialysis Sternal wound infection Gastrointestinal complications Gastrointestinal bleeding Intestinal ischemia Intensive care unit stay (days) In-hospital stay (days)

Overall (n¼85)

Surgical technique Off-pump surgery 3 (3.5%) On-pump beating 7 (8.2%) heart surgery Conversion to 3 (3.5%) on-pump surgery On-pump surgery 72 (85%) Internal mammary a. graft 47(55%) No. of distal anastomoses 2.61.1 Cross-clamp time (min) 5933 Cardiopulmonary 12453 bypass time (min)

Survived In-hospital p-value to discharge death (n¼55) (n¼30) 0.607 2 (3.6%) 4 (7.3%)

1 (3.3%) 3 (10%)

3 (5.5%)

0

46 (84%) 36 (65%) 2.61.2 6037 11046

26 (87%) 11 (37%) 2.51.0 5424 14956

0.011 0.821 0.873 0.002

Nominal variables are reported as counts and percentages (in parentheses); continuous variables are reported as mean and standard deviation.

2005 to 2015. Permission to perform this study was granted by institutional review boards. Baseline characteristics were defined according to the EuroSCORE definition criteria.3 Salvage CABG was defined as a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. This does not include cardiopulmonary resuscitation after induction of anesthesia.3 Preoperative and intraoperative characteristics of this study population were collected in a dedicated datasheet and are reported in Table 1. Follow-up information was collected by direct contact with the patients or their general practitioners or using national registry data. The main outcome end point of this study was inhospital mortality. The secondary outcome end points were 30-day mortality, late mortality, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, inotropes >12 hours, blood loss 12 hours after surgery, resternotomy for bleeding and/or hemodynamic instability, use of blood products (red blood cells, fresh frozen plasma/Octaplas, and platelets transfusions), stroke, de novo dialysis, gastrointestinal complications, deep sternal wound infection, length of stay in the intensive care unit, and length of stay in hospital. Statistical analysis was computed using SPSS version 22.0 statistical software (IBM SPSS Inc., Chicago, Illinois). Group differences were evaluated by the ManneWhitney, the Pearson chi-square, and Fisher’s exact tests. Multivariate analysis was not performed because of the small size of this series. Survival analysis was performed using the KaplaneMeier method. All tests were 2 sided with the a level set at 0.05 for statistical significance. Results Preoperative patient characteristics and operative data are summarized in Tables 1 and 2. A PCI procedure preceded salvage CABG in 55 patients (64.7%). External cardiac massage was performed in 31.8% of patients at the time of

Outcome end-points

No. (%)/meanSD 30 (35%) 28 (33%) 8 (9.4%) 65 (76%) 70 (82%) 12 (14%) 20 (23%) 19 (22%) 20 (23%) 13 (15%) 68 (80%) 46 (54%) 37 (43%) 43 (51%) 16 (19%) 9 (11%) 11 (13%) 8 (9.4%) 3 (3.5%) 7.710.0 15.215.7

Nominal variables are reported as counts and percentages (in parentheses); continuous variables are reported as the mean and standard deviation (SD). IABP ¼ intra-aortic balloon pump; ECMO ¼ extracorporeal mechanical oxygenation.

sternotomy. Thirty patients (35.3%) died during the inhospital stay (Table 3). The observed-to-expected ratio, that is, the ratio of observed proportion of deaths to the mean EuroSCORE II, was 1.08. The delay from onset of symptoms to surgery (data available for 81 patients) was the only preoperative variable associated with significantly increased risk of inhospital mortality (Table 1). In the baseline covariates, univariate analysis showed that acute neurologic impairment immediately before surgery (47.8% vs 30.6%, p ¼ 0.141), external cardiac massage at the time of sternotomy (40.7% vs 32.8%, p ¼ 0.473), a PCI procedure preceding salvage CABG (40.0% vs 26.7%, p ¼ 0.219), and cardiogenic shock secondary to PCI-related complication (45.8% vs 31.3%, p ¼ 0.202) were associated with an increased, but not statistically significant, inhospital mortality rate. In the operative variables, prolonged cardiopulmonary bypass time was a significant predictor of mortality (p ¼ 0.002). Salvage CABG was frequently associated with significant adverse postoperative events such as stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), de novo dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%; Table 3). The high proportion of these severe adverse events translated in prolonged stay in the intensive care unit (mean 7.7 days) and inhospital stay (mean 15.2 days). Five patients were lost to follow-up. Actuarial analysis showed that overall survival (including operative deaths) at 1, 3, and 5 years was 58.6% (38 patients at risk), 49.8% (26 patients at risk), and 40.9% (16 patients at risk), respectively. Twenty patients (23.5%) were treated postoperatively by extracorporeal membrane oxygenation (ECMO). ECMO

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Table 4 Baseline characteristics of 20 patients who were treated with extracorporeal membrane oxygenation after salvage coronary surgery Patient no.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Proportion and meanSD

Age (years)

Gender

Prior cardiac surgery

Acute neurological problems

STEMI

PCI-related complication

LVEF30%

Preop. IABP

Cardiac massage atthe time of sternotomy

EuroSCORE II

48 49 53 53 56 56 58 58 61 62 64 65 66 68 68 71 71 74 77 77 62.88.8

F M F M M F M M M M M M M M M M M M F M 80%/20%

No No No No No No No No No No Yes No No No No No No No Yes No 10%

Yes No No No No Yes No No No No No No No No Yes No Yes No No No 20%

Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No 85%

Yes Yes No No No No No No No No No No Yes No Yes No No No No No 20%

Yes No Yes Yes N/A Yes No No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No 65%

No Yes Yes No Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes 80%

No No No Yes No No No No No No Yes No Yes Yes No Yes Yes Yes No No 35%

49.4% 16.7% 26.5% 33.7% 28.6% 43.6% 13.0% 11.1% 17.1% 17.7% 45.4% 60.5% 41.9% 46.4% 58.0% 43.2% 54.5% 49.0% 55.7% 19.4% 36.616.4

F ¼ female; IABP ¼ intra-aortic balloon pump; LVEF ¼ left ventricular ejection fraction; M ¼ male; PCI ¼ percutaneous coronary intervention; SD ¼ standard deviation; STEMI ¼ ST elevation myocardial infarction.

was used in 5 of 11 hospitals participating in this study. The individual baseline characteristics and postoperative outcome of these patients are summarized in Tables 4 and 5. Eight of these patients (40%) survived to hospital discharge. Three of these patients died at 3, 5, and 18 months after surgery. Five patients with postoperative ECMO (25%) were alive after a mean of 40 months after surgery (range 4 to 117 months). The actuarial survival rate in this patient subset was 29.2% at 1 year. Hospitals using ECMO during the study period had a higher inhospital mortality rate (47.8% vs 20.5%, p ¼ 0.009). However, the EuroSCORE II in centers using ECMO was significantly greater (35.8  15.2% vs 27.5  17.4%, p ¼ 0.005).

Discussion Cardiogenic shock secondary to acute myocardial infarction is one of the most challenging condition in cardiac surgery. The heart team faces significant clinical and ethical issues in the decision-making process on whether to perform salvage CABG and to use mechanical circulatory support in the ischemic failing heart. Indeed, the decision to perform surgery in patients arriving in the operating room on cardiopulmonary resuscitation is often made on compassionate basis without any solid data on the benefit of this approach. There are convincing data which support the role of PCI in cardiogenic shock,4 whereas data on the benefit of surgical revascularization in this condition are scarce. A recent study by Kunadian et al4 showed that PCI in patients with cardiogenic shock is associated with a 30-day mortality rate

of 37%. In their series, only 17 of 6,184 patients underwent CABG after PCI.4 The results of the present multicenter study suggest that surgical myocardial revascularization in cardiogenic shock, even if often performed on compassionate basis, may translate in acceptable early and intermediate survival rates. Despite the high proportion of severe adverse events observed after surgery (major bleeding, deep sternal wound infection, gastrointestinal complications, and stroke), salvage CABG was associated with a survival to discharge rate of 65% and a 3-year survival rate of 50%. The observed-to-expected mortality ratio was 1.08, which confirms the predictive ability of EuroSCORE II in this category of high-risk patients. It is worth noting that even in the most critically ill patients such as those requiring external cardiac massage at the time of sternotomy and those with preoperative acute neurologic impairment, CABG achieved a survival to discharge rates of 52% and 59%, respectively. These results should be considered as encouraging because patients requiring surgical revascularization are at extremely high risk as a result of a failed or complicated PCI, more extensive coronary artery disease, and/or poor hemodynamic conditions which does not allow PCI. A significant difference was observed between survivors and operative deaths in terms of delay from onset of symptoms to surgery. Although we have data on this variable in only 87% of patients, it seems that in presence of STelevation myocardial infarction, prompt coronary revascularization is a key issue to prevent worsening of myocardial ischemia and cardiogenic shock.5 These findings demonstrate that there exists a particular subset of critically ill patients who require alternative, prompt treatment strategies

Table 5 Operative data and postoperative outcome in 20 patients who were treated with extracorporeal membrane oxygenation after salvage coronary surgery Patient no.

ECMO duration (hours)

Re-exploration for bleeding

Stroke

Dialysis

GI complications

Deep sternal wound infection

ICU stay (days)

Hospital stay (days)

Hospital mortality

Survival at last follow-up

Follow-up (months)

Yes No No Yes No No No No Yes No No No No No No No No No No No 15%

38 78 240 2 24 96 98 432 72 240 96 32 115 98 63 110 85 48 24 148 10799

Yes No Yes No Yes Yes Yes No Yes Yes No No Yes Yes No Yes Yes Yes No No 60%

No Yes Yes No No Yes Yes No No No No No Yes Yes No No Yes No No Yes 40%

No Yes No No No Yes No No No No No No Yes Yes Yes Yes Yes No No No 35%

No GI bleeding GI bleeding No GI bleeding Intest. ischemia No No No No No No No No No No Intest. ischemia No No Intest. ischemia 30%

No No Yes No No Yes Yes No No Yes Yes No No No No No Yes No No No 30%

2 18 55 1 2 4 29 18 4 25 31 7 5 4 13 2 7 11 1 6 1214

2 42 82 1 2 4 42 18 4 35 40 14 5 4 13 20 7 29 1 6 1921

Yes No No Yes Yes Yes No Yes Yes No No No Yes Yes Yes No Yes No Yes Yes 60%

Died Alive Alive Died Died Died Died Died Died Alive Alive Alive Died Died Died Died Died Died Died Died 25%

0 117 4 0 0 0 3 1 0 20 19 40 0 0 0 5 0 18 2 0 1227

Coronary Artery Disease/Salvage Coronary Surgery

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Proportion and meanSD

IABP inserted postop.

ECMO ¼ extracorporeal membrane oxygenation; GI ¼ gastrointestinal; IABP ¼ intra-aortic balloon pump; ICU ¼ intensive care unit; SD ¼ standard deviation.

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aiming to preserve viable myocardium and favoring early restoration of hemodynamic stability using mechanical circulatory support, if appropriate. Although the small size of the present series does not allow any analysis of interhospital outcome, a recent study showed that more aggressive treatment of cardiogenic shock by mechanical circulatory support was associated with decreased early mortality.6 Indeed, a few small studies reported encouraging results with the use of ECMO in patients who underwent coronary revascularization for acute myocardial infarction leading to cardiogenic shock. Esper et al7 reported a survival to discharge rate of 67% in a series of 18 patients who underwent PCI (15 patients) or CABG (3 patients) for severe cardiogenic shock secondary to acute coronary syndrome. Wu et al8 reported the outcome of 35 patients with cardiogenic shock secondary to myocardial infarction treated with ECMO after PCI and/or CABG. ECMO weaning rate was 63% and survival to hospital discharge was 40%.8 Sixteen of these patients underwent CABG; the weaning rate from ECMO in these patients was 69% and survival to discharge was 50%. Chen et al9 reported the results of a series of 28 patients who underwent CABG and ECMO treatment with a survival to discharge rate of 43%. Kim et al10 reported on 7 patients who underwent CABG and ECMO treatment. ECMO was started before surgery in 1 patient, and 5 patients (71%) were successfully weaned from ECMO and survived to hospital discharge. A large study by Rastan et al11 in patients with postoperative refractory cardiogenic shock after cardiac surgery showed that ECMO treatment after isolated CABG was associated with a hospital survival rate of 35%. This series confirmed that patients requiring ECMO are at high risk for major bleeding, gastrointestinal complications, cerebrovascular events, and lower limb ischemia, still with favorable outcome in 2/3 of patients.11 It is worth noting that in the present study, no other left ventricular assist device such as percutaneous devices was used. Although the benefits of such alternative devices in patients requiring salvage myocardial revascularization have not been yet sufficiently investigated, a recent study suggests that percutaneous cardiac assist devices could be a valid alternative to surgical cardiac assist devices.12 This study showed that about a PCI procedure or attempt preceded salvage CABG in 65% of patients. Even without reaching statistical significance, inhospital mortality rate was higher than patients who underwent a PCI procedure or attempt (40.0% vs 26.7%). This finding was not significantly driven by PCI-related complication (45.8% vs 31.1%), and therefore, it means that, in a number of cases, CABG could have been performed with better results in stable conditions without significant delay. A number of limitations of this study must be acknowledged. First, the retrospective nature may introduce a bias in this analysis. Second, this series includes a small number of patients from 11 European cardiac surgery centers with different referral pathways, preoperative treatment strategies, and approach toward extracorporeal mechanical support. These factors may have an important impact on the prevalence of this critical condition and its outcome. Third, the definition of salvage CABG herein used is the one proposed by the EuroSCORE investigators. However, this

definition may refer to a rather heterogeneous patient population which may encompass patients requiring cardiopulmonary resuscitation whose hemodynamic conditions may stabilize during the way to the operating room and those in whom sternotomy is performed after a prolonged and unsuccessful external cardiac massage. The heterogeneity of this condition is difficult to assess in a retrospective study and may have an impact on the immediate and late outcome of this patients. Furthermore, the size of this study is rather small and does not allow an appropriate identification of risk factors associated with poor outcome. However, the present study is to date the largest in patients with myocardial infarction requiring salvage CABG. Disclosures The authors have no conflicts of interest to disclose. 1. White HD, Assmann SF, Sanborn TA, Jacobs AK, Webb JG, Sleeper LA, Wong CK, Stewart JT, Aylward PE, Wong SC, Hochman JS. Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation 2005;112:1992e2001. 2. Biancari F, Onorati F, Rubino AS, Mosorin MA, Juvonen T, Ahmed N, Faggian G, Mariani C, Mignosa C, Cottini M, Beghi C, Mariscalco G. Outcome of emergency coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2015;29:275e282. 3. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, Lockowandt U. EuroSCORE II. Eur J Cardiothorac Surg 2012;41: 734e744. 4. Kunadian V, Qiu W, Ludman P, Redwood S, Curzen N, Stables R, Gunn J, Gershlick A. Outcomes in patients with cardiogenic shock following percutaneous coronary intervention in the contemporary era: an analysis from the BCIS database (British Cardiovascular Intervention Society). JACC Cardiovasc Interv 2014;7:1374e1385. 5. Hudson MP, Armstrong PW, O’Neil WW, Stebbins AL, Weaver WD, Widimsky P, Aylward PE, Ruzyllo W, Holmes D, Mahaffey KW, Granger CB. Mortality implications of primary percutaneous coronary intervention treatment delays: insights from the Assessment of Pexelizumab in Acute Myocardial Infarction trial. Circ Cardiovasc Qual Outcomes 2011;4:183e192. 6. Shaefi S, O’Gara B, Kociol RD, Joynt K, Mueller A, Nizamuddin J, Mahmood E, Talmor D, Shahul S. Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock. J Am Heart Assoc 2015;4:e001462. 7. Esper SA, Bermudez C, Dueweke EJ, Kormos R, Subramaniam K, Mulukutla S, Sappington P, Waters J, Khandhar SJ. Extracorporeal membrane oxygenation support in acute coronary syndromes complicated by cardiogenic shock. Catheter Cardiovasc Interv 2015 (in press). 8. Wu MY, Tseng YH, Chang YS, Tsai FC, Lin PJ. Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: the impact of early coronary revascularization. Resuscitation 2013;84:940e945. 9. Chen JS, Ko WJ, Yu HY, Lai LP, Huang SC, Chi NH, Tsai CH, Wang SS, Lin FY, Chen YS. Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue. Crit Care Med 2006;34:950e957. 10. Kim H, Lim SH, Hong J, Hong YS, Lee CJ, Jung JH, Yu S. Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock. Resuscitation 2012;83:971e975. 11. Rastan AJ, Dege A, Mohr M, Doll N, Falk V, Walther T, Mohr FW. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg 2010;139:302e311. 12. Maini B, Gregory D, Scotti DJ, Buyantseva L. Percutaneous cardiac assist devices compared with surgical hemodynamic support alternatives: cost-effectiveness in the emergent setting. Catheter Cardiovasc Interv 2014;83:E183e192.