Commentary: Myocardial infarction after cardiac surgery: Putting it all together

Central MessageEarly identification of patients with MI after cardiac surgery is difficult, but this well-presented algorithm can make the choice watchful waiting or immediate action an easier one to make.See Article page 1195. Early make. See In their expert opinion, Nicolas and colleagues1Nicolas J. Soriano K. Salter B. Gross C.R. Oloomi M. Dangas G. Myocardial infarction surgery: when intervene?.J Thorac Cardiovasc Surg. 2023; 165: 1195-1201Abstract Full Text PDF Scopus (2) Google Scholar discuss difficult clinical scenario postcardiac (PCS) myocardial (MI). Diagnosing active ischemia early critical mitigating negative sequelae PCS-MIs,1Nicolas namely reducing infarct size preserve ventricular function. acknowledging dilemma we all face, authors summarize limitations in data available us postoperative phase care, eg, who are intubated sedated unable give a history, poststernotomy chest pain as common complaint, worrisome ST-segment changes, which be normal findings surgery, troponin elevations, nonspecific seen more than 90% PCS some degree,2Thielmann Sharma V. Al-Attar N. Bulluck H. Bisleri Bunge J.J.H. et al.ESC Joint Working Groups on cardiovascular cellular biology heart position paper: peri-operative injury undergoing coronary artery bypass graft surgery.Eur Heart 2017; 38: 2392-2411Crossref PubMed (98) suboptimal echocardiogram windows for evaluation wall motion abnormalities. Aiming overcome these difficulties, propose simplify diagnostic approach PCS-MI. The algorithm's foundation rests assessment hemodynamic parameters, electrocardiogram (ECG), biomarkers. Whenever 1 tests abnormal, suggest obtaining echocardiogram, if abnormalities territory, then prompt transfer either catheterization laboratory back operating room (OR) patient hemodynamically unstable. If does not stable condition, preferred. includes de-emphasizes role that ECG plays evaluation, downgrading importance elevations. We would argue emphasis traditional analysis (ST elevation vs non-ST elevation) essential belongs at top approach. These have been hallmark acute (AMI) algorithms decades, aimed detection emergent reperfusion (door-to-balloon times <90 minutes). medical patients, strategies dramatically reduced 30-day mortality3Anderson Goldman L. Schafer A.I. Goldman's Cecil Medicine. 25th ed. Elsevier Saunders, Philadelphia2016Google from 20% less 5% current era. Unmentioned by additional intensive care unit (ICU) practices could aid diagnosis PCS-MI, including OR-to-ICU hand-offs, intraoperative transesophageal handoffs, extubation protocols, point-of-care ultrasound training, multidisciplinary AMI activation teams. Standardized, well-performed handoffs demonstrated ability reduce preventable complications, do increase resource use, represent opportunity ischemia.4Chatterjee S. Shake J.G. Arora R.C. Engelman D.T. Firstenberg M.S. Geller C.M. al.Handoffs cardiothoracic Society Thoracic Surgeons Workforce Critical Care.Ann 2019; 107: 619-630Abstract (9) Inclusion optimal preload (central venous pulmonary diastolic pressure), baseline hemodynamics (cardiac output level inotropic support bypass), any specific concerns surgeon regarding target vessel quality provide significant information above beyond was emphasized coauthors. A thorough discussion pre- postbypass findings, routinely virtually procedures,5Metkus T.S. Thibault D. Grant M.C. Badhwar Jacobs J.P. Lawton al.Transesophageal echocardiography surgery.J Am Coll Cardiol. 2021; 78: 112-122Crossref (15) allows comparative echocardiographic increasing sensitivity. As OR extubations occur frequently, sedation offers symptoms patient, helping inform other signs ischemia.6Subramaniam DeAndrade D.S. Mandell D.R. Althouse A.D. Manmohan R. Esper S.A. al.Predictors adult 154: 1656-1665.e2Abstract (20) Scholar, 7Chamchad Horrow J.C. Nachamchik Sutter F.P. Samuels L.E. Trace C.L. al.The impact hospital lengths stay.J Cardiothorac Vasc Anesth. 2010; 24: 780-784Abstract (35) 8Engelman Ben Ali W. Williams J.B. Perrault L.P. Reddy V.S. al.Guidelines perioperative surgery.JAMA 755Crossref (434) Although expected, recognition angina experienced bedside clinician workup suspected Finally, using efficiencies institutional team, rapidly disseminates about coordinates suite estuations, important. It should used it exists, case its development made not. coauthors1Nicolas offer thoughtful PCS-MI commended efforts. add analysis, gained directly well-organized complete handoff substantive information, further improve our making what diagnosis. When intervene?The Journal Cardiovascular SurgeryVol. 165Issue 3PreviewFeature Editor's Introduction—Diagnosing following challenging. Hospitals different protocols suspected, ultimately aim myocardium loss timely restoration blood flow. Individual such physical examination, biomarkers, electrocardiographic changes rather often teams unsure appropriate management. Full-Text