Surgical Treatment of Acute Myocardial Infarction

¹ Professor of Surgery, Harvard Medical School; Chief, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston.

Thus, in 1987, the following indications for surgical treatment of acute myocardial infarction are: 1) acute evolving myocardial infarction less than six hours from onset, in patients in whom PTCA or streptokinase, depending on the coronary anatomy, has been unsuccessful; in single vessel disease, CABG is unlikely; in multiple-vessel disease, CABG is preferable to SK/PTCA therapy unless a very major "culprit" lesion can be identified with certainty; 2) post-infarction angina hours to days after a transmural myocardial infarction unyielding to maximal medical therapy and in patients with a coronary artery obstruction not amenable to PTCA; 3) occlusion of a coronary artery during cardiac catheterization that cannot be fixed by PTCA and/or streptokinase; 4) occlusion of a coronary artery during PTCA causing hemodynamic obstruction and threatened myocardium subtended by the obstructed coronary artery; 5) balloon-dependent patients in cardiogenic shock without mechanical defects who have adequate residual left ventricular function as determined by regional wall motion studies; 6) ventricular septal defect secondary to myocardial infarction unless there is terminal organ damage; 7) mitral valve replacement with or without coronary bypass for acute papillary muscle rupture; 8) semiemergent cardiac transplantation, either with or without a mechanical bridge to transplant in young individuals (less than 50 years) who have suffered massive destruction of left ventricular myocardium by an acute coronary occlusion with or without recurring ventricular tachyarrhythmias. Ejection fraction in this clinical category is always under 0.20 and usually under 0.15.