Remote muscle salvage by regional substrate enhancement during on-bypass beating-heart treatment of cardiogenic shock

Surgical revascularization for postinfarction cardiogenic shock carries 20-50% mortality. Beating-heart techniques have been favoured, but their impact on the avoidance of additional myocardial injury is unknown. Ten consecutive patients with postinfarction cardiogenic shock, unsuitable anatomy for percutaneous coronary intervention (Syntax score 34.0±7.5; triple-vessel disease, 10/10; left main stenosis, 5/10), and no associated cardiac procedure, were selected for salvage/emergent on-pump beating-heart coronary bypass surgery. Remote muscle was sequentially substrate-enhanced reperfused through the grafts after construction of distal anastomoses. Early/late mortality, preoperative/peak postoperative enzyme release, and baseline/pre-discharge ventricular function were analysed. One early death occurred. Patients received 2.9±0.6 grafts, always employing the left internal mammary artery. Cardiopulmonary bypass duration was 140±62 min. Left ventricular ejection fraction (29.4±5.8 vs. 37.5±8.3%), wall motion score index (2.10±0.29 vs. 1.86±0.28), and end-systolic volume index (42.1±11.5 vs. 33.1±14.0 ml/m(2)) acutely improved (P≤0.001), whereas functional mitral regurgitation decreased from 1.4±0.8 to 0.8±0.4 (P=0.051). Total creatine kinase levels significantly increased (P=0.017), but myocardial band isoenzyme did not (P=0.18). After 3.1±1.4 years, eight patients are alive and seven are free of recurrent heart failure. Satisfactory functional outcome can be achieved with beating-heart on-pump revascularization for postinfarction cardiogenic shock. Perioperative enzyme releases and ventricular functional variables may suggest reduced perioperative myocardial injury.