Sequential intervention procedures after intracoronary thrombolysis; balloon dilatation, bypass surgery, and medical treatment

Primary coronary angioplasty in acute myocardial infarction

It is well established that recanalisation of the infarct-related artery is of great benefit in the early hours after acute myocardial infarction. This can be achieved by the use of thrombolytic agents and/or by percutaneous transluminal coronary angioplasty (PTCA). This article reviews data on the role of primary PTCA and summarises current opinion on its use.

Results of primary angioplasty for acute myocardial infarction in patients with multivessel coronary artery disease

The influence of multivessel coronary artery disease on the outcome of reperfusion therapy for myocardial infarction has not been fully characterized. Direct coronary angioplasty without antecedent thrombolytic therapy was performed during evolving myocardial infarction in 285 patients with multivessel coronary artery disease at 5.2 +/- 4.2 h after the onset of chest pain. Two vessel disease was present in 163 patients (57%) and three vessel disease in 122 (43%). An anterior infarct was present in 123 patients (43%), cardiogenic shock in 33 (12%) and age greater than or equal to 70 years in 59 (21%). Angioplasty of the infarct-related vessel was successful in 256 patients (90%), including 92% with two vessel and 88% with three vessel disease (p = NS). Emergency bypass surgery was needed in six patients (2%). In-hospital death occurred in 33 patients (12%), including 13 with two vessel and 20 with three vessel disease (p less than 0.05). The mortality rate was only 4% in the subgroup of 101 patients who met entry criteria for thrombolytic trials. The in-hospital mortality rate was 45% in patients in shock and 7% in patients not in shock (p less than 0.01). Logistic regression analysis identified shock and age greater than or equal to 70 years as independently associated with in-hospital death. In 135 patients who underwent predischarge left ventriculography, global ejection fraction increased from 50% to 57% (p less than 0.001) and regional wall motion in the infarct zone improved in 59% of patients. Follow-up data were available in 251 patients (99%) at a mean of 35 +/- 19 months.(ABSTRACT TRUNCATED AT 250 WORDS)

PTCA following myocardial infarction: use of bailout fibrinolysis to improve results

The results of percutaneous transluminal coronary angioplasty (PTCA) in 307 lesions in 235 patients within 60 days of myocardial infarction (MI) were compared with the PTCA results in 591 lesions in 489 patients without recent MI, and the effect of fibrinolysis to treat recurring occlusive clot during angioplasty was studied. In 210 lesions in patients with MI who did not receive fibrinolysis during the MI (group A), 58 lesions were categorized as primary failures; bailout fibrinolysis brought the final failure incidence to 42 lesions (20%). In 97 lesions in patients with MI who received fibrinolysis during the acute MI (group B), 22 lesions were categorized as primary failures; bailout fibrinolysis resulted in final failures of 16 lesions (16.5%). In 591 lesions in patients without a recent MI (group C), there were 85 primary failures and 81 final failures after bailout fibrinolysis. Analysis of the PTCA results in each group with respect to whether the lesions were totally or partially occluded showed that more of the lesions attempted in the groups with MI (groups A and B) were totally occluded (TO) and that with use of bailout fibrinolysis the success rate of PTCA in TO lesions was the same in all groups. Similarly, with use of fibinolytic bailout during PTCA the success rate in partially occlusive lesions was not different between the groups. We conclude that bailout thrombolysis during PTCA is usually effective, especially in those who have recently had an MI, and that with availability of bailout fibrinolysis, PTCA in those with recent MI is not any less sucessful than in those without recent MI.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency coronary artery bypass surgery preserves global and regional left ventricular function after intravenous tissue plasminogen activator therapy for acute myocardial infarction

Emergency coronary bypass surgery was performed in 24 (6.2%) of 386 consecutive patients enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Multicenter Trial. Intravenous tissue plasminogen activator was administered 2.6 +/- 0.7 h and bypass surgery was performed 7.3 +/- 1.9 h after the onset of infarction. Infarct artery patency was achieved in 21 (88%) of the 24 patients (pharmacologically in 18 or mechanically with coronary angioplasty in 3) in the catheterization laboratory before bypass surgery. The indication for surgery was left main or equivalent coronary artery disease in 7 patients, coronary anatomy unsuitable for angioplasty in 4 patients and unsuccessful coronary angioplasty in 13 patients. A coronary perfusion catheter was inserted before surgery in 11 of 13 patients with unsuccessful angioplasty. All three deaths occurred postoperatively in patients with preoperative cardiogenic shock. Three patients required surgical reexploration for postoperative hemorrhage. Comparison of preoperative and predischarge contrast left ventriculograms demonstrated significant preservation of global (left ventricular ejection fraction 49 +/- 6 to 56 +/- 6%; p = 0.008) and regional (standard deviation/chord -2.6 +/- 0.5 to -1.5 +/- 1.1; p = 0.001) left ventricular function. Emergency coronary bypass surgery can be performed with a low morbidity and mortality in patients treated with intravenous tissue plasminogen activator therapy for acute myocardial infarction. Such therapy is associated with significant preservation of global and regional (infarct zone) left ventricular function.

Newer emergency reperfusion techniques in acute myocardial infarction

We have given an overview of the management of the acute myocardial infarction patient utilizing the aggressive reperfusion techniques available today. Anatomic reperfusion rates have been over 95% with the combined methods described. The remaining problems technically are those of earlier reperfusion, methods to enhance myocardial recovery after ischemia, and prevention of restenosis or reocclusion. The use of laser methodology, coronary sinus retroperfusion, partial left heart bypass, and other innovative strategies may improve these results. The introduction of tissue plasminogen activator will affect our approach and will profoundly alter society's expectations of therapeutic success. Still, patients will die from acute myocardial infarction and its complications. The search for a prevention must, therefore, not be overshadowed by our current enthusiasm for reperfusion techniques. Hopefully, our current approach will become a historical footnote as breakthroughs in preventive strategies occur.

Percutaneous transluminal coronary angioplasty after thrombolytic therapy: a prospective controlled randomized trial

In 162 patients with acute transmural myocardial infarction, combined intravenous and intracoronary thrombolytic therapy with streptokinase was initiated. In vessels that remained occluded, mechanical recanalization was performed with a 3F recanalization catheter (group I, n = 79) or a 4F Grüntzig balloon catheter (group II, n = 83). After reperfusion, intracoronary streptokinase was administered superselectively. After termination of streptokinase infusion, angioplasty was performed only in patients in group II. There was no difference between the groups in relation to sex, age, infarct location, creatine kinase levels and time between onset of symptoms and start of treatment. Initial coronary angiography showed an open vessel in 27 (34%) of 79 patients in group I and 21 (25%) of 83 patients in group II. The final reperfusion rate was 90% (71 of 79) in group I and 86% (71 of 83) in group II. Angioplasty was attempted in 69 of the 71 patients in group II with a success rate of 65% and an occlusion rate of 3%. During the hospital stay, reocclusion occurred in 14 (20%) of 71 patients in group I. After thrombolytic therapy, coronary luminal narrowing in group I was 75 +/- 17% in patients without and 87 +/- 6% in patients with reocclusion (p less than 0.05). In group II, reocclusion was found in 10 (14%) of 71 patients. After angioplasty, the degree of coronary stenosis in group II was reduced from 82 +/- 12 to 51 +/- 30% (p less than 0.001). Reocclusion was found in 3 (7%) of the 45 patients with successful angioplasty and in 7 (32%) of the 22 patients with unsuccessful angioplasty (p less than 0.01). Improvement in regional left ventricular function was observed only in patients from group II with anterior myocardial infarction. In conclusion, by combined medical and mechanical recanalization, the rate of coronary reperfusion can be increased and infarct time shortened, providing the possibility of full revascularization by angioplasty, with improvement of regional wall motion and reduction of the rate of reocclusion.

Percutaneous coronary angioplasty: technique, indications, and results

The simplicity, safety, and economic advantages of percutaneous transluminal coronary angioplasty (PTCA) over coronary bypass surgery have encouraged its wide use as an alternative revascularization procedure. Four major problem areas require solutions before the technique fulfills its potential. First, PTCA technology requires further development to enhance success rates in severe, old, calcified lesions and in chronic total occlusions. Second, acute vessel reclosure needs intensive study to determine how this important complication can be foreseen and effectively managed if not avoided entirely. Third, effective treatment strategies for patients with multivessel disease require definition. Finally, the problem of late lesion recurrence needs to be solved. Until these goals are achieved, the general practice of PTCA should be restricted to treatment of early-stage coronary artery disease, single-vessel, or discrete two- and three-vessel disease.

Percutaneous transluminal coronary angioplasty: state of the art and future directions

Current developments in the practice of percutaneous transluminal coronary angioplasty concern increasing the safety of the procedure and reducing the incidence of lesion recurrence. Technical improvements and increased operator experience have greatly expanded the indications for the procedure. With experience, success in dilating proximal discrete lesions is now almost absolute. Old, calcified lesions and chronic total occlusions remain the barriers to total success. Careful case selection and expert anaesthesiology and surgical support are paramount in maintaining low complication rates. The largely unpredictable occurrence of acute vessel reclosure in approximately 2% of patients remains the major problem. This complication is usually the result of uncontrolled intimal dissection. These risks are considerably increased in patients with multivessel and diffuse disease and long lesions. Randomized trials are required to determine if such patients are best managed with bypass graft surgery. Early detection of less advanced coronary disease will ultimately lead to the most effective application of PTCA. Lesion recurrence may be reduced, in part, by careful attention to achieving an optimal, initial arteriographic and haemodynamic result. Otherwise, the solution to restenosis will depend on the development of pharmacological agents which prevent the rapid regrowth of atheromatous plaque.