1001-25 Combined Intralesional Tissue Plasminogen Activator and Intracoronary Heparin in Patients with Unstable Angina and Coronary Thrombus Undergoing PTCA

Abstract

PTCA in the setting of unstable angina (UA) and coronary thrombus (CT) is associated with adverse outcomes. We performed a pilot study of intralesional tPA (20 mg) using an end-hole infusion (Tracker) catheter and intracoronary heparin (5,000 units). delivered over 20 mins, prior to PTCA in 53 pts with UA and CT. Full delivery of tPA and heparin was possible in 47 pts. Activated clotting time was > 300 sec in all pts. PTCA was performed in 48 pts 20 mins after completion of the infusion. Systemic fibrinogenolysis (fibrinogen pre 408 ± 120 mg/dL, post 398 ± 114) and thrombin activation (no increase in fibrinopeptide A or fragment 1.2) did not occur but prolonged clot lysis was evident (D-Dimer pre 196 ± 179 ng/mL, 4 hours post 849 ± 746, P = 0.0001). Angiographic outcomes were (mean ± SD): Baseline Post-tPA Post-PTCA TIMI Thrombus Scale 2.2 ± 1.0 1.6 ± 1.2 ** 0.5 ± 0.9 * MLD by QCA (mm) 0.82 ± 0.42 0.89 ± 0.57 *** 1.90 ± 0.59 * TIMI Grade Flow 2.6 ± 0.8 2.5 ± 1.0 2.9 ± 0.5 * p = 0.001 ** p = 0.007 *** p = 0.07 (All comparison made with preceding group) PTCA was successful ( < 50% residual stenosis) in 87% and 6% had a major bleeding event. In-hospital outcomes were as follows: death 0, myocardial infarction 4%, abrupt reclosure 11%, repeat PTCA 11%, and CABG 6%. Intralesional tPA with intracoronary heparin causes prolonged thrombolysis without thrombin activation and reduces the extent of coronary thrombus in the setting of unstable angina. It is associated with a high PTCA success rate and favorable in-hospital outcome. Further investigations of this method of local adjunctive thrombolysis and PTCA are warranted.