Management of evolving myocardial infarction by intracoronary thrombolysis and subsequent aorta-coronary bypass

Abstract

From February, 1980, through May 1, 1981, nonsurgical recannulation of acutely thrombosed coronary arteries by selective intracoronary infusion of streptokinase and plasminogen was attempted in 72 patients in our institution. All patients were admitted to the hospital within 4 hours after the onset of symptoms of acute myocardial infarction, and in all patients significant electrocardiographic changes were noted. Re-establishment of orthograde coronary blood flow was achieved in 56 patients. The overall mortality was 13% (9/72 patients). Twenty patients (28%) required early surgical coronary revascularization because of persistent subtotal stenosis, intermittent severe coronary spasm, or unstable angina. Six patients (8%) presented with a history of previous myocardial infarction. One patient had a large anterior left ventricular aneurysm and another patient had significant mitral valve disease, both of which were treated surgically concomitantly with coronary revascularization. Seven patients received single aorta-coronary bypass grafts, nine patients received double grafts, two patients received triple grafts, and two patients received quadruple grafts. The mean interval between thrombolysis and aorta-coronary bypass was 3.9 days. Six patients underwent operation within 8 hours of thrombolysis. There were no early deaths, but there was one late sudden death 4 months after operation and there was one instance of reinfarction owing to severe coronary spasm in the presence of graft occlusion. Seventeen of 20 patients undergoing operation were restudied angiographically. The overall graft patency rate was 81%. Left ventricular ejection fractions, calculated from the right anterior oblique projection of the left ventricular angiogram, increased from 42% at the time of intracoronary lysis to 55% at the time of restudy. Early aorta-coronary bypass may be safely combined with successful thrombolysis using selective intracoronary streptokinase with plasminogen in the setting of acute myocardial infarction, and early operation may be useful in preventing reocclusion of the previously thrombosed vessel.