Pontage coronarien et défibrination après thrombolyse à la phase aiguë d'un infarctus du myocarde

Abstract

Coronary bypass was carried out in four patients who have received an intracoronary streptokinase infusion for acute myocardial infarction. Indications for emergency operation were a myocardial ischaemia time of less than 4 h and a slow flow in the reopened artery despite percutaneous transluminal coronary angioplasty. Two patients were in cardiogenic shock treated by inotropic drugs and intra-aortic balloon pump. In all cases, the level of fibrinogen was less than 1 g · 1 −1. During the operation, the fibrinolysis was stopped by the intravenous injection of aprotinine (3 000 000 U × 2) and tranexamic acid (15 mg · kg −1), the coagulation factors used by the fibrinolysis being replaced by fibrinogen (1 g per litre of blood volume) and fresh plasma (6 to 8 packs in function of the haemodynamic state). Patient heparinization was as usual (300 IU · kg −1). At the end of the cardiopulmonary bypass, after injection of protamine, clotting quality was good and the fibrinogen level was more than 1 g · 1 −1. In the postoperative period, blood loss was of little importance. Coagulation troubles due to therapeutic fibrinolysis were reversible. It was possible to return quickly the patient's coagulation state to normal, and so carry out emergency coronary arterial surgery in a defibrinated patient. The indications for surgery depended on cardiogenic factors only.