International experience with percutaneous transluminal coronary recanalization by streptokinase-thrombolysis reperfusion in acute myocardial infarction: new, safe, landmark therapeutic approach salvaging ischemic muscle and improving ventricular function

False aneurysm formation after ventricular rupture associated with reinfarction following successful thrombolysis

A 69-year-old woman underwent successful thrombolysis for total occlusion in the right coronary artery using urokinase. One week later, the patient developed reinfarction in the area supplied by the right coronary artery, followed by ventricular rupture. She was resuscitated with drainage of the pericardial effusion. Cardiac catheterization confirmed that the site of the right coronary artery reocclusion was identical to that in the acute phase. A false aneurysm developed over the true aneurysm located in the inferior portion of the left ventricle as demonstrated by a ventriculogram at the convalescent stage and at surgery. The orifice of the false aneurysm has closed by suture.

Streptokinase thrombolysis in experimental coronary artery thrombosis: pattern of reflow and effect of a stenosis

We studied recanalization of an obstructed left circumflex coronary artery by streptokinase in open-chest anesthetized dogs. Thrombotic occlusion was induced by a 100 microA anodal current selectively delivered to the intimal surface of the vessel. Intracoronary streptokinase (50,000 U) or saline was infused over a 50-min period beginning at either 30 min or 90 min after occlusion. Continuous recordings were made of antegrade circumflex flow and regional myocardial function, which was quantitated using sonomicrometer crystals in the regions of the left anterior descending and circumflex coronary arteries. In some experiments a fixed stenosis, having no effect on mean circumflex coronary artery blood flow, was placed at the site of subsequent thrombus formation. The presence of a stenosis decreased the weight of occlusive thrombi obtained from nonreperfused saline controls by 40% and increased the proportion of animals successfully reperfused by streptokinase from 13 to 76%. Streptokinase reduced thrombus mass by 44% in animals recanalized in the presence of the stenosis. On the average, reflow was established after 26 min of streptokinase infusion, was less in magnitude than pre-occlusion flow, and was unstable and intermittent, being marked by frequent reocclusions. Initiating treatment at 30 min or 90 min post-occlusion did not influence characteristics of the reflow. Return of myocardial contractility in the ischemic bed was not detected during the immediate reperfusion period in the majority of these experiments.

Patients with myocardial infarction and normal coronary arteriogram

Eighteen patients who survived an acute myocardial infarction were found to have a normal coronary arteriogram. Seven patients were younger than 35 years and six were female. The myocardial infarction was nontransmural in 11 cases. The mean follow-up was 21.6 months. Eleven patients developed residual chest pain at rest early after myocardial infarction. One, treated by beta-blockers, suffered a recurrent myocardial infarction. Eight became asymptomatic, and two improved under antispastic therapy. Another patient developed a severe form of variant angina three months after myocardial infarction; she died following plexectomy. Finally, two patients experienced rare episodes of angina at rest. The stress ECG was negative in all cases. Provocative test for spasm was positive in three out of nine patients. Diffuse narrowing associated with chest pain was demostrated in two patients at angiography. Thus, myocardial infarction and subsequent normal coronary angiogram are mainly found in young female patients, and infarction is often nontransmural. Clinical evidence of vasospastic phenomena and increased vasomotor tone are found in most patients. Whenever residual chest pain is controlled by antispastic therapy, the follow-up course seems benign.

Importance of follow-up medical and surgical approaches to prevent reinfarction, reocclusion, and recurrent angina following intracoronary thrombolysis with streptokinase in acute myocardial infarction

Thirty-four patients with acute myocardial infarction (mean age 55 years) who received intracoronary streptokinase for coronary thrombosis were followed for a mean of 9.4 months (longest 25 months) following the procedure of percutaneous transluminal coronary recanalization (PTCR). Twelve patients had undergone coronary artery bypass graft surgery (CABG), one had percutaneous transluminal coronary angioplasty (PTCA), and 21 received medical therapy. Among patients having CABG and PTCA, nearly 70% no longer had chest pain or reinfarction, and 62% were in New York functional class I status; there were no deaths, and there was only one reinfarction, in a patient who had graft closure. In contrast, 43% of medically treated patients had chest pain or reinfarction or had died on follow-up; only 32% of survivors were in class I functional status. Further, 71% of medically treated patients who were receiving warfarin had no chest pain and on reinfarction, whereas the majority (56%) of patients who did not receive either warfarin or antiplatelet agents either had chest pain or reinfarction or died. The importance of CABG/PTCA and anticoagulant therapy is stressed to prevent recurrent ischemia, reinfarction, and reocclusion following successful reperfusion by means of PTCR in acute myocardial infarction.