Acute complications of elective coronary angioplasty: a review of 500 consecutive procedures.

In 500 consecutive procedures of elective coronary angioplasty attempted at a centre with a primary success of 86%, one or more major acute complications occurred in 34 cases (6.8%). Twenty four patients (4.8%) sustained an acute myocardial infarction (in six this was despite emergency coronary artery bypass surgery) and two patients (0.4%) had emergency coronary bypass without myocardial infarction. Ventricular fibrillation was a complication without sequelae in five (1.0%) patients; one (0.2%) patient died because of refractory ventricular fibrillation and ensuing electromechanical dissociation. "Benign" coronary artery rupture occurred in one (0.2%) patient, and one (0.2%) patient had elective coronary surgery to retrieve the tip of a fractured guide wire after an otherwise successful angioplasty. Despite a low mortality, coronary angioplasty is associated with major complications in about one of 14 procedures; the complication is usually acute myocardial infarction caused by occlusion of the vessel.     

Coronary angioplasty in unstable angina. Immediate and short-term results

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in 67 consecutive patients with unstable angina. Twenty patients had new onset (less than 2 months) angina, 33 patients had crescendo angina and 14 had early postinfarction angina. Fifty-one patients had one-vessel disease, 12 patients had two-vessel disease and two patients had three-vessel disease; two patients had a stenosis of a venous graft. In cases with multivessel disease, we performed only the dilatation of the ischaemia-related vessel identified by morphologic features of coronary lesion and electrocardiographic changes during chest pain. The procedure was successful in 54 cases (80.6%). Seven patients (10.4%) had major complications. Emergency coronary artery bypass graft surgery was performed in 6 cases (8.9%) because of occlusion of the left anterior descending artery; despite emergency operation one patient died and two patients sustained a myocardial infarction. One patient had occlusion of the right coronary artery and inferior myocardial infarction. In all patients in whom angioplasty was successful unstable angina disappeared. At 6 months follow-up there were no infarctions or deaths but 14 of 42 patients (33%) had recurrent angina. Restenosis occurred in 16 of 33 patients (48%) who had repeat coronary angiography. Four patients with recurrence of unstable angina had repeat angioplasty; it was successful in 3 cases. One patient died of refractory cardiac arrest. The mortality rate of 71 procedures performed in 67 patients was 2.8% (2/71) and the overall myocardial infarction rate was 4.2% (3/71).(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute complications of elective coronary angioplasty: a review of 500 consecutive procedures

In 500 consecutive procedures of elective coronary angioplasty attempted at a centre with a primary success of 86%, one or more major acute complications occurred in 34 cases (6.8%). Twenty four patients (4.8%) sustained an acute myocardial infarction (in six this was despite emergency coronary artery bypass surgery) and two patients (0.4%) had emergency coronary bypass without myocardial infarction. Ventricular fibrillation was a complication without sequelae in five (1.0%) patients; one (0.2%) patient died because of refractory ventricular fibrillation and ensuing electromechanical dissociation. "Benign" coronary artery rupture occurred in one (0.2%) patient, and one (0.2%) patient had elective coronary surgery to retrieve the tip of a fractured guide wire after an otherwise successful angioplasty. Despite a low mortality, coronary angioplasty is associated with major complications in about one of 14 procedures; the complication is usually acute myocardial infarction caused by occlusion of the vessel.     

Angioscopic observation of the coronary luminal changes induced by percutaneous transluminal coronary angioplasty

Coronary luminal changes induced by percutaneous balloon or laser coronary angioplasty were examined angioscopically in 10 patients with ischemic heart disease. A fiberscope (2.6F to 5.3F) was introduced into the coronary artery with the use of a guiding catheter with or without a balloon at the tip. Angioscopy was successful before angioplasty in nine and after angioplasty in 10 of 11 coronary segments. Before angioplasty, the stenotic segments were composed of yellowish or whitish atheromatous plaques with smooth surfaces or spiral folds in patients with stable angina pectoris. In one patient with unstable angina pectoris, the stenotic segment was scalloped angiographically and showed an irregular and whitish plaque angioscopically. After angioplasty, endothelial exfoliation with scattered thrombi (10 segments), bellows-like folds (two), longitudinal cleft (one), plaque rupture (two), and intimal dissection (two) could be identified angioscopically. These changes, with the exception of dissection, could not be identified angiographically. In one patient who underwent thermal argon laser angioplasty, the dilated segment appeared brownish, which indicated carbonization. In one patient with acute myocardial infarction, the occlusive thrombi were vaporized by thermal laser angioplasty. The results demonstrate the clinical feasibility of percutaneous angioscopy for pathologic documentation of coronary luminal changes before and after angioplasty.     

Desirability of immediate surgical standby for coronary angioplasty

OBJECTIVE--To assess the value of emergency surgical standby for percutaneous transluminal coronary angioplasty. DESIGN--Retrospective review of the major complications of coronary angioplasty in a regional cardiac centre. SETTING--All angioplasties were performed in the cardiac catheterisation laboratory of Wythenshawe Hospital with surgical standby in an adjoining operating theatre. PATIENTS--1262 vessels were dilated in 1032 patients (mean age 53 years) between 1984 and 1989. MAIN OUTCOME MEASURES--In-hospital mortality from emergency surgical revascularisation after angioplasty; the rate of myocardial infarction and overall morbidity. RESULTS--Coronary angioplasty achieved primary success in 90% of cases. Thirty eight (3.7%) patients (five women (mean age 55.8) and 33 men (mean age 53.0] were referred for urgent surgical revascularisation--36 direct to operation and two within 24 hours. All patients survived surgery. Five of the 38 had had a previous angioplasty to the same vessel and one had had previous coronary artery grafts. Four of the 38 had an angioplasty for unstable angina. Eighteen had single, 13 double, and seven triple vessel coronary artery disease. The target vessel was the left anterior descending in 25, right coronary artery in nine, circumflex in three, and the left anterior descending and circumflex coronary arteries in one. Five required external cardiac massage on the way to the operating theatre; two of them had a left main stem occlusion. Four internal mammary artery and 60 reversed saphenous vein grafts were implanted (1.6 per patient). Complete revascularisation was achieved in 36 (94.7%) patients. Q wave myocardial infarction occurred in six (15.8%). The final outcome was: none dead, three patients with angina, one late death, one cerebrovascular accident, one late operation for a new left anterior descending lesion, two patients on diuretics with or without an angiotensin converting enzyme inhibitor. One orthotopic transplant was performed in a patient in whom cardiogenic shock developed after the left anterior descending coronary artery became occluded 72 hours after angioplasty. CONCLUSION--There was no surgical mortality and low morbidity among patients for whom immediate surgical cover was requested.     

Desirability of immediate surgical standby for coronary angioplasty.

OBJECTIVE--To assess the value of emergency surgical standby for percutaneous transluminal coronary angioplasty. DESIGN--Retrospective review of the major complications of coronary angioplasty in a regional cardiac centre. SETTING--All angioplasties were performed in the cardiac catheterisation laboratory of Wythenshawe Hospital with surgical standby in an adjoining operating theatre. PATIENTS--1262 vessels were dilated in 1032 patients (mean age 53 years) between 1984 and 1989. MAIN OUTCOME MEASURES--In-hospital mortality from emergency surgical revascularisation after angioplasty; the rate of myocardial infarction and overall morbidity. RESULTS--Coronary angioplasty achieved primary success in 90% of cases. Thirty eight (3.7%) patients (five women (mean age 55.8) and 33 men (mean age 53.0] were referred for urgent surgical revascularisation--36 direct to operation and two within 24 hours. All patients survived surgery. Five of the 38 had had a previous angioplasty to the same vessel and one had had previous coronary artery grafts. Four of the 38 had an angioplasty for unstable angina. Eighteen had single, 13 double, and seven triple vessel coronary artery disease. The target vessel was the left anterior descending in 25, right coronary artery in nine, circumflex in three, and the left anterior descending and circumflex coronary arteries in one. Five required external cardiac massage on the way to the operating theatre; two of them had a left main stem occlusion. Four internal mammary artery and 60 reversed saphenous vein grafts were implanted (1.6 per patient). Complete revascularisation was achieved in 36 (94.7%) patients. Q wave myocardial infarction occurred in six (15.8%). The final outcome was: none dead, three patients with angina, one late death, one cerebrovascular accident, one late operation for a new left anterior descending lesion, two patients on diuretics with or without an angiotensin converting enzyme inhibitor. One orthotopic transplant was performed in a patient in whom cardiogenic shock developed after the left anterior descending coronary artery became occluded 72 hours after angioplasty. CONCLUSION--There was no surgical mortality and low morbidity among patients for whom immediate surgical cover was requested.     

Coronary histology after percutaneous transluminal coronary angioplasty

This article describes previously unreported histologic changes in the vessels of a patient who was admitted with an evolving myocardial infarction due to subtotal occlusion of the left anterior descending coronary artery. The patient died of cardiogenic shock 15 hours after undergoing a technically successful percutaneous transluminal coronary angioplasty procedure. Upon early postmortem study, histologic sections from the proximal, middle, and distal thirds of the left anterior descending coronary artery were polymorphic in appearance. Sections from the most proximal angioplasty site revealed intimal proliferation of polymorphonuclear leukocytes, as well as intimal fibrosis with plaque cleavage. Sections from the more distal angioplasty sites revealed plaque cleavage, intimal polymorphonuclear infiltration, and intimal, medial, and adventitial fracture with dissecting hemorrhage, although mural integrity had been maintained. Intense subintimal proliferation with inflammatory cells has previously been described only in an experimental animal model. Our case also appears to be the first in which adventitial disruption has been observed after percutaneous transluminal coronary angioplasty; this finding provides new evidence that an atherosclerotic coronary artery can tolerate vigorous dilatation without rupture.     

Prospective study of the incidence, pathogenesis and therapy of spontaneous, by coronary angiography diagnosed coronary artery dissection

Spontaneous coronary artery dissection is a rare cause of ischemic heart disease. Incidence, etiology and optimal treatment are ill-defined. Between July 1995 and December 1997, we prospectively identified 42 patients (36 men, six women, mean age 59 +/- 12 years) with spontaneous coronary artery dissection among 3803 consecutive angiographic examinations in which the diagnosis of coronary artery disease was established for the first time (incidence 1.1%). In comparison to the remaining study population with stable angina pectoris (8 cases of spontaneous coronary artery dissection among 2852 patients; incidence: 0.3%), the incidence of spontaneous coronary artery dissection was significantly higher in the patient subgroups with acute myocardial infarction (13/450; 2.9%) and with unstable angina pectoris or postinfarction angina (21/501; 4.2%). Dissection was most frequently located in the left anterior descending coronary artery (19 cases), followed by the right coronary artery (15 cases) and the left circumflex coronary artery (8 cases). Because of an ambiguous angiographic lesion appearance intravascular ultrasound imaging was performed in 13 patients to confirm the diagnosis. The presumed etiology of spontaneous coronary artery dissection was atherosclerotic plaque rupture in 35 cases, heavy physical exercise in four cases and hormonal influences related to pregnancy and contraception in one case. In two cases, no obvious risk factor could be identified. Therapy consisted of intracoronary stenting in 24 patients (including ten patients with acute myocardial infarction), coronary artery bypass grafting (CABG) in 8 patients and balloon angioplasty (PTCA) in seven patients. Three patients were treated conservatively. During a mean follow-up period of 13.5 +/- 9.9 months, two patients died and 31 patients remained entirely asymptomatic, including all patients who were treated with CABG. Restenosis developed in three patients after stent implantation (restenosis rate: 12.5%). Following primary PTCA, spontaneous coronary artery dissection recurred in two patients, one of whom subsequently died.     

Outcome of early surgery after coronary angioplasty

Nineteen of 69 patients undergoing coronary angioplasty required immediate coronary surgery after the procedure. Six of these operations were planned as a result of angioplasty that failed without producing any complication. The remaining 13 cases were operated upon because complications occurred during angioplasty. These were coronary artery dissection in four, occlusion in five, continuing severe spasm in two, tamponade in one, and in one other detachment of a guidewire tip. In these 13 cases the vessel in which angioplasty had been attempted was the left anterior descending coronary artery in eight, the right in four, and the circumflex artery in one. This distribution was no different from that in the 56 patients without complications. There was one early postoperative death due to extensive anterior myocardial infarction, and there was electrocardiographic evidence of new infarction in three other patients. A mean of 16 months postoperatively, 16 of the 18 surviving patients had no cardiac symptoms, while angina had improved in the remaining two. Sixteen of the 18 patients had nuclear left ventricular angiography after a mean of 27 months. When the results of this investigation were compared with the left ventricular cineangiograms performed before angioplasty was attempted only two patients showed evidence of a new left ventricular wall motion abnormality. Prompt operation after complications of angioplasty is usually successful with good symptomatic relief and without left ventricular damage. The incidence of complications requiring operation, however, was high in this group of patients, most of whom had single vessel coronary artery disease.     

Transluminal percutaneous coronary angioplasty of the left coronary artery]

This paper describes our preliminary experience with left main coronary angioplasty in 8 patients (9 procedures). In 6 patients the left main coronary artery was "protected" either by previous by-pass surgery (4 patients) or by collateral vessels from the right coronary artery (2 patients). Three patients had a total occlusion of the left main coronary artery and 2 of them had a recent or acute myocardial infarction and the coronary angiogram suggested a thrombotic occlusion of the infarct-related artery. Three patients were not considered surgical candidates and an additional patient, who was in cardiogenic shock, required an emergency coronary angioplasty as "rescue" procedure. A successful dilatation was achieved in 6 patients (including a patient with successful deployment of a Palmaz-Schatz stent) but, unfortunately, one them eventually died 7 days later from a femoral sepsis related to the procedure. However in the 2 remaining patients--with a total occlusion of the left main coronary artery in relation with a myocardial infarction--the dilatation procedures were unsuccessful. One patient underwent a successful repeat coronary angioplasty for restenosis of left main coronary artery. Our preliminary experience confirms previous reports suggesting the value of coronary angioplasty in patients with left main coronary artery disease providing a careful selection of possible candidates is performed prior to the procedure.     

Local morphologic effects of coronary artery balloon angioplasty

The morphologic effects of percutaneous transluminal coronary artery balloon angioplasty (PTCA) on atherosclerotic vessels is described in six patients who died at varying intervals after the procedure (four early and two late). In the early group (less than one week post PTCA) one patient died because of electromechanical dissociation during emergency PTCA for evolving infarct; in the three other patients PTCA was performed for left main occlusion and cardiogenic shock with deaths 3, 24 and 25 h after PTCA. The two late deaths were patients who died one and nine months after PTCA from unrelated causes. There were 12 sites of balloon inflation in the six patients, all in left main, isolated marginal or left anterior descending arteries. Post mortem examinations, with in toto serial sectioning of the ballooned coronary arteries, revealed a number of local morphologic changes. Plaque fractures and disruptions of the arterial wall to variable depths were observed. At four sites these fractures were through media, and at one site was associated with a large dissection. These cases had only small epicardial hemorrhages or reactive adventitial changes associated with these deep fractures. Four of the six patients had intramural arterial emboli (athero/thrombo/calcium/foreign body). These findings confirm that a large part of the effect of PTCA is due to physical disruption of plaque and underlying native vessel.     

Outcome of early surgery after coronary angioplasty.

Nineteen of 69 patients undergoing coronary angioplasty required immediate coronary surgery after the procedure. Six of these operations were planned as a result of angioplasty that failed without producing any complication. The remaining 13 cases were operated upon because complications occurred during angioplasty. These were coronary artery dissection in four, occlusion in five, continuing severe spasm in two, tamponade in one, and in one other detachment of a guidewire tip. In these 13 cases the vessel in which angioplasty had been attempted was the left anterior descending coronary artery in eight, the right in four, and the circumflex artery in one. This distribution was no different from that in the 56 patients without complications. There was one early postoperative death due to extensive anterior myocardial infarction, and there was electrocardiographic evidence of new infarction in three other patients. A mean of 16 months postoperatively, 16 of the 18 surviving patients had no cardiac symptoms, while angina had improved in the remaining two. Sixteen of the 18 patients had nuclear left ventricular angiography after a mean of 27 months. When the results of this investigation were compared with the left ventricular cineangiograms performed before angioplasty was attempted only two patients showed evidence of a new left ventricular wall motion abnormality. Prompt operation after complications of angioplasty is usually successful with good symptomatic relief and without left ventricular damage. The incidence of complications requiring operation, however, was high in this group of patients, most of whom had single vessel coronary artery disease.     

Unstable angina and evolving myocardial infarction following coronary bypass surgery: pathogenesis and treatment with interventional catheterization

Effective therapy for patients with unstable angina or evolving myocardial infarction following coronary bypass surgery requires accurate delineation of the pathoanatomy and prompt intervention. We therefore performed cardiac catheterization in 10 consecutive patients: four with acute myocardial infarction and six with refractory unstable angina (NYHA class IV). All patients with acute myocardial infarction were found to have completely thrombosed vein grafts supplying totally occluded native coronary arteries. In three patients with evolving myocardial infarction occurring within 4 weeks of coronary bypass surgery, graft thrombosis was caused by venous valves in two patients and a suboptimal anastomosis in a third. The fourth patient sustained a myocardial infarction 7 years after coronary bypass surgery with atherosclerotic plaque rupture causing vein graft thrombosis. Therapy with intragraft streptokinase resulted in complete clearing of thrombus, pain relief, and control of injury current in all four patients. Rest angina with concomitant ST and T wave changes occurred in six patients. In two patients symptoms occurred early (within 6 months), whereas angina developed 4 to 10 years after coronary bypass graft surgery in four patients. In the two patients with early recurrence of symptoms suboptimal anastomosis was found in one, while the other patient had a venous valve in the vein graft in conjunction with a stenosis in the native coronary artery. In three of four patients with late recurrence of angina, symptoms developed as a result of atherosclerotic stenosis in their vein grafts; in the fourth patient an occluded graft was found to supply a stenosed native coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary angioplasty for acute myocardial infarction complicated by cardiogenic shock on admission.

AIM: To evaluate primary angioplasty results for the treatment of acute myocardial infarction complicated by cardiogenic shock on admission. POPULATION AND METHODS: Retrospective analysis of 11 consecutive patients with acute myocardial infarction complicated by cardiogenic shock (defined as systolic blood pressure below 80 mmHg and signs of hypoperfusion, despite volume expanders and/or vasopressors infusion) treated with primary angioplasty. Clinical characteristics, angiographic data, hospital outcome and follow-up were analysed. RESULTS: There were ten males (90.9%) with a mean age of 66 years. Eight patients had anterior wall myocardial infarction and three patients had inferior wall myocardial infarction, two of which with extension to the right ventricle. The mean time between symptom onset and angioplasty was 3.5 hours. Three patients had left main coronary artery occlusion; three patients had single vessel disease and five patients had multivessel disease. The angiographic success rate (open infarct-related artery and TIMI III flow) was 90.9% (ten patients). Stent implantation was performed in five patients. Abciximab was given in five patients. In-hospital mortality rate was 36.4% (four patients). The surviving patients had a mean ejection fraction of 43.1% on discharge. In a mean follow-up of 16.2 months, one patient had coronary artery bypass graft and one had stroke. CONCLUSION: Based on published data, our experience with this short series of cases shows that primary angiography should be regarded as a positive option for the treatment of acute myocardial infarction complicated by cardiogenic shock.     

Myocardial infarction complicating exercise test performed 72 hours after coronary angioplasty]

The authors report a case of myocardial infarction complicating an exercise stress test performed 48 hours after successful angioplasty of a stenosed left anterior descending artery in a patient with unstable angina. Three similar cases have been previously reported. The probable mechanisms of coronary obstruction in this context are rupture of an atheromatous plaque, thrombosis and coronary spasm.     

Percutaneous transluminal coronary angioplasty in patients with prior myocardial infarction: angioplasty at a distance from the prior infarct zone

Patients undergoing coronary angioplasty who have had a prior transmural myocardial infarction in the distribution of a contralateral coronary artery are considered a high-risk group because of potentially severe left ventricular dysfunction if an ischemic complication occurs. The purpose of this study was to evaluate the safety and efficacy of coronary angioplasty in 28 patients with prior myocardial infarction remote from the artery undergoing dilatation. Prior myocardial infarction was defined by the presence of pathologic Q waves on ECG or segmental akinesis on ventriculography. Angioplasty was successful in 30 of 33 lesions (91%) and in 25 of 28 patients (89%). Mean stenosis diameter was reduced from 91% +/- 7% to 28% +/- 16%; mean translesional gradient after angioplasty was 6 +/- 5 mm Hg. No patient developed severe hemodynamic deterioration from transient coronary occlusion during balloon inflation or from an acute ischemic complication. Three patients underwent coronary artery bypass surgery after unsuccessful angioplasty. There were no new Q wave infarctions or deaths. The results of coronary angioplasty in patients with prior infarction were compared with those of 203 patients without prior remote infarction. Primary success and occurrence of major complications were comparable in both groups. At a mean follow-up of 12 +/- 6 months, 18 of the 25 patients (72%) who underwent initially successful dilatation have remained symptom free with angioplasty alone. Therefore, coronary angioplasty is a suitable therapeutic procedure in carefully selected patients with angina pectoris and prior myocardial infarction at a distance from the site of angioplasty.     

Percutaneous transluminal coronary angioplasty: Its potential impact on surgery for coronary artery disease

The potential impact of percutaneous transluminal coronary angioplasty on surgery for angina pectoris was evaluated in 500 consecutive patients referred because of intractable symptoms. A positive lesion, that is, one appropriate for percutaneous transluminal coronary angioplasty, was defined as proximal, discrete, segmental, subtotal, noncalcific and stenotic. Significant disease was observed in 1,079 major coronary arteries, of which 9.4 percent were not appropriate for bypass surgery. Positive lesions were observed in 115 arteries (10.7 percent); these were in the left anterior descending artery in 60; in the right coronary artery in 37 and in the left circumflex artery in 18 cases. Main left coronary artery disease was present in 31 patients with six lesions appropriate for coronary angioplasty. Of these six patients none had isolated left main coronary artery disease. Operable coronary lesions were noted in 474 patients of whom 105 (22 percent) had positive lesions appropriate for angioplasty. The age of patients with such lesions was not significantly different from that of the remaining patients. However, the duration of clinical heart disease was significantly (p <0.01) shorter in those with positive lesions, with the frequency of such lesions inversely related to duration of disease, and myocardial infarction was less frequent in those with angioplastic lesions (28.6 versus 43.5 percent, p <0.01). An ideal patient for percutaneous transluminal coronary angioplasty was defined as one with a positive lesion in all operable coronary arteries. Thus, 40 patients were considered ideal for this procedure and represented 8.4 percent of operable candidates. Thirty patients had single vessel disease (of the left anterior descending artery in 19, the right coronary artery in 8 and the circumflex artery in 3) and 10 had disease of two vessels. No patient with triple or left main coronary artery disease was ideally suited for percutaneous transluminal coronary angioplasty. The only factor that distinguished the patient ideally suited for angioplasty from the remaining patients was a shorter duration (2.0 versus 4.1 years) of clinical disease (p <0.01) and a lesser frequency (15 versus 43 percent) of myocardial infarction (p <0.01). Seven additional patients were noted as being less ideal for coronary angioplasty, but still potential candidates. It is concluded that percutaneous transluminal coronary angioplasty may play a role in only 8 to 10 percent of patients with angina pectoris.     

Rupture of a left ventricular papillary muscle during acute myocardial infarction: analysis of 22 necropsy patients

Certain clinical and cardiac morphologic findings are described in 22 patients, aged 45 to 80 years (mean 64) (15 men [68%]), in whom rupture of a papillary muscle occurred during acute myocardial infarction. In most, the acute infarction associated with papillary muscle rupture was a first coronary event (only 18% had a myocardial scar consistent with prior infarction and 29% had angina pectoris). The posteromedial papillary muscle, presumably because of its more tenuous blood supply, ruptured almost three times more frequently than the anterolateral one (73 and 27%, respectively). Quantitative examination of the amounts of narrowing by atherosclerotic plaque in each of the four major epicardial coronary arteries (right, left main, left anterior descending and left circumflex) disclosed less narrowing in the patients with rupture than in the patients with fatal acute myocardial infarction unassociated with rupture. Of the 519 five mm sections of coronary artery examined (11 patients), only 68 sections (13%) were narrowed greater than 75% in cross-sectional area compared with 34% of 1,403 sections from 27 patients with fatal myocardial infarction without rupture.     

Multiple myocardial infarctions: pancoronary destabilization evaluated by cardiac MRI

PURPOSE: Complete intravascular ultrasound study examination of all three coronary arteries in patients with first acute coronary syndrome very frequently revealed one or more atherosclerotic plaque ruptures associated with the culprit lesion. The aim of this study was to evaluate using cardiac MRI the incidence of multiple necroses in patients with myocardial infarction. The study sought to detect delayed enhancement in a zone different from the necrosis area concerned by the culprit occlusion. METHODS: Eighty consecutive patients who were referred for a first myocardial infarction underwent angioplasty within the first 12hours after chest pain beginning. Each patient was examined within four to eight days following the acute phase. Cardiac MRI evaluated left-ventricle function (TrueFISP sequence) and used a T2 weighted short-inversion-time, inversion recovery sequence (STIR) in order to visualize myocardial oedema; delayed enhancement imaging data were then acquired after injection of gadolinium. RESULTS: In eight patients (10%), we observed two delayed enhancement areas associated with wall-motion abnormalities. One was attributed to the culprit occlusion; the second corresponded to a different coronary artery. In five patients, this second zone was related to an old coronary occlusion confirmed by angiography and the STIR sequence. However, in three patients, the second delayed enhancement area corresponded to a coronary artery stenosis with normal flow. CONCLUSION: In patient with acute myocardial infarction, MRI sometimes detects a necrosis area which was not initially suspected. This observation illustrates the consequences of pancoronary destabilization.     

One-year follow-up after recombinant tissue plasminogen activator administered to patients with acute myocardial infarction

Of 106 patients seen within 4 h of chest pain with 107 episodes of acute myocardial infarction, nine died before or during hospitalization mainly from cardiogenic shock, and four died during the next year, three were sudden deaths. The 93 survivors were reviewed at a mean of 53 (range 49-70) weeks after infarction. Of these 93, 18 had had attempted angioplasty (successful in 12) and 15 had had coronary artery bypass grafting (including one patient who had coronary artery bypass grafting performed after unsuccessful angioplasty). The remaining 61 patients continued on medical therapy only. During the one-year follow-up two patients suffered reinfarction and a further 22 had one or more cardiac admissions, mostly for chest pain. At review, 22 patients had angina (16 New York Heart Association Grade I or II) and five dyspnoea (all NYHA Grade II). Forty-three patients were taking oral nitrates, 53 were receiving calcium antagonists, 54 were using betablocking agents and 73 used anti-platelet agents. However, many of these patients continued on anti-anginal therapy prophylactically after their myocardial infarction, without continuing chest pain. Thus after recombinant tissue plasminogen activator therapy and following hospital discharge the mortality rate for patients with acute myocardial infarction was four out of 97 (4.1%) and reinfarction rate among survivors was two out of 93 (2.2%). Although the incidence of cardiac symptoms was low this may be partly due to the high incidence of angioplasty and coronary artery grafting, together with the use of anti-anginal agents.