Appropriate timing of surgical intervention after transmural acute myocardial infarction

OBJECTIVE: Recommended timing of coronary revascularization after transmural acute myocardial infarction ranges from immediate surgical intervention to repair 4 weeks after infarction. Such wide variation has created a dilemma in the management of these patients. The objective of this study was to delineate the optimal timing of revascularization after transmural acute myocardial infarction in a large and contemporary patient population. METHODS: We performed a retrospective multicenter analysis of 32,099 patients who underwent coronary artery bypass grafting as the sole procedure after transmural myocardial infarction between 1991 and 1996 by 179 surgeons at 33 hospitals in New York State. RESULTS: Overall hospital mortality for all patients who underwent coronary revascularization with a history of transmural myocardial infarction was 3.3%. Hospital mortality decreased with increasing time interval between revascularization and transmural acute myocardial infarction: 14.2%, 13.8%, 7.9%, 3.8%, 2.9%, and 2.7% for less than 6 hours, 6 hours to 1 day, 1 to 3 days, 4 to 7 days, 7 to 14 days, and greater than 15 days, respectively. Multivariate analyses of 43 potential risk factors suggests that revascularization within 3 days of transmural acute myocardial infarction is independently associated with mortality. CONCLUSIONS: Coronary revascularization within 3 days of a transmural acute myocardial infarction might be an added risk for mortality. In the absence of absolute indications for emergency surgical intervention, such as structural complications and ongoing ischemia, a 3-day waiting period before surgical revascularization should be considered.     

Early operative intervention after thrombolytic therapy for acute myocardial infarction

Thrombolytic therapy effectively interrupts acute myocardial infarction but does not correct the underlying plaque causing acute thrombosis. Early operation and treatment of the residual coronary artery disease has therefore been evaluated. Over 29 months, 184 patients with acute myocardial infarction of less than 6 hours duration were treated with intracoronary (IC) or intravenous (IV) streptokinase (SK). Angiography was performed early and thrombolysis found to be successful in 70% of the IC-SK group and 82% of the IV-SK group. One hundred six patients with successful thrombolysis had early revascularization surgery performed 3.3 +/- 2.1 days following SK treatment (range 0 to 11 days). These patients were compared with 110 consecutive patients who underwent coronary artery bypass grafting for standard indications. The SK group had an average of 3.0 +/- 1.4 grafts, 4.3 +/- 3.1 units of blood, and 10.8 +/- 5.3 days in the hospital postoperatively per patient and had an operative mortality rate of 2.7%. The control group averaged 3.6 +/- 1.3 grafts, 4.0 +/- 2.4 units of blood, and 9.6 +/- 3.5 days in the hospital postoperatively per patient with an operative mortality rate of 2.7%. This experience indicates that early operation following SK therapy can be performed with low operative risk and without prolonged hospitalization.     

Myocardial surgical revascularization after streptokinase treatment for acute myocardial infarction

Eighty-six patients admitted with evolving myocardial infarction within 6 hours of symptom onset were treated with streptokinase. Thirty-nine received intracoronary streptokinase, and 47 received intravenous streptokinase. There were no streptokinase-related complications. Twenty-three patients treated with intracoronary streptokinase and 28 patients receiving intravenous streptokinase underwent coronary artery bypass grafting. On admission, 16 patients receiving intracoronary streptokinase had electrocardiographic evidence of anterolateral evolving myocardial infarction and seven had evidence of inferior evolving myocardial infarction. Time from first symptom to intracoronary streptokinase was 4.4 +/- 1.6 hours. In seven patients, intracoronary streptokinase failed to open the obstructed coronary. All developed severe left ventricular hypokinesia in the area supplied by that coronary artery. In spite of recanalization, nine of 14 patients developed severe hypokinesia in the supplied area, and one an apical aneurysm. Four patients developed mild to moderate hypokinesia, and one had no left ventricular damage. On admission, 14 patients receiving intravenous streptokinase had electrocardiographic evidence of anterolateral evolving myocardial infarction and four had evidence of inferior evolving myocardial infarction. Time from first symptom to intravenous streptokinase was 3.2 +/- 1.5 hours. In seven patients, intravenous streptokinase failed to open the coronary, and all developed severe hypokinesia of the supplied area, with formation of apical left ventricular aneurysm in three. In 21 patients, intravenous streptokinase opened the artery. Eighteen angiographies performed 9.6 +/- 7.9 days after therapy showed a normal left ventricle in eight patients, moderate hypokinesia in seven, and severe hypokinesia in three. Time from first symptom to therapy was shorter in the patients receiving intravenous therapy (p less than 0.01). Coronary artery bypass grafting and four resections after left ventricular aneurysm were performed without operative death. Two patients receiving intracoronary therapy died in the hospital, and one died 2 months later from arrhythmias. Freedom from angina and rehabilitation (New York Heart Association Class I) were achieved in 69.5% of patients receiving intracoronary streptokinase and in 75% of patients receiving intravenous streptokinase. Thus streptokinase-induced thrombolysis salvages myocardium, and the intravenous route seems as effective as the intracoronary. Advantages of the former are earlier administration that might increase myocardial salvage, no invasive procedure, and lesser cost.     

Cost-effectiveness of primary percutaneous coronary intervention versus thrombolytic therapy for acute myocardial infarction

OBJECTIVES: We sought to determine the long-term cost-effectiveness of two reperfusion modalities in patients with acute ST-segment elevation myocardial infarction: primary percutaneous coronary intervention (PCI) versus thrombolytic therapy. DESIGN: A state-transition model that follows patients from when they develop STEMI until they die was developed. The model encompassed events and health states. Sensitivity analyses were undertaken. RESULTS: For a 65-year old man, life expectancy was 8.3 years with primary PCI and 7.6 years with thrombolytic therapy. The lifetime costs were 19,250 euros (NOK 154,000) and 29,250 euros (NOK 234,000), respectively, for patients living close to an invasive unit. Cost savings from PCI were mainly due to the reduction in future coronary interventions. For patients needing helicopter transport to arrive in time to an invasive unit for PCI, the costs were 24,000 euros (NOK 192,000) and 29,250 euros (NOK 234,000), respectively (all costs undiscounted). For women, the estimates were somewhat higher due to lower mortality. CONCLUSION: Compared with thrombolytic therapy, reperfusion by primary PCI results in greater health benefits at reduced lifetime costs. These findings may have important clinical implications in an increasing cost-conscious health care environment.     

Surgery for acute myocardial infarction

We discuss the current status and outcome of surgery for acute myocardial infarction (AMI). The optimal timing of surgical revascularization following AMI is a matter of controversy. Early surgery after an AMI involves high risk If elective surgery is possible under mechanical cardiac support cardiac artery bypass grafting (CABG) can be performed with acceptable mortality rates early after AMI. On-pump beating heart revascularization is efficacious in patients in cardiogenic shock or with unstable hemodynamics early after AMI. For postinfarct ventricular septal perforation, an infarct exclusion technique is a standard surgical procedure. For an oozing-type postinfarction left ventricular free wall rupture, a sutureless technique is effective. For papillary muscle rupture, emergent mitral valve replacement concomitant with CABG is recommended.     

Acute type A aortic dissection combined with surgical treatment with acute myocardial infarction

Acute myocardial infarction, as a result of coronary malperfusion caused by acute type A aortic dissection, has been identified as one of significant factors relating to operative mortality. This complication could be diagnosed with a combination of electrocardiography and echocardiography in acute phase. However, the indication of coronary angiography and/or intervention has been controversial as it is time-consuming and renders additional stress to a critical patient requiring an emergency operation. We report a case of myocardial infarction successfully treated with percutaneous transluminal coronary angioplasty (PTCA) at first, after that, recognition of dissection of aorta necessitated subsequent surgical therapy. In this particular case, coronary intervention in advance proved to be mandatory.     

急性心肌梗死患者遵医行为和护理干预的调查分析

目的探讨护理干预对急性心肌梗死患者遵医行为的影响。方法对156例门诊急性心肌梗死患者按遵医行为分组调查,并针对调查结果对患者进行个体化护理干预分析。结果急性心肌梗死给予常规心理护理组的患者康复效果明显低于针对性护理干预组（P〈0.01）。结论针对急性心肌梗死患者依从性不良的相关因素,需采取个体化的护理干预,以增加急性心肌梗死患者对疾病和治疗的认识,减轻患者的焦虑程度,提高治疗效果,从而减少并发症的发生,促进心脏功能的恢复。     

急性心肌梗死急诊介入治疗中替罗非班冠状动脉内注入对疗效的影响

目的观察急性心肌梗死患者急诊经皮冠状动脉介入治疗（PCI）术中冠状动脉内应用替罗非班的临床疗效。方法76例急性心肌梗死患者随机分为替罗非班组（39例）和对照组（37例）,均于发病12h内行急诊PCI。替罗非班组PCI术中冠状动脉内注入替罗非班,并静脉维持48h,术后应用达肝素钠注射液。对照组PCI术中仅给予普通肝素。两组PCI术前均服用氯吡格雷、阿司匹林。观察PCI术前、术后梗死相关血管心肌梗死时溶栓（TIMI）血流、心肌灌注分级（TMPG）、术后2周内并发症及主要心脏不良事件的发生情况。结果替罗非班组PCI术后TIMI 3级占94.9％（37／39）,高于对照组的78.4％（29／37）,替罗非班组TMPG 3级占89.7％（35／39）,高于对照组的67.6％（25／37）,两组比较差异均有统计学意义（P值均〈0.05）。替罗非班组主要心脏不良事件的发生率7.7％（3／39）低于对照组的18.9％（7／37）（P〈0.05）,出血发生率与对照组比较差异无统计学意义（P〉0.05）。结论PCI术中冠状动脉内应用替罗非班能改善急性心肌梗死患者梗死心肌的再灌注,减少术后主要心脏不良事件的发生率,且安全性好。     

导管血栓抽吸联合冠状动脉支架植入治疗急性心肌梗死

目的冠状动脉内血栓是影响急性心肌梗死(AMI)介入治疗效果的重要因素,本研究通过冠状动脉内血栓抽吸,并联合球囊成型及支架植入术治疗AMI,评价其安全性、有效性。方法进行急诊PCI的AMI患者共52例,对其中20例进行冠状动脉内血栓抽吸,然后进行球囊扩张及支架植入治疗。术后造影观察冠状动脉扩张效果及梗死相关血管血流及心肌灌注等情况。结果抽吸组即刻血栓消失16例,血栓减少4例。和未抽吸组比较梗死部位前向血流由术前TI-MI 0级(无血流)均达到TIMI 3级(正常血流),术中及术后无严重并发症。而未抽吸组术后前向血流TIMI 1级(血流严重受损)1例(占3.1%),2级(正常血流但较慢)9例(占28.1%),3级22例(占68.8%),二者有明显差异(P<0.05)。结论经导管进行冠状动脉内血栓抽吸,是治疗冠状动脉狭窄合并血栓病变的简单有效的方法,并可提高经皮冠状动脉介入治疗的成功率及减少无再流等并发症的发生。     

延迟经皮冠状动脉介入治疗急性心肌梗死的近期并发症

目的探讨延迟经皮冠状动脉介入治疗对于急性心肌梗死(AMI)的安全性。方法对486例AMI患者(包括108例非ST段抬高型心肌梗死和378例ST段抬高型心肌梗死患者)行延迟经皮冠状动脉介入治疗,回顾分析术中和术后1周内的并发症。结果所有486例患者中,无复流4例(4/486,0.82%),慢血流6例(6/486,1.23%),冠状动脉破裂2例(2/486,0.41%),急性血栓形成3例(3/486,0.62%),冠状动脉内夹层1例(1/486,0.21%),支架脱落3例(3/486,0.62%),死亡6例(6/486,1.23%)。结论延迟经皮冠状动脉介入治疗AMI并发症发生率相对较低,适于基层医院开展。     

Stanford type A acute dissection developing acute myocardial infarction.

A 75-year-old female, exhibiting epigastric pain and vomiting, underwent treatment for acute gastritis. She also experienced incontinence of urine and chest pain. A diagnosis of acute myocardial infarction was made upon examination of electrocardiographic findings and the patient was transferred to our hospital. Diffuse infarction of the left ventricle and acute aortic dissection (Stanford type A) were diagnosed by electrocardiographic and echo-cardiography. An emergency operation was performed. After induction of anesthesia, elevation of pulmonary artery pressure and fall of pulse pressure were observed, indicating acute cardiac tamponade. Transesophageal ultrasonography disclosed the entry of dissection in the descending aorta. Dissection of the aorta extended proximally up to the annulus of the aortic valve and the right and left coronary arteries were compressed by its aneurysm. As aortic insufficiency was mild, only reconstruction of the ascending aorta was carried out. The patient was discharged in fair condition one month after operation under use of postoperative long-term administration of catecholamines.     

Surgical treatment for complications of acute myocardial infarction

Objective: We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction. Methods: We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74±8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72±5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP. Results: The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%. Conclusion: The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.     

A successful surgical repair of ventricular septal perforation following acute myocardial infarction in a 83-year-old man

A 83-year-old man, who experienced a sudden severe malacia 13 days before, was admitted, complaining of dyspnea since 8 hours before. A loud systolic murmur of Levine IV/VI was audible on the left sternal border of the 4th intercostal space. The chest X-ray film demonstrated severe pulmonary congestion. The ECG showed abnormal Q waves in II, III, a VF and V1-5. The right heart catheterization revealed an intraventricular shunt from left to right and thus ventricular septal perforation (VSP) 13 days after acute anteroseptal-inferior myocardial infarction was diagnosed. Continuing an aggressive medical treatment with the intraaortic balloon pumping, an emergency operation for VSP was performed 2 days after the onset. A single Teflon patch was sutured on the left side of the septum around VSP (2.5 x 2.5 cm) and the ventricular free wall was closed including the patch with two felt strips. The patient survived through the operation and is doing well at the 11 months of follow-up. Twenty patients above 70 years old have been surgically treated with success for VSP after acute myocardial infarction in Japan. Our patient was the oldest.