Intracoronary Thrombolysis and Early Bypass Surgery for Acute Myocardial Infarct: Five Years' Experience

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Abstract
During the five-year period between March 1980 and February 1985 selective intracoronary thrombolysis with streptokinase was performed in 469 patients with clinical and ECG signs of acute transmural myocardial infarct. Coronary arteriography prior to thrombolysis showed the infarct related vessel still or again patent in 21 % of the patients. Among 372 patients with complete occlusion streptokinase infusion was successful in 87%, but failed in 13%. Due to the high risk of reocclusion, early bypass surgery was performed in 69 patients (18.5 %) of the successfully reperfused group. Indication was based primarily on an ischemic time interval of less than 4 hours between the acute onset of clinical symptoms and reperfusion. Early mortality was 1.5 % in this surgically treated group and actuarial survival was 92 % at 5 years with all but 3 patients in functional class I or II. Marked but non-fatal early congestive heart failure was more significant when patients underwent operation within the first 2 days after thrombolysis than thereafter. Late recatheterization studies in 29 patients showed a slight but statistically insignificantly higher occlusion rate for vein grafts to the infarct vessel (14 %) than to concomitantly grafted arteries (6 %). No correlation was found between the initial ischemic time interval and graft patency. Late left ventricular function was excellent or minimally impaired in 52 % of these patients while 48 % had significantly reduced LV function. Again, no correlation was found between the ischemic time interval and late LV function. LV aneurysm, however, occurred only in patients with an ischemia of more than 3 hours. Thrombolysis combined with early bypass surgery represents the optimal therapy for acute myocardial infarct. In patients with single vessel disease simultaneous or early PTCA may be an alternative to surgical treatment.

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