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Background: The results from studies of coronary angioplasty after failed thrombolysis (rescue-PTCA) in acute myocardial infarction are contradictory. Long-term results were not presented till now. Therefore we analyzed the data from our registry of those patients whose acute and long-term results were available., Patients and Methods: Data of 49 patients were analyzed who had been admitted for rescue-PTCA from other hospitals. Thrombolysis had to be started < 6 hours (mean 2.7 hours) from onset of symptoms. Rescue-PTCA had to be completed within < 24 hours (mean 10.5 hours). 37 patients received streptokinase, seven rt-PA, three urokinase and two prourokinase. Electrocardiographic and clinical criteria were used to define failure of thrombolysis. The data of the acute results were from a prospective registry and the long-term results came from clinical follow-up visits and a questionnaire sent to the patients., Results: Mean age of the patients was 48.5 years (38-78 years), 45 male, nine patients in cardiogenic shock (18%), infarct related artery (IRA): RCA 22x, LAD 21x, LCX 5x, CABG 1x, single vessel disease 27x, multiple vessel disease 22x. Acute results: Initial IRA-TIMI flow 0 in 28 patients, 1 in twelve patients, 2 in 9 patients; after rescue-PTCA TIMI flow 1 in one patient, 2 in two patients, 3 in 46 patients (procedural success 94%). Hospital mortality 8.2% (four patients), all in cardiogenic shock. Early reocclusion rate 10%. Bleeding complications 14%, no fatal complications. Long-term results: Observation period 2.5 years in 42 patients (0.5-6.5 years). Three more deaths. Total mortality 14% (7/49). Angiographic follow-up: Ejection fraction initially 50%; 53% after 3 months. Repeat revascularization in 43% (15/35): Re-PTCA in 8/35, surgery in 6/35 patients, 1x transplantation. 80% of the patients were free from angina or heart failure., Conclusions: Rescue-PTCA in acute myocardial infarction has a high procedural success rate with a low hospital mortality. It is the treatment of choice for patients in cardiogenic shock. Transportation to an interventional center is safe. The reintervention rate is comparably high. The long-term results are good.

Background and Objective: Coronary stents are used nowadays not only for the reduction of restenosis and for treating acute vessel occlusions after PTCA but also after acute myocardial infarction. This study was undertaken to determine whether widening the indications has affected the incidence of acute complications and to compare acute cardiac and vascular complications., Patients and Methods: The data on 197 consecutive patients (155 men, 42 women; mean age 62 +/- 9 [37-85] years) with coronary stents were analysed retrospectively, divided into 5 groups depending on the indications for the stent implantation: 1) acute or threatened vessel occlusion after elective PTCA ("bail-out"); 2) acute myocardial infarction (AMI); 3) unstable angina with threatened vessel occlusion; 4) suboptimal primary results (angiographically assessed) after PTCA; 5) elective stent implantation to prevent restenosis. Acute or subacute stent thrombosis, side-branch occlusion, intra- and transmural infarction, death and emergency aortocoronary bypass operation were classified as acute cardiac complications. Haemorrhage in the inguinal region requiring blood transfusion, false aneurysm and operative vascular reconstruction were classified as vascular complications., Results: An intended stent implantation was impossible in 18 patients (primary success rate 91%). Independent of indication an acute or chronic stent stenosis occurred in three (1.6%) and seven (3.9%) patients, respectively. Side-branch occlusion was observed in 12 patients (6.7%), transmural infarction in nine (5.6%). No emergency bypass operation had to be performed. Comparing the different indication groups there was a significantly increased rate of "non-Q" infarctions in patients with unstable angina pectoris (P < 0.014). Among acute vascular complications (10 [5%] inguinal haemorrhages requiring transfusion and 5 [2.5%] operative vascular reconstructions), false aneurysm was significantly more common in patients with AMI (P < 0.014). Comparing emergency and elective stent implantations, side-branch occlusions were significantly more common in the former (12% vs. 0%; P < 0.08), as were also "non-Q" infarcts (10% vs. 0%; P < 0.002)., Conclusion: Coronary stent implantation for these indications, including AMI, can be taken as firmly established. Stent thrombosis was not significantly increased after "bail out". Implantation in an acute ischaemic episode led to a significantly higher incidence of side-branch occlusion and "non-Q" infarction.

Background and Objective: The time elapsed until effective infarct vessel perfusion has been identified as an essential determinant of survival after acute myocardial infarction (MI). Significant mortality rate reduction has not been demonstrated for patients who received thrombolytic treatment more than 12 to 24 hours after MI. For this reason such patients have so far largely been denied reperfusion treatment and have thus been excluded from any potential benefit of an reopened infarct vessel. It was the aim of this study to assess the applicability and safety of achieving reperfusion by percutaneous transluminal coronary angioplasty (PTCA) without prior thrombolysis (primary PTCA) within 12 (> 12) to 24 (< or = 24) hours after onset of pain, taking into account early and late results in selected consecutive patients., Patients and Methods: The data were analysed retrospectively of 35 patients (29 men, 6 women; mean age 60 [49-78] years) who had been admitted and treated by primary PTCA for MI more than 12-24 hours after onset of pain, with persisting ECG changes and (or) continuing chest pain. Reperfusion rates, acute haemodynamic parameters, acute cardiac and noncardiac complications, 30-day mortality rate, 3-month angiographic results and late mortality rate were obtained after an average of 23 (4-36) months., Results: Complete infarct vessel reperfusion was achieved in 30 patients (85.7%), the infarct vessel remaining occluded in five. The early measurement of mean left ventricular ejection fraction was 53% (8-76%). A small, conservatively managed pericardial effusion occurred in one patient due to coronary artery penetration. Three patients who were in cardiogenic shock on admission died (8.6% 30-day mortality rate). Nine cases of restenosis and two of re-occlusion of the infarct vessel were documented in 24 patients who were investigated invasively 3 months after the primary PTCA. One patient had sustained a nonfatal MI. During the follow-up period one patient died of a noncardiac cause., Interpretation: In this selected group of patients who received treatment more than 12 to 24 hours after MI primary PTCA achieved a high rate of reperfusion, while early and late complications were rare. Using individualized criteria of patient selection, primary PTCA can accomplish recanalization. The question of prognostic advantage can only be answered by results in a larger and randomized cohort of patients.

Basic Problem and Objective: Percutaneous transluminal coronary angioplasty (PTCA) is being increasingly considered as an alternative to thrombolytic treatment of acute myocardial infarction. Studies performed so far, some on selected groups of patients, have produced high initial results of success. This prospective study was undertaken to determined primary success, complications and recurrence after primary PTCA in acute myocardial infarction (AMI)., Patients and Methods: Primary treatment in the form of immediate PTCA of the infarct vessel was undertaken in 111 patients (84 men, 27 women; mean age 58.6 +/- 10.3 years) with AMI. PTCA was judged successful if the infarct vessel had been reopened to perfusion grade 3 and restenosis was < 50%. No thrombolytic treatment was given, but heparin infusions were given during and for 24-48 hours after the procedure. 13 patients (11.7%) were in cardiogenic shock or required cardiopulmonary resuscitation for infarct-related arrhythmias., Results: The primary success rate of PTCA for the whole group was 91% (101 of 111 patients), but only 77% (ten of 13) among patients in cardiogenic shock and (or) after resuscitation. Acute re-occlusion (0-6 days after PTCA) occurred in seven patients. Eight patients (7.2%) died during the hospital phase (0-4 weeks), seven of whom had been in shock or required resuscitation (death rate 54%). The overall complication rate of the intervention was 6.3%. No emergency aortocoronary bypass was necessary. Repeat coronary angiography was performed in 71 of the 101 successfully treated patients 6 or 12 weeks after the PTCA. Re-occlusion was demonstrated in four (5.6%), a restenosis of more than 50% in 25% of patients. Mean left ventricular ejection fraction, obtained by planimetry from the levocardiogram was 58.6 +/- 9.3%., Conclusion: PTCA, performed immediately after acute myocardial infarction is an effective therapeutic measure with a high primary success rate.

In a 52-year-old patient with beginning dilatative cardiomyopathy dizziness and syncopes could be observed due to a ventricular bigeminy at rest and under exercise conditions. The patient also showed a marked reduction of exercise capacity and was handicapped in his profession as electrician and unable to work for more than 10 months. Antiarrhythmic drug therapy including the subsequent use of all available antiarrhythmic agents failed in suppressing this arrhythmia. In an electrophysiological study the arrhythmogenic focus could be localized in the right ventricular outflow tract. Application of radiofrequency current resulted in instantaneous termination of the extrasystoly; this result could be documented in repeat Holter monitorings over 12 weeks to present. This case report shows that radiofrequency catheter ablation can in special cases be applied for therapy of extrasystolic phenomena when clinical symptoms necessitate treatment and antiarrhythmic drug therapy fails.

In this case report the electrophysiological findings in a 24 year old female patient are demonstrated. For about 12 years she suffered from recurrent atrioventricular reentrant tachycardia with a rate of 230 beats per minute. Electrophysiological study resulted in diagnosis of a posteroseptal accessory pathway. Ablation was attempted primarily from a left ventricular access, but the pathway could not be reached from this position. After contrasting the coronary sinus a large coronary sinus aneurysm could be diagnosed. The accessory pathway was located in the "neck"-region of the aneurysm. By application of radiofrequency current in this location the bypass tract could be ablated. This case report shows that accessory pathways in coronary sinus aneurysms can be ablated without complications in this location.

Since the first implantation in 1980 about 55,000 automatic Cardioverter/Defibrillators (ICD) were implanted worldwide. This paper overviews the development of indications for ICD implantation as well as clinical results especially with respect to prophylaxis of sudden cardiac death.

From January 1990 to February 1993, 88 patients (group 1) received an emergency stent implantation with threatening vascular occlusion within the framework of an elective PTCA or a second emergency PTCA after up to 5 days following a primary successful PTCA. In addition, 36 patients (group 2) received an intracoronary stent during emergency PTCA of instable angina pectoris or acute myocardial infarction. The attempted stent implantation was not successful in 6 other patients. All patients were anticoagulated with heparin, aspirin (100 to 500 mg), and phenprocoumon. Since October 1991, 3 x 75 mg dipyridamole was given and heparinization was stopped after measuring the anticoagulation factor II (prothrombin time < 40%). Main complications within the first 2 to 3 weeks were acute and subacute stent thrombosis (21.8%) and complications of the puncture site (bleeding 19.3%, a. spurium/av-fistula 1.6%). The risk of acute stent thrombosis was significantly higher in patients of group 2 (instable angina pectoris despite of drug therapy or acute myocardial infarction) compared with group 1 (42.4 versus 14.8%). Implantation of multiple stents to stabilize extended dissections had a lower occlusion rate (6.3%). Acute myocardial infarctions were registered in group 1 in 25% (11.4% following implantation, 13.6% following stent occlusion, CK 153 to 3380 U/I, average 826 U/I) and in 58.3% of the high risk patients in group 2 (50% just before or following implantation, 36.1% infarctions or re-infarctions caused by stent occlusion, CK 152 to 1950 U/I, average 657 U/I). The risk of infarction could be limited to approximately 58% of the patients of group 2.(ABSTRACT TRUNCATED AT 250 WORDS)