Emergency coronary angioplasty in patients with severe left ventricular dysfunction or cardiogenic shock after acute myocardial infarction.

Emergency percutaneous transluminal coronary angioplasty (PTCA) was performed during an acute myocardial infarction (AMI) after either systemic or intracoronary thrombolytic therapy in six patients with severe ischaemic left ventricular dysfunction or cardiogenic shock, among 37 patients (17%) who were treated with PTCA during AMI over a 13-month period. Thrombolytic therapy with streptokinase (1.5×10 Units) was initiated after a mean (± SD) time delay of 55±1.3 h from the onset of symptoms. The infarct-related artery was found to be occluded (TIMI grade 0–1) in three patients and partially reperfused (TIMI grade 2) in the remaining patients at baseline coronary angiography. Intracoronary administration of urokinase (100–200 000 Units) was ineffective in those patients failing systemic thrombolysis and resulted in only a slight increase of residual lumen in three patients. The coronary artery could be opened by a guidewire mechanical technique in patients with persistent coronary artery occlusion and coronary dilation could be done in all patients. The mean percentage diameter stenosis of the infarct-related vessel was reduced from 98.8 ± 2% to 27±11% (< 0.005). After the procedure, left ventricular ejection fraction increased from 27±8% to 41±7% (<0.02), systemic blood pressure and cardiac index increased respectively from 86+10 to 126±14 mmHg (< 0.005) and from 2.2±0.6 to 3.3±0.6 (<0.01). Left ventricular end-diastolic pressure decreased from 26±8 to 18 ± 3mmHg(<0.05). Severe mitral regurgitation was relieved in one patient. Rapid recovery from pump dysfunction occurred in all patients and both dopamine and intra-aortic balloon counterpulsation support could be discontinued. No death occurred during catheterization. One patient died, however, 15 days after successful PTCA with acute re-infarction. One patient with late restenosis had successful repeated angioplasty after 1 month. Our experience confirms previous encouraging pilot trials on the immediate efficacy of emergency PTCA in patients with severe pump dysfunction during AMI. Although, myocardial necrosis may not be prevented, cardiogenic shock may be relieved after successful reperfusion by reducing the size of ischaemic myocardium. The procedure could be performed with counterpulsation support and without surgical stand-by. However early restenosis of the infarct-related coronary artery and re-infarction may occur, suggesting that repeat PTCA or immediate bypass surgery should be considered. [ABSTRACT FROM PUBLISHER]