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Intraoperative local fibrinolysis as emergency therapy after early coronary artery bypass thrombosis
Insights
Acute graft occlusion after coronary artery bypass grafting (CABG) can be fatal. Intraoperative fibrinolysis with recombinant tissue plasminogen activator (rt-PA) significantly reduces myocardial infarction and mortality in these high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Thrombolytic Therapy
Background:
- Acute graft occlusion post-coronary artery bypass grafting (CABG) is a rare but severe complication.
- Emergency reoperation for graft occlusion has high mortality (up to 50%) and morbidity.
- Adjuvant intraoperative fibrinolysis using recombinant tissue type plasminogen activator (rt-PA) was introduced to mitigate these risks.
Purpose of the Study:
- To evaluate the efficacy and safety of adjuvant intraoperative intracoronary fibrinolysis with rt-PA in patients experiencing acute graft occlusion after CABG.
- To compare outcomes between patients undergoing emergency reoperation with and without rt-PA therapy.
Main Methods:
- A retrospective analysis of 4231 CABG patients between 1/1994 and 8/1998.
- 18 patients required emergency reoperation within 12 hours of CABG due to acute myocardial infarction.
- Nine patients received intraoperative intracoronary rt-PA lysis via a left atrial catheter, while nine did not.
Main Results:
- Patients receiving rt-PA (Group II) had significantly lower rates of Q-wave myocardial infarction (3/9) and zero mortality compared to the non-thrombolysis group (Group I: 7/9 with large myocardial infarction, 3 deaths).
- Maximum creatine kinase levels were significantly lower in the rt-PA group (CK=502 U/L, CK-MB=61 U/L) versus the non-thrombolysis group (CK=1254 U/L, CK-MB=197 U/L).
- No lysis-associated complications were observed, although postoperative bleeding was elevated in both groups.
Conclusions:
- Emergency reoperation for acute thrombotic bypass occlusion after CABG is associated with high mortality and morbidity.
- Adjuvant intraoperative rt-PA fibrinolysis appears to restore myocardial perfusion effectively, reducing infarction and mortality.
- The non-systemic application of rt-PA is feasible, easy to perform, and does not lead to harmful complications, making it a valuable therapeutic option.
Objective:
Acute graft occlusion early postoperatively after coronary artery bypass grafting (CABG) is a rare but dramatic complication, frequently making resuscitation necessary. Emergency reoperation with reanastomosing of the concerning grafts is the normal procedure to restrict the otherwise unavoidable myocardial damage. Mortality in these cases is up to 50%. Due to this unsatisfying situation, we perform since 1995 in such cases an adjuvant intraoperative intracoronary installed fibrinolysis with recombinant tissue type plasminogen activator (rt-PA; alteplase).
Methods:
Between 1/1994 and 8/1998, 4231 patients underwent CABG. In 18 of these patients, emergency reoperation within the first 12 h after CABG due to clinical signs of acute myocardial infarction was necessary. In nine of the patients (group II) additionally intraoperative rt-PA lysis of the involved vessel/s has been performed. When the peripheral anastomosis was reopened and the thrombotic material was removed, we inserted for this a left atrial-catheter (LA-catheter) of 1.2 mm in diameter, into the coronary artery. Then we administered within 3-5 min, up to 100 mg rt-PA (t1/2: 5-9 min.) locally into the vessel. All patients were treated postoperatively with acetylsalicyl acid (ASA) and heparine.
Results:
In group I (n = 9; seven males, two females) without thrombolytic therapy, 78% of the patients (n = 7) could not have been prevented from large myocardial infarction despite emergency reoperation. Three of these patients died during or early after reintervention. In group II with fibrinolytic therapy (n = 9) three of the patients developed Q-wave myocardial infarction following reoperation. None of the patients died. Creatinkinase maximum were in group I significantly higher than in group II (group I: CK = 1254 units/I, CK-MB = 197 units/l; group II: CK = 502 units/l, CK-MB = 61 units/l; P < 0.01). Postoperative bleeding was considerable elevated in both groups. In group I, 832 ml/24 h (375-1420 ml), in group II 1164 ml/24 h (520-1560 ml). Lysis-associated complications were not observed.
Conclusions:
Reoperation of patients with acute thrombotic bypass occlusion after CABG is characterized by a high mortality and morbidity. If additionally fibrinolysis is performed, a sufficient myocardial perfusion seems to be restored. A short half-life in combination with the presented non-systemic application technique of rt-PA seem to prevent unpredictable bleeding. Rt-PA lysis apparently contributes very effectively to the restoration of the macro- and microcirculation within the infarct-related area. Thrombolytic therapy during cardiac surgery with rt-PA is feasible, its application easy and harmful complications are not seen.