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Immediate coronary bypass following failed streptokinase infusion in evolving myocardial infarction
Insights
For evolving myocardial infarction (EMI) patients unresponsive to streptokinase, emergency coronary bypass surgery is a viable option. This approach offers acceptable outcomes despite severe disease and cardiac dysfunction.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- 184 patients with evolving myocardial infarction (EMI) received streptokinase treatment since 1980.
- 68 patients underwent percutaneous transluminal coronary angioplasty (PTCA) concurrently.
- 24 patients with severe triple-vessel disease and ventricular dysfunction required emergency coronary bypass surgery.
Observation:
- Eight patients (33%) needed intra-aortic balloon pump (IABP) support due to severe cardiac decompensation.
- All 24 patients underwent immediate coronary bypass grafting (average 4.1 grafts per patient).
- Postoperative outcomes included four operative deaths and two late deaths.
Findings:
- Average blood loss was 1,453 ml, with an average transfusion of 8.2 units per patient.
- Only two patients developed coagulopathy (hyperfibrinolysis); 13 had normal clotting.
- Four patients required reoperation for bleeding or coagulopathy.
Implications:
- Emergency coronary bypass grafting is a feasible option for EMI patients who do not achieve adequate reperfusion with streptokinase.
- The procedure demonstrates reasonable morbidity and acceptable hematologic consequences.
- This strategy may be considered for patients with complex coronary artery disease and compromised cardiac function.
Abstract:
Since December of 1980, 184 patients with evolving myocardial infarction (EMI) have undergone streptokinase infusion, with associated percutaneous transluminal coronary angioplasty (PTCA) in 68 patients. Emergency coronary bypass was deemed necessary in 24 of these patients. All 24 patients had severe triple-vessel disease and moderate to marked ventricular dysfunction, with eight (33%) requiring intra-aortic balloon pump (IABP) support for profound cardiac decompensation preoperatively. All 24 patients underwent immediate coronary bypass (average 4.1 grafts/patient), with four operative and two late deaths. Average postoperative blood loss was 1,453 ml, and average blood transfusion postoperatively was 8.2 units per patient. Thirteen patients had normal clotting studies immediately postoperatively, and only two patients developed frank coagulopathy (hyperfibrinolysis). Four patients required reexploration; two for coagulopathy, one for surgical bleeding, and one to rule out tamponade (negative). In those patients with EMI in whom streptokinase fails to result in adequate reperfusion, immediate emergency saphenous vein bypass grafting may be performed with reasonable morbidity and with acceptable hematologic consequences.