Andrew J. Doorey

Recanalization of Chronically Occluded Aortocoronary Saphenous Vein Bypass Grafts With Long-Term, Low Dose Direct Infusion of Urokinase (ROBUST): A Serial Trial

OBJECTIVES This multicenter study sought to evaluate the short-term efficacy and safety of prolonged, low dose, direct urokinase infusion in recanalization of chronically occluded saphenous vein bypass grafts in a large sample of patients, as well as to determine the 6-month patency rates for this procedure. BACKGROUND Patients with chronically occluded aortocoronary vein grafts and uncontrolled angina pectoris have limited options for therapy. Previous work has shown that chronically occluded vein grafts can be recanalized by thrombolysis. METHODS A coaxial infusion of urokinase (100,000 U/h) was given directly into occluded vein grafts in 107 patients. Balloon angioplasty was performed after lysis was achieved. Patients were discharged with warfarin and aspirin therapy. Six-month clinical follow-up data were obtained, and repeat angiography was encouraged. RESULTS Initial patency was achieved in 74 patients (69%). Mean duration of infusion was 25.4 h, and mean urokinase dosage was 3.70 million U. Acute adverse events included acute myocardial infarction in 5 patients (5%), enzyme level elevation in 18 (17%), emergency coronary artery bypass graft surgery in 4 (4%), stroke in 3 (3%) and death in 7 (6.5%). Recanalization was unsuccessful in all seven patients who died. Six-month follow-up angiograms were obtained for 40 patients (54%), 16 of whom maintained a patent graft (40%). Angina was present in 13 patients with successful (22%) and 12 with unsuccessful (71%) recanalization at 6-month follow-up. CONCLUSIONS Chronically occluded aortocoronary vein grafts can be recanalized in approximately 70% of appropriately selected patients. Complications are similar to those observed with repeat operations. Clinical follow-up shows an improvement in angina. This procedure is intended for patients with only one occluded vein graft. Strict adherence to the protocol will improve patency and reduce complications.

Anistreplase versus alteplase in acute myocardial infarction: Comparative effects on left ventricular function, morbidity and 1-day coronary artery patency

OBJECTIVES This double-blind, randomized, multicenter trial was designed to compare the effects of treatment with anistreplase (APSAC) and alteplase (rt-PA) on convalescent left ventricular function, morbidity and coronary artery patency at 1 day in patients with acute myocardial infarction. BACKGROUND Anistreplase (APSAC) is a new, easily administered thrombolytic agent recently approved for treatment of acute myocardial infarction. Alteplase (rt-PA) is a rapidly acting, relatively fibrin-specific thrombolytic agent that is currently the most widely used agent in the United States. METHODS Study entry requirements were age less than or equal to 75 years, symptom duration less than or equal to 4 h, ST segment elevation and no contraindications. The two study drugs, APSAC, 30 U/2 to 5 min, and rt-PA, 100 mg/3 h, were each given with aspirin (160 mg/day) and intravenous heparin. Prespecified end points were convalescent left ventricular function (rest/exercise), clinical morbidity and coronary artery patency at 1 day. A total of 325 patients were entered, stratified into groups with anterior (37%) or inferior or other (63%) acute myocardial infarction, randomized to receive APSAC or rt-PA and followed up for 1 month. RESULTS At entry, patient characteristics in the two groups were balanced. Convalescent ejection fraction at the predischarge study averaged 51.3% in the APSAC group and 54.2% in the rt-PA group (p less than 0.05); at 1 month, ejection fraction averaged 50.2% versus 54.8%, respectively (p less than 0.01). In contrast, ejection fraction showed similar augmentation with exercise at 1 month after APSAC (+4.3% points) and rt-PA (+4.6% points), and exercise times were comparable. Coronary artery patency at 1 day was high and similar in both groups (APSAC 89%, rt-PA 86%). Mortality (APSAC 6.2%, rt-PA 7.9%) and the incidence of other serious clinical events, including stroke, ventricular tachycardia, ventricular fibrillation, heart failure within 1 month, recurrent ischemia and reinfarction were comparable in the two groups; and mechanical interventions were applied with equal frequency. A combined clinical morbidity index was determined and showed a comparable overall outcome for the two treatments. CONCLUSIONS Convalescent rest ejection fraction was high after both therapies but higher after rt-PA; other clinical outcomes, including exercise function, morbidity index, and 1-day coronary artery patency, were favorable and comparable after APSAC and rt-PA.

Out-of-hospital cardiac arrest patients with ST-segment elevation on electrocardiogram: don't rush patients for emergent percutaneous coronary intervention in the era of aggressive door-to-balloon time.

As an institution that has a great interest in and has studied cardiac arrest and ST-segment elevation myocardial infarction (STEMI) ([1][1]), we read with great interest and agree with Dr. Kern ([2][2]) that we should provide “operators and medical centers the opportunity to do what is best for

Coronary Angiography After Out-of-Hospital Cardiac Arrest

Management of out-of-hospital cardiac arrest (OHCA) is problematic, and several issues remain unresolved. One is whether all patients who survive to reach the hospital after OHCA should undergo immediate cardiac catheterization and revascularization. Randomized trial data are lacking in this area,