Medical and surgical management of early Q wave myocardial infarction. II. Effects on mortality and global and regional left ventricular function at 10 or more years of follow-up.

To determine the long-term effect of surgical reperfusion on survival and left ventricular function of patients with anterior and inferior Q wave myocardial infarction, 387 patients were followed up for greater than or equal to 10 years after early Q wave infarction. In the anterior infarction group, 102 received conventional therapy and 101 underwent surgical reperfusion. The overall hospital mortality rate in the medically and surgically treated patients was different (16.7% [17 of 102] versus 6.9% [7 of 101], p less than 0.05). The cumulative 13 year actuarial mortality rate widened between the anterior medical and surgical groups (54% versus 31%, p = 0.0003) by the adjusted Cox proportional hazards model. The hospital mortality rate with early reperfusion (that is, less than or equal to 6 h of symptom onset) was 2% (1 of 51), whereas the mortality rate with late reperfusion was 12% (6 of 50). The 13 year actuarial cumulative mortality rate was significantly lower in both the early and late reperfusion groups (30% and 33%, respectively) than in the conventional therapy group (54%, p = 0.0006). The mortality rate in patients receiving surgery after surviving initial medical therapy was 50% (15 of 30). In the survivors of anterior Q wave myocardial infarction, improved global ejection fraction was seen in the patients undergoing early (54 +/- 13%) and late (50 +/- 10%) surgery relative to those receiving conventional therapy (43 +/- 11%, p less than 0.05). Only the early reperfusion group had better regional function of the anterior wall than that of the conventional therapy group. Thus, ventricular function correlated with improved long-term survival. In the patients with inferior Q wave myocardial infarction, the overall hospital mortality rate in the medical and surgical groups was not different (6.1% [6 of 98] versus 4.6% [6 of 86], p = NS). Likewise, the 13 year actuarial cumulative mortality rate was not different between the medical and surgical groups overall (32% versus 30%, p = 0.29) by the adjusted Cox proportional hazards model. The hospital mortality rate in the early reperfusion group was lower than that in the late reperfusion group (2.0% [1 of 49] versus 8.1% [3 of 37], p = NS). The 13 year actuarial cumulative mortality rate was lower in the early surgical group compared with that in the medical group (19% versus 32%, p = 0.04). The late surgical group had a similar 13 year actuarial cumulative mortality rate to that of the medical group (47% versus 32%, respectively, p = 0.47).(ABSTRACT TRUNCATED AT 400 WORDS)

A technique for direct-vision sternal reentry.

A simple technique in which the retrosternal tissues are dissected from the body of the sternum under direct vision, allowing for relatively quick and safe reentry of the sternum, is presented.

Coronary arteriographic findings in acute transmural myocardial infarction.

To describe the coronary arteriographic findings during early transmural myocardial infarction and to define the prevalence of coronary thrombosis by arteriography, we performed coronary arteriography and left ventriculography within 24 hours from symptom onset of transmural myocardial infarction in 517 patients. The coronary arteriographic findings included total and nontotal coronary occlusion with and without coronary thrombosis. Coronary spasm or severe stenosis in the affected vessel were discovered in a minority of patients. The coronary arteriographic characteristics of thrombus included persistent staining of intraluminal material by the contrast material, local retention of the contrast agent in the involved coronary artery, and intracoronary filling defect occurring mostly in nontotal occlusion. Of the 517 patients, 368 were studied within 6 hours of symptom onset, 85 within 6-12 hours and 64 within 12-24 hours. There was a systematic difference between total coronary occlusion and coronary thrombosis in each group. This was determined by arteriographic findings (judged positive or negative) relative to surgical findings. Both total coronary occlusion and coronary thrombosis were more prevalent in the early treatment (within 6 hours from symptom onset) group. Total occlusion and thrombosis declined significantly in the 6-12- and 12-24-hour groups. These data suggest that thrombus is encountered by arteriography and confirmed by surgical exploration within the first 6 hours from symptom onset of transmural infarction in approximately 80% of patients. Coronary thrombosis by coronary arteriography decreases in parallel with total coronary occlusion during the first 24 hours after acute transmural infarction, suggesting that coronary spasm or thrombus formation with subsequent recanalization are important in the evolution of transmural infarction. Despite many factors involved in the pathogenesis of transmural myocardial infarction, coronary thrombosis appears to be the final common pathway converting chronic coronary disease to acute myocardial infarction in the majority of patients.

Surgical treatment of acute evolving anterior myocardial infarction.

A series of 101 consecutive patients underwent coronary revascularization within a mean of 5.8 hours after anterior myocardial infarction. Forty-one patients had obstruction of the left anterior descending coronary artery (LAD), 35 had obstruction of the LAD and of the right or circumflex coronary artery and 25 had obstruction of the LAD and both the right and circumflex coronary arteries. Sixty-four patients (63%) had total occlusion of the LAD. In-hospital mortality was 2%. The total mortality during a mean follow-up of 43 months was 5%, and 90% of the patients were free of angina. Thirty-six patients had repeat coronary arteriography a mean of 13.4 months after operation. Fifty-two of 62 grafts (84%) were patent. Cardiac catheterization and immediate coronary artery bypass grafting in the first hours of anterior myocardial infarction can be done safely and may reduce in-hospital and long-term mortality.

Immediate coronary artery bypass for acute evolving myocardial infarction.

Two hundred twenty-seven consecutive patients had chest pain and electrocardiographic, coronary angiographic, ventriculographic, and retrospective enzyme changes consistent with acute evolving myocardial infarction (AEMI). These patients underwent coronary artery bypass grafting an average of less than 6 hours after the start of chest pain. The mean age was 55.8 years (range 28 to 79 years). Sex, coronary artery involvement, and preoperative and postoperative enzymes and electrocardiograms are presented. Follow-up angiocardiograms done an average of 12.7 months postoperatively revealed 99 patent primary grafts in 102 patients (94.3%). Ejection fractions were normal, unchanged, or improved in 86.3% of the patients. Two ventricular aneurysms measuring less than 2.5 cm in diameter were noted. Surgical in-hospital mortality was 1.76% and first-year mortality was 1.44%. Conventional therapy in 200 AEMI patients treated at the same hospitals resulted in an in-hospital mortality of 11.5%. Follow-up of 213 patients having coronary artery bypass grafting revealed that 14% had mild angina. AEMI interrupted by coronary artery bypass grafting early in the syndrome yields results which are superior to conventional management.

An alternative approach to the apex of the left ventricle.

Because of the risk of performing a left ventriculotomy in a patient with a left ventricular mass as well as decreased myocardial function, secondary to a myocardiopathy, my colleagues and I sought an alternate method for removal of the mass. Our decision to follow the procedure to be described in this report provided ideal access to the tumor, and the excellent results obtained in this and a subsequent case established the validity of this alternative to a left ventriculotomy. Although we realize not all masses of this nature need be removed, we present this technique as a useful addition to our armamentarium.