Non surgical coronary artery recanalization in acute transmural myocardial infarction.

In 41 consecutive patients with an acute transmural myocardial infarction (AMI) admitted within 3 hours after the onset of symptoms, we tried to recanalize the occluded coronary artery by an intracoronary infusion of streptokinase (SK) (2000 units/min). SK infusion was preceded by (1) an intracoronary injection of 0.5 mg nitroglycerin to rule out coronary artery spasm, (2) an attempt to recanalize the vessel mechanically with a flexible guidewire, and (3) an intracoronary injection of plasminogen (500 units) to increase the efficacy of the subsequent SK infusion. Coronary angiography revealed a total coronary artery occlusion in 39 patients and a subtotal occlusion in two patients. In 30 patients (73%), the occluded coronary artery was successfully recanalized within 1 hour (mean 29 ± 15 minutes), resulting in prompt contrast filling of the previously occluded vessel. An arteriosclerotic stenosis always remained at the site of the occlusion. Nitroglycerin opened the occluded coronary artery in one patient, contrast injection in seven patients and guidewire perforation in four of the 15 patients, in whom it was attempted. In 18 patients the occluded coronary artery was recanalized by intracoronary SK infusion alone. After the initial opening of the occluded coronary artery, subsequent SK infusion markedly reduced the degree of stenosis and visible thrombi disappeared. Clinically, recanalization was associated with significant relief of ischemic chest pain. None of the successfully recanalized patients died, including three patients with cardiogenic shock. Recanalization, however, did not prevent myocardial infarction, as shown by new Q waves and/or R-wave reduction in 24 of the 30 patients and by the rise in serum CPK with an early peak, indicating CPK washout by coronary artery reperfusion. Repeat angiography 7-21 days later revealed a patent coronary artery in 12 of 15 successfully recanalized patients. The left ventricular ejection fraction had significantly improved, from 37