Impaired fibrinolysis determines the outcome of percutaneus transluminal coronary angioplasty (PTCA).

BACKGROUND: Coronary artery stenosis lesions dilated by percutaneus transluminal coronary angioplasty (PTCA) show a disappointingly frequent recurrence of stenosis. We have investigated the possible role of fibrinolysis and various platelet-release factors - specifically in the locality of the affected vessel - by following 19 patients for 6 months after PTCA. METHODS: PTCA was performed on 19 patients with a significant primary coronary stenosis, proven by quantitative CAAS analysis. Blood for measurement of local fibrinolysis and platelet activity was drawn from the aortic root and the coronary sinus, at three times: just before PTCA, 10 min after it, and 6 months later. RESULTS: The incidence of restenosis at the 6 months follow-up was 37%. PTCA almost doubled the platelet-derived growth factor level (PDGF) in coronary sinus blood in all patients. The seven restenosis patients had a substantially higher tissue plasminogen activator inhibitor antigen (PAI-1ag) level in the aortic root before PTCA than the 12 who remained stenosis-free (mean 62.4 +/- 31.6 ng mL -1 compared with 33.1 + 25.3; P < 0.04) and a lower tissue plasminogen activator activity (t-PAac) level (mean 0.32 +/- 0.19 IU mL-1 compared with 0.68 +/- 0.34; P < 0.03). This was corroborated by the levels of tissue plasminogen activator inhibitor activity (PAI-1ac). At reassessment after 6 months, the restenosis patients had developed, in coronary sinus blood, a large rise of PAI-1ac (7.7 +/- 4.8 IU mL-1 rising to 15.7 +/- 13.9, P < 0.04) and a large rise of of PAI-1ag (48.8 +/- 31.3 ng mL-1 vs. 72.4 +/- 47.2; P < 0.03). But no such increase occurred in the patients who remained stenosis-free. Conclusion Our results indicate that the minor balloon injury, which is inseparable from PCTA, stimulates the local release of PDGF. We suggest that, in those patients whose fibrinolytic activity is inherently low, this rise of PDGF could be a major causative factor in restenosis. We also discuss the possibility that the preoperative level of PAI-1ac could provide a limited but useful prediction of the outcome of PTCA.

[Coronary artery bypass without use of the heart-lung-machine]. / Koronar bypass uden hjerte-lunge-maskine.

INTRODUCTION: Off pump coronary artery bypass via sternotomy (OPCAB) and via a small left anterior thoracotomy (MIDCAB) on the anterior coronary arteries of the heart was introduced at the present center in 1997. Starting this year we decided to increase OPCAB and MIDCAB to constitute at least 50% of CAB procedures including the posterior aspect of the heart. METHODS: From January 1st through April 16th 1999 we performed 152 CAB procedures: 108 CABG, 6 MIDCAB, 13 OPCAB (on the anterior cornary arteries) and 25 OPCAB-Cx (including the circumflex artery). OP procedures were done using OCTOPUS-II to expose and stabilize the arteriotomies, and control angiography was performed before discharge. RESULTS: Off pump CAB was performed in 2% of the first 50 CAB patients, 36% of the next 50 and 50% of the last 52. The CABG and OPCAB-Cx groups were comparable as regards degree of coronary artery disease and number of distal anastomoses, but differed as regards poor left ventricular function and unstable preoperative status. Early mortality was 1.9% in the CABG group and 0% in the OP groups. Control angiograms in the OP groups showed a patency from 92 to 100%. CONCLUSIONS: In this short preliminary series, it was possible to increase the fraction of OP procedures to nearly 50% with good results.