[Late thrombolysis in acute myocardial infarct. Demonstration of myocardial tissue salvage by the assessment of pre- and post-thrombolytic perfusion and left ventricular function].

Abstract

Pre and post treatment perfusion scintigraphy with Tc-99m-sestamibi is an accurate method to evaluate the effectiveness of thrombolytic therapy in patients with acute myocardial infarction. In the present study this method was used to verify whether thrombolytic therapy performed late (6 to 24 hours) after symptoms onset was still able to produce significant salvage of jeopardized myocardial tissue.
Fifteen patients (mean age 60.9 +/- 9 years) admitted to CCU 8-23 hours (mean 13.2 +/- 4 hours) after symptoms onset of their first acute myocardial infarction were studied. Both myocardial perfusion and left ventricular function were assessed before and after thrombolysis. Myocardial perfusion was studied using Tc-99m-sestamibi Single Photon Emission Tomography (SPET) before (pre-lysis SPET), 4.4 +/- 0.9 days (post-lysis SPET A) and 32 +/- 6 days (post-lysis SPET B) after thrombolysis. Uptake defects were graded from 0 to 4 using a 20-segment scheme. Regional ventricular function was evaluated using two-dimensional echocardiography before (pre-lysis ECHO), simultaneously with post-lysis SPET A (post-lysis ECHO A) and 32 +/- 4 days after treatment (post-lysis ECHO B); asynergy was graded from 1 to 4. Global left ventricular function was estimated using gated blood pool imaging and measuring the ejection fraction (EF) 5.3 +/- 1 (GBP 1) and 32 +/- 4 days after treatment (GBP 2). Within 6-9 days of admission all patients underwent coronary angiography.
In pre-lysis SPET all patients had uptaken defects (score range 17-52, mean 34.6 +/- 12). According to the comparison between pre-lysis SPET and post-lysis SPET A, patients were divided into two groups: 7 patients with perfusion recovery (Group I) and 8 patients with absent or minimal perfusion recovery (Group II). In Group I the mean uptaken score decreased significantly (from pre-lysis SPET 34.2 +/- 12 to post-lysis SPET A 21.7 +/- 7, p < 0.05); in Group II the uptaken score remained unchanged (from pre-lysis SPET 34.8 +/- 12 to post-lysis SPET A 33.6 +/- 12, ns). In post-lysis SPET B both groups showed a defect reduction compared to post-lysis SPET A; however, the defect score of SPET B in Group I was significantly lower than that in Group II (18.7 +/- 16 vs 30.1 +/- 10, p < 0.05). The asynergic score in pre-lysis ECHO was the same in the two groups (19.5 +/- 4); in post-lysis ECHO A no significant decrease was observed in the two groups. In post-lysis ECHO B a significant decrease was seen in Group I (14.8 +/- 5, p < 0.05 vs pre-lysis ECHO and vs post-lysis ECHO A), but not in Group II (19.8 +/- 5, ns); the asynergic score in post-lysis ECHO B was significantly lower in Group I than in Group II (p < 0.05). In GBP 1 the EF was 38% +/- 6 in Group I and 40% +/- 6 in Group II (ns). In GBP 2 a significant increase was registered in Group I (47% +/- 10, p < 0.05), whereas in Group II the EF remained unchanged (40% +/- 6, ns). Coronary angiography showed a patent infarct related vessel in all Group I patients and in 2 Group II patients (p < 0.05).
These results show that in patients with acute myocardial infarction treated with thrombolysis late after symptoms onset it is still possible to obtain an effective reperfusion and the consequent salvage of jeopardized tissue, as demonstrated by the recovery of both regional and global left ventricular function.