Management of Acute Coronary Syndromes - part 9 pdf

Table 5 Angioplasty and Cardiogenic Shock Mortality (%) Stent Series Thrombolysis Reperfusion Time Hosp/ Successful Unsuccessful Long MVD Support reference N Age (%) (%) (h) 30d RP RP Term (%) Yr (%) O’Neill (212) 27 — 41 88 17 a 30 25 67 — — Pre-1985 0 Lee (47) 69 58 29 71 4.7 b 45 31 80 45% at 24 m 60 1982–1985 0 Shani (214) 959 0 67 2.3 a 33 — — 38% at 10 m — Pre-1986 0 Heuser (215) 10 — 0 60 — 40 17 75 — — Pre-1986 0 Laramie (216) 39 64 0 86 3.9 a 41 — — 32% at 24 m 87 1981–1987 0 Hibbard (45) 45 63 29 6 6 a 44 29 71 56% at 27 m 58 1982–1989 0 Yamamoto (217) 26 67 23 62 3.5 a 62 44 90 69% at 12 m 53 1985–1990 0 Moosvi (48) 38 63 25 76 33 b 44 38 78 — 66 1985–1990 0 Gacioch (218) 48 59 46 73 24 b 55 39 93 64% at 12 m — 1985–1990 0 Eltchaninoff (44) 33 65 21 76 23 a 36 24 75 48% at 12 m 67 1986–1990 0 Bengston (93) 50 66 36 85 2.8 b 43 38 71 — — 1987–1988 0 Morrison (219) 17 — 0 71 — 53 25 100 — 65 1988–1994 0 Himbert (220) 21 67 14 86 4.5 a 70 72 66 84% at 17 m 68 1989–1993 0 Emmerich (221) 16 53 0 100 2.9 a 19 19 — 19% at 14 m 69 1990–1994 0 Urban (222) 27 66 34 85 — 67 62 — 77% at 12 m 83 1982–1996 13 Webb (223) 276 64 — 75 3.3 b 46 33 86 — 78 1993–1997 24 Yip (224) 42 62 — 83 4.7 a 31 — — — 26 1993–2000 0 Perez-Castellano (225) 65 67 — 72 — 70 62 94 — 72 1994–1997 50 Zeymer (226) 390 64 — 78 4.1 a 52 40 83 — 65 1994–1998 0 Calton (227) 18 53 0 79 1.8 b 28 21 50 — 45 1995–1997 0 Antoniucci (228) 66 65 0 94 3.3 b 26 21 100 29 at 6 m 67 1995–1997 47 Ajani (229) 46 64 0 63 3.8 a 37 — — 40 at 2 m 35 1995–1999 35 Time Interval: a MI symptoms—angioplasty. b Shock—angioplasty. RP, reperfusion; MVD; Multivessel disease. reported by Himbert et al. (220) demonstrated a mortality of 81% in patients with a suc- cessful procedure. However, a more contemporary report of 66 consecutive patients reported by Antoniucci and colleagues (228) demonstrated a procedure success rate of 94% and a hospital mortality of 26% with early shock (within 1 h of admission) under- going stent (47%) supported angioplasty. In the SHOCK registry, patients who underwent angioplasty had a lower hospital mortality rate than medically treated patients (46.4 vs 78%, p Ͻ 0.001). The mortality rate did correlate with reperfusion efficacy (33% with TIMI grade 3 flow, 50% with TIMI grade 2 flow, and 86% with TIMI 0–1 grade flow) (223). M ODERN ADVANCES IN TRANSLUMINAL REVASCULARIZATION Stents have ascended to a predominant role in transluminal revascularization. Although the impact was delayed by early concerns regarding implantation of stents in the thrombotic mileau of an acute infarct artery, stenting evolved from a bailout proce- dure to routine application to patients undergoing primary catheter-based reperfusion. Randomized trials comparing primary stenting with angioplasty in acute infarction have consistently demonstrated a reduction in recurrent ischemia and reinfarction (210). However, in the Stent Primary Angioplasty in Myocardial Infarction (Stent-PAMI) trial, the final TIMI 3 flow rate was lower in the stent group (93 vs 89%, p ϭ 0.0006) with a trend for a higher 6-mo mortality (4.3 vs 2.8%, p ϭ 0.06) (235). These limitations were not seen in the Controlled Abciximab and Device to Lower-Late Angioplasty Compli- cations (CADILLAC) trial with an overall significant reduction in 6 mo Major Adverse Cardiac Events (MACE) in the stent group (10.4 vs 18.4%, p Ͻ 0.001) and no evidence of reduced TIMI grade 3 flow or survival with stent implantation (236). In cardiogenic shock, initial utilization of stent support after balloon angioplasty for suboptimal results or complications (dissection) has enhanced reperfusion success (228,237). Several reports suggest that this improved efficacy may translate into a sur- vival benefit (238–241). In the SHOCK trial, stent use was associated with improved procedure success in the early revascularization group (92 vs 76%, p ϭ 0.045) and suc- cess was correlated with reduced 30-d mortality (38 vs 79%, p ϭ 0.003) (242). Glycoprotein IIb/IIIa inhibitors have been clearly established as important adjuncts for transluminal revascularization principally by reducing ischemic events (243). How- ever, the use of IIb/IIIa inhibition with catheter-based reperfusion therapy for acute ST- elevation infarction remains controversial (244). Trial data are somewhat discordant in regards to the advantage of the addition of abciximab over primary stenting alone (236,245). Analysis of two prospective databases of patients with cardiogenic shock determined a benefit for patients undergoing primary angioplasty and a synergistic advantage with the use of stents (241,246). Although directional and transluminal extraction atherectomy devices have been uti- lized as primary reperfusion modalities in acute myocardial infarction, superiority over balloon angioplasty and stenting has not been demonstrated (247,248). However, exten- sive thrombus burden may be present in some infarct arteries (particularly large [Ͼ4.0 mm] right coronary arteries) and result in reduced procedure success, the no reflow phe- nomenon, and decreased survival (224). Recently, successful thrombus removal utiliz- ing the AngioJet rheolytic thrombectomy device has been reported during acute infarction and in the setting of cardiogenic shock (249,250). Future investigation of this and other thrombectomy devices may validate the effectiveness of this approach. Strategy for Cardiogenic Shock 627 628 Lane and Holmes Coronary Artery Bypass Surgery The introduction of the intra-aortic balloon pump brought considerable immediate hemodynamic improvement to patients in cardiogenic shock. However, the challenge of balloon pump-dependent patients and the realization of limited survival benefits led to early use of cardiac surgery. Patients were commonly operated on Ͼ24–48 h after the onset of shock, but mortality rates of less than 60% were encouraging (46,251,252). Infarctectomy or aneurysmectomy (sometimes performed without revascularization) was often combined with bypass grafting. The benefits of myocardial resection have not been proven, and this is now rarely performed (253,254). The reports (Table 6) of patients undergoing coronary artery bypass surgery for car- diogenic shock share many of the same drawbacks (primariy related to selection bias) as noted with angioplasty series (146,152,153,223,251,255–272,330). Dewood and colleagues (153) emphasized the importance of early revascularization in achieving successful results of bypass surgery. In their series, patients operated on within 16 h of infarction onset had a significantly lower mortality than those operated on later (25 vs 71%, p Ͻ 0.03). If revascularization is delayed, and there is evidence for mulitorgan failure, mortality rates are high (254,266). Patients undergoing bypass sur- Table 6 Coronary Artery Bypass Surgery and Cardiogenic Shock Series Hospital reference N Age Time Mort. (%) Year Johnson (255) 5582.5–12 a 40 1962–1974 Mundth (256) 22 51 Ͼ24 40 1968–1972 Keon (257) 21 — 7.8 b 67 1970–1974 Mills (258) 10 50 Ͻ24–48 a 0 1971–1974 Miller (259) 10 55 36–144 b 40 Pre-1974 O’Rourke (251) 654 74 a 67 1971–1972 Cascade (260) 757 4–24 b 29 1971–1974 Bardet (146) 45424–40 b 50 1972–1974 Ehrich (261) 351 Ͼ24 b 67 1972–1974 Willerson (152) 346 48 b 67 Pre-1975 Dewood (153) 19 52 — 42 1973–1978 Nunley (330) 14 58 — 14 1974–1981 Subramanian (262) 20 55 — 45 1976–1978 Hines (263) 7— 276 b 14 1976–1980 Phillips (264) 34 51 8 a 24 1975–1982 Connolly (265) 14 66 230 a 28 1982–1984 Laks (266) 50 — 103 a 30 1981–1986 Guyton (267) 963 6.7 a 22 1983–1986 Sergeant (268) 89 61 2.8 a 21 1971–1992 Allen (269) 66 59 6.3 a 9 1986–1991 Donatelli (270) 865 2.2 b 50 1994–1995 Edep (271) 185 70 — 23 1994 Webb (223) 109 64 — 34 1993–1997 Time Interval: a MI symptoms—surgery. b Shock—surgery. Strategy for Cardiogenic Shock 629 gery for cardiogenic shock may have a relatively high rate of postoperative complica- tions (267). The results of coronary bypass surgery in cardiogenic shock have improved over the past 3 decades. Although better patient selection may play a role, the necessity of early and complete revascularization has been recognized. Advances in surgical practice have evolved that have led to impressive results in some series. There has been considerable progress in techniques of myocardial protection utilizing blood-based cardioplegia solu- tions, sometimes substrate-enriched (amino acids, oxygen, glucose), and implemented through novel methods of administration (continuous, retrograde). These techniques continue to evolve. The strategy of revascularization may depend on the timing of sur- gery proceeding with the infarct artery in early evolving infarction and revascularizing critical “remote” vessels initially when surgery occurs later in the course. Controversy remains regarding the choice of conduits (mammary artery or vein grafts) with some utilizing double grafting techniques to the left anterior descending artery (126,273). A few patients have been reported to undergo bypass surgery without cardiopulmonary bypass support (“off-pump”) in the setting of cardiogenic shock (274). Perhaps the most compelling results have been reported by Allen et al. (269) in a mul- ticenter study reporting a 9% mortality for 66 patients in cardiogenic shock undergoing controlled surgical reperfusion, including vented cardiopulmonary bypass and warm amino acid-enriched blood cardioplegia. Although the investigators emphasize the ben- efits of prolonged controlled surgical reperfusion in minimizing reperfusion injury (126,269), the surgical advantage allowing early complete revascularization of remote ischemic myocardium is likely the predominant influence explaining these results. Of 2972 patients with cardiogenic shock in the GUSTO-I trial, 11.4% underwent coronary bypass surgery with an average 30-d mortality of 29% (3). In the SHOCK reg- istry, 109 patients underwent bypass surgery as primary therapy for shock secondary to left ventricular failure with a hospital mortality of 23.9% (223). An analysis of hospital admissions with cardiogenic shock in California during 1994 revealed that 185 patients underwent coronary bypass surgery with a hospital mortality of 23.4% (271,272). In reviewing the breadth of recent studies involving reperfusion therapy of cardiogenic shock in myocardial infarction, coronary bypass surgery has shown the most favorable overall results. Concern remains regarding the nonrandomized nature of these studies and the selection process that occurs before the patient reaches the operating room, yet this procedure remains a vital approach in patients with left main or multivessel disease and in patients with concomitant mechanical complications of the infarction. The Essential Role of Revascularization in Cardiogenic Shock Although the reperfusion paradigm is at the foundation of modern therapy of acute myocardial infarction, there is persistent debate over the influence of revascularization on the outcome of patients with cardiogenic shock (193,275). Analysis of several prospective databases support a role for revascularization therapy. The association of improving survival and more aggressive treatment strategies, includ- ing revascularization, was noted in both the Worcester Heart Attack Study and the NRMI-2 registry (see Reperfusion and Survival in Cardiogenic Shock section) (5,12). A similar fall in hospital mortality (71 to 60%) from 1992–1997 was accompanied by an increase in the proportion of patients undergoing revascularization (34 to 51%) in the SHOCK Registry (276). The California analysis (n ϭ 1122) of cardiogenic shock admis- sions in 1994 recognized revascularization independently reducing the odds of death by 80% (272). Mortality (n ϭ 837) was also independently decreased by revascularization therapy (62.5 vs 84.3%, p ϭ 0.001) in the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) study (277). In the GUSTO-I trial, the 30-d mortality was reduced among patients undergoing angioplasty and/or bypass surgery (38 vs 62%, p ϭ 0.001), although revascularization patients were younger with less prior infarction and shorter thrombolytic reperfusion times (278). However, in multivariate logistic regression analysis, an invasive revascularization strategy was independently associated with reduction in 30-d and 1-yr mortality (278,279). Only two randomized trials of urgent revascularization therapy have been conducted. The Swiss Multicenter trial of Angioplasty for Shock (SMASH) enrolled only 55 patients because of insufficient recruitment (222). The reduction in 30-d mortality noted for the invasive group 69 vs 78%) was not significant. The SHOCK trial deserves special attention (6). Patients with shock due to predom- inantly left ventricular dysfunction (ST-elevation or new left bundle-branch block) were enrolled. Notably, 55% were transferred from other hospitals with a median time to ran- domization equaling 11 h. Over the recruitment period (1993–1998), 302 patients were randomly assigned to an early revascularization strategy (angioplasty [55%] or bypass surgery [38%]) within 6 h of randomization (median ϭ 1.4 h). Thrombolytic therapy (63%) was recommended in the medical stabilization group,and delayed (Ն54 h) revas- cularization (angioplasty [14%], bypass surgery [11%]) was recommended if clinically appropriate. Intra-aortic balloon support was recommended (86% in both groups). At 30 d, the survival advantage (primary end point) observed with early revasculariza- tion did not achieve statistical significance. However, a significant benefit was noted at 6 mo and 1 yr (Fig. 6) (6,280). This benefit appeared to be limited to patients Ͻ75 yr of age. Although the treatment difference in the primary end point did not achieve statistical significance, the trial was somewhat underpowered, and the aggressive treatment 630 Lane and Holmes Fig. 6. The temporal relation to survival for patients randomized in the SHOCK trial by treatment strategy (6,280). (thrombolysis and balloon counterpulsation) in the medical stabilization group may have mitigated the apparent benefits. The SHOCK registry confirmed similar benefits for an early revascularization strategy (4). The experimental and clinical importance of multivessel disease in the pathophysiol- ogy of cardiogenic shock has been established (42,43,49). In some studies, multivessel disease and incomplete revascularization have been related to mortality (224,228). In the SHOCK trial, angioplasty was recommended for patients with 1 or 2 vessel disease and bypass surgery for severe triple vessel or left main disease (281). In both the SHOCK trial and registry, mortality was increased in patients undergoing angioplasty with triple vessel disease (223,282). There has been little investigation regarding the role of multivessel angioplasty in the setting of cardiogenic shock, although utilization of stents may allow safer application of this strategy. Although controversy remains, available evidence supports the application of early revascularization procedures to patients with cardiogenic shock secondary to left ven- tricular failure (Table 7) (108). Special Clinical Situations RIGHT VENTRICULAR INFARCTION In the SHOCK registry, the prognosis of patients with shock due to primarily left ven- tricular or right ventricular shock was similar (61 vs 54%) (283). The initial management of patients with shock from right ventricular infarction involves administration of volume to augment right ventricular function and maintain adequate left ventricular preload. Venous dilatation with drugs such as nitroglycerin must be avoided. Volume loading alone may not optimize hemodynamic parameters. This may result from accentuated right ventricular distension and adverse ventricular interdependence effects. The use of inotropic agents, such as dobutamine, have been reported to increase the cardiac output in this situation (284). Strategy for Cardiogenic Shock 631 Table 7 ACC/AHA Guidelines a for Emergency Revascularization for Acute Myocardial Infarction with Cardiogenic Shock Primary percutaneous interventions (PCI) Class I In patients who are within 36 h of an acute ST-elevation/Q wave or new LBBB MI who develop cardiogenic shock, are Ͻ75 yr old, and in whom revascularization can be per- fromed within 18 h of the onset of shock. PCI after thromblysis Class IIa Cardiogenic shock or hemodynamic instability. Emergency coronary bypass surgery Class I 1. Failed angioplasty with persistent pain or hemodynamic instability. 2. At the time of surgical repair of postinfarction ventricular septal defect. Class Iia Cardiogenic shock with coronary anatomy suitable for surgery. a 1999 revision (108). PCI, percutaneous coronary intervention; LBBB, left bundle-branch block; MI, myocardial infarction. Maintenance of right atrial contraction is important and may require AV sequential pacing or cardioversion of arrhythmias. Intra-aortic balloon counterpulsation should be employed with persistent hypotension, especially in the presence of multivessel coro- nary artery disease. Percutaneous cardiopulmonary bypass, right ventricular assist devices, and pulmonary artery counterpulsation have also been utilized (50). Revascularization therapy has been shown to improve the hemodynamic status and outcome of patients with right ventricular infarction (283,285,286). Bowers et al. (285) reported a series of 53 patients with acute right ventricular infarction who underwent primary angioplasty. In patients with successful complete reperfusion of the right main coronary artery and major right ventricular branches, marked improvement in right ven- tricular function occurred. Unsuccessful reperfusion resulted in more frequent hypoten- sion and low cardiac output (83 vs 12%, p ϭ 0.002) and a higher mortality (58 vs 2%, p ϭ 0.001) than in those with successful reperfusion. A CUTE ISCHEMIC SYNDROMES WITHOUT ST-ELEVATION In two large trials evaluating patients with non-ST-elevation acute coronary syn- dromes, cardiogenic shock developed 2.5% of patients (91,287). In both the SHOCK registry and GUSTO IIb trial, patients developing shock without ST-elevation were older and had more frequent comorbid factors, including more prior infarction, congestive heart failure, and bypass surgery compared to shock patients with ST-elevation (95,287). The onset of shock in the GUSTO-IIb trial was significantly later (76.2 vs 9.6 h, p Ͻ 0.001) in patients without ST-elevation (287). Although mechanical causes of shock are uncommon in this setting, the pathogene- sis of this syndrome is heterogeneous. Compared with ST-elevation infarction, recurrent ischemia and reinfarction are more common. Triple vessel disease is significantly more likely. The left circumflex coronary artery is more frequently identified as the culprit artery (95,287). It is known that total occlusion of the left circumflex artery may occur without ST-elevation on a standard 12-lead ECG (288). Despite typically smaller infarctions in patients with shock secondary to non-ST-ele- vation infarction, the outcome is similar to patients with ST-elevation. In the SHOCK registry, hospital mortality occurred in 62.5% with non-ST-elevation compared with 60.4% of ST-elevation infarction (95). The 30-d mortality of patients without ST-eleva- tion in the GUSTO-IIb trial was actually higher than with ST-elevation (72.5 vs 63%, p ϭ 0.05) (287). The role of revascularization for patients with shock secondary to non-ST-elevation syndromes remains uncertain (95). In the PURSUIT trial, the 30-d mortality was lower in patients who received eptifibatide (58.2 vs 73.5%, p ϭ 0.02) (91). T HE ELDERLY Approximately 85% of deaths from myocardial infarction occur in patients Ն65 yr (289). The senescent cardiovascular system has a reduced capacity to compensate for myocardial injury sustained during infarction (290,291). In the GUSTO-I trial, older age is the variable most strongly predictive of the development of shock and 30-d mortality with shock (79,292). The advantage of primary angioplasty over thrombolysis is magnified in the elderly (293). However, in the SHOCK trial patients Ն75 yr in the early revascularization group had a higher mortality at 30 d compared to those assigned to medical stabilization (53 632 Lane and Holmes vs 75%) (6). Echocardiographic data accumulated during the trial suggested that elderly patients in this small cohort (n ϭ 56) had a significant excess of low ejection fractions and remote zone hypokinesis at randomization compared to younger patients (294). In contrast, in the SHOCK registry, there was an apparent survival benefit for those aged Ն75 yr who were clinically selected for early revascularization (4,295). A decline in hospital fatality rate was noted for elderly patients (Ͼ65 yr) over time in the Worcester Heart Attack Study. Early revascularization was an independent pre- dictor of hospital survival (296). The excess mortality and complex comorbid status in the elderly patient with cardiogenic shock impedes definition of the expected advan- tages of revascularization. Further investigation is necessary to refine selection for ther- apy in this high risk group. P RIOR CORONARY BYPASS SURGERY Patients presenting with infarction and previous coronary bypass surgery are older and have more extensive coronary artery disease, worse left ventricular function, and more associated comorbidities (297,298). In the GUSTO-I trial, patients with prior CABG exhibited a higher 30-d mortality (10.7 vs 6.7%, p Ͻ 0.001) and more cardio- genic shock (9 vs 5.8%, p Ͻ 0.001) (299). Although angioplasty was performed on equivalent proportion of patients with (26.5 vs 29.6%) and without prior bypass surgery in the SHOCK registry, very few patients in the latter group underwent repeat bypass surgery (300). There was a reduction in mortality associated with revascularization in the prior bypass surgery group (56.5 vs 84.45, p ϭ 0.018) similar to those without prior surgery (44 vs 80%, p Ͻ 0.001). Revascularization should be considered for cardiogenic shock in patients with prior coronary bypass surgery. T HE LEFT MAIN SHOCK SYNDROME As one might expect, the extensive myocardial insult resulting from left main coro- nary artery occlusion is characterized commonly by a dramatic presentation and a sub- stantial hemodynamic derangement. The timing of shock onset and mortality related to the culprit infarct vessel is depicted in Table 1 (17,18). The rapid onset of shock is asso- ciated with widespread ST-elevation, especially associated with ST-elevation in a VR (94). Quigley et al. (301) reported a 94% mortality for the “left main shock syndrome” (acute anterior infarction, severe left main stenosis, and cardiogenic shock) and sug- gested that conservative therapy may be indicated in this subset. Although infarction and shock arising from left main obstruction is often a catastrophic event, several reports have demonstrated survival with an aggressive approach including emergency catheter- ization and revascularization with either surgery and/or transluminal revascularization (302–304). Shock and Mechanical Complications of Myocardial Infarction VENTRICULAR SEPTAL RUPTURE Cardiogenic shock associated with rupture of the interventricular septum is a highly lethal event. In the shock registry (n ϭ 55) the hospital mortality was 87% (69). Risk factors for this complication include advanced age, female gender, hypertension, and lack of previous infarction (63,69). Strategy for Cardiogenic Shock 633 Intra-aortic balloon counterpulsation may stabilize the patients’ hemodynamic status (137), but the potential for sudden decompensation remains (305). Previous data sug- gested a lower operative mortality when surgery was delayed. However, a deadly selec- tion process occurs with a substantial proportion of patients unable to survive until a late operation. Early surgical repair is a necessary strategy. Very few patients in cardiogenic shock survive without surgery (57,69,305). In the SHOCK registry, mortality was reduced with surgery (81 vs 96%) (69). Other surgical reports suggest better outcome (306,307), but preoperative cardiogenic shock is a predictor of operative mortality (308,309). Patients with inferior infarction and posterior septal rupture have an increased mortality due to more complex defects and extensive right ventricular involve- ment (63,69,71). Recently, successful closure of postinfarction septal defects has been reported with transcatheter septal occluder devices (310–313). Future trials will clarify the role of these devices in the management of this lethal complication (314). P APILLARY MUSCLE DYSFUNCTION OR RUPTURE Acute severe mitral regurgitation resulting in shock during myocardial infarction is also likely to resultant in death without prompt surgical intervention (315–317). In the SHOCK registry, patients with this complication were more likely female (52 vs 37%, p Ͻ 0.004) and were less likely to exhibit ST-elevation (41 vs 63%, p Ͻ 0.001) com- pared to shock due to left ventricular failure (318). Shock developed at a median of 12.8 h after onset of the infarction. As with septal rupture, intense medical therapy and balloon pump support may sta- bilize the patient, but the prognosis is poor without surgical intervention (137). Again, surgical delay often leads to rapid clinical deterioration and death. Early surgery is rec- ommended (319). Several series have documented success with this approach (92,320). In the SHOCK registry, mortality was lower with early (16.6 h) surgery (318). Valve repair without replacement was possible in 6 out of 42 patients. A few patients with pap- illary muscle dysfunction have been treated successfully with angioplasty (321,322). However, this approach must be taken cautiously. Tcheng et al. reported higher mortal- ity with angioplasty compared with medical or surgical treatment (323). In the SHOCK registry 9 patients were treated with angioplasty and 6 died (318). F REE WALL RUPTURE Free wall rupture of the left or right ventricle is commonly a fatal event. Risk fac- tors include advanced age, female gender, hypertension, and less prior infarction (60,324,325). Patients identified by electromechanical dissociation requiring ongoing cardiopul- monary resuscitation have rarely survived, although a few successful surgical cases have been reported (253). Surgical results in subacute rupture are more favorable (50% sur- vival) (67,326,327). Hemodynamic improvement may occur through the maneuvers of volume administration, inotropic agents, and pericardiocentesis, allowing stabilization for transfer to the operating room. Medical management of selected patients with left ventricular free wall rupture has been reported by Figueras and colleagues (328). Sur- vivors (15 out of 19) were successfully treated with intravenous volume and dobutamine and survived with subsequent bedrest and b-blocker administration. A method utilizing pericardiocentesis, followed by injection of “fibrin glue” (composed of fibrinogen, Fac- tor XIII, and aprotinin) in the pericardial space, has also been reported to successfully 634 Lane and Holmes [...]... 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(268) 89 61 2.8 a 21 197 1– 199 2 Allen (2 69) 66 59 6.3 a 9 198 6– 199 1 Donatelli (270) 865 2.2 b 50 199 4– 199 5 Edep (271) 185 70 — 23 199 4 Webb (223) 1 09 64 — 34 199 3– 199 7 Time Interval: a MI symptoms—surgery. b Shock—surgery. Strategy. 70 62 94 — 72 199 4– 199 7 50 Zeymer (226) 390 64 — 78 4.1 a 52 40 83 — 65 199 4– 199 8 0 Calton (227) 18 53 0 79 1.8 b 28 21 50 — 45 199 5– 199 7 0 Antoniucci (228) 66 65 0 94 3.3 b 26 21 100 29 at 6. 198 7– 198 8 0 Morrison (2 19) 17 — 0 71 — 53 25 100 — 65 198 8– 199 4 0 Himbert (220) 21 67 14 86 4.5 a 70 72 66 84% at 17 m 68 198 9– 199 3 0 Emmerich (221) 16 53 0 100 2 .9 a 19 19 — 19% at 14 m 69 199 0– 199 4