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Predictors of PTCA Failures in Q Wave AMI.
Uni and Multivariate Analysis

Torresani, E.M.; Weisshein, N.;
Martino, G.; Hrabar, A.; Fernández, A.;
Cohen M.; De Benedetti, L.; Buján L.;
Alvarez, C.; Leguizamón, J.H.

Dpto. de Cardiología, Sanatorio Modelo Quilmes, Buenos Aires, Argentina

SUMMARY
PTCA failures (F) in Q wave AMI has more In-Hospital mortality and increased MACE at the first year follow up if compare them with successful ones. The purpose of the present study is to analyze Clinical and/or Angiographic predictors of failures of the PTCA in Q wave AMI. From 8/94 until 8/99, 239 pts with AMI < 12 hrs were admitted; 135 pts (56,4%) were treated with PTCA, Primary (PA) in 84 pts and Rescue (RA) in 51pts. Stetting was indicated in 55 pts (40,7%) due to suboptimal results (recoil, dissection and/or <30% residual stenosis). All Killip-Kimball (KK) 4 pts were also treated with IABP. Primary Success (PS) was defined as a residual obstruction < 30% with TIMI 3 Flow without Major Complications (death or emergency CABG) and it was of 90.3%. Non PS without major complications was defined as F. There were 13 F due to: TIMI < 2 Flow (8/13 or 61.5%), non dilatable artery (1/13 or 7.6%) or inability to cross the occlusion (4/13 or 30.7%). Univariate and Multivariate analysis was made. There were no significative differences in age, gender, risk factors, AMI localization, treated artery, long lesion, angle, calcification, difficult access, reference diameter, ostium, bifurcational lesion and Stent utilization. An increased index of F was observed in pts with greater time interval to admission (<4hs: 5.8%, 4-6hs: 5.6%, > 6hs: 9.1% - O.R.: 2.29-p<0.041) and with worse KK [KK1 (3.7%), KK2 (9.5%), KK3 (9%), KK4 (21.4%) -O.R.:1.81-p<0.025].
Conclusion: 1) The worse KK and a delayed time interval to admission are related with an increased index of F of PTCA in AMI. 2) Another adjunctive therapeutics should be evaluated.

INTRODUCTION
   The transluminal coronary angioplasty is the preferred treatment for acute myocardial infarction in centers with appropriate infrastructure and well-trained personnel (1-2), especially in high-risk patients (3-4),however, in many studies Killip 3-4 patients, previous failed trombolysis, etc, have been frequently excluded. We carry out PTCA in the AMI from 1987 (5) and we have the tactical possibility of making it during the 24 hs of the day by means of passive guards' systems through we have achieved a vast experience and high success (6 ), however there is a small percentage of patient in those that in spite of a tactics and meticulous technique is not possible to obtain angiographic success. The PTCA in AMI has increased the reperfusion indexes and had a favorable impact on the intra-hospital and far away events, however they are not clear the behaviors in the face of the failures, those that bear a bigger intra-hospital mortality and combined cardiac event rate during the first year of follow-up if it compares it with the successful ones (7). The purpose of the present study is to analyze clinical and/or angiographic predictors of failures of the PTCA in Q wave AMI.

MATERIAL AND METHOD
   Between 8/94 - 8/99, 239 pts with AMI < 12 hs evolution were admitted, being treated with PTCA 135 pts (56.4%), primary (AP) 84 pts and of rescue (AR) 51 pts due to negative clinical reperfusion syndrome post thrombolytic. After identifying the culprit vessel by coronariography , carried out initially Balloon PTCA being complemented with Stent in case of recoil, dissection and/or residual stenosis >30%, being used in 55 pts (40.7%); all the Killip-Kimball (KK) 4 patients were also treated with Intra Aortic Balloon Pump.

   Definition of primary success: It was considered primary success a residual obstruction < 30% with TIMI 3 flow (8) and without major complications.

   Definition of failure: The failure was defined as the impossibility of achieving primary success for difficulty in to cross or to dilate the obstruction appropriately or not to achieve TIMI 3 flow in absence of major complications.

   Definition of major complication: Death, emergency surgical revascularization or worsening of the clinical picture (Killip-Kimbal to grades 3 - 4).

   Statistical analysis: Were used the Fisher´s test, Chi square test, Walk's test, Student's t test, Mann- Whitney's test and multivariate analysis for logistical regression with multiple regression coefficient for failure yes/no, determining the statistical significance (p < 0.05). The proportions were analyzed by determination of differences among standard error. The continuous variables were expressed as mean ± 1 SD.

RESULTS
   The primary success was of 90.3% (122/135 pts). There were 13 failures (9.6%) due to TIMI < 2 flow (8/13-61.5%), non dilatable artery (1/13-7.6%) or inability to cross the occlusion with the guide-wire (4/13-30.7%). There were no significant differences in age, gender, coronary risk factors (Diabetes, tobacco, Hypertension or hipercholesterolemia), AMI localization, culprit vessel, lesion length, angle localization, calcification, tortuous access, reference diameter, ostial or bifurcation localization, Stent utilization, primary or rescue PTCA (Table 1- 2 - 3).

   Bigger index of failures was observed in pts with greater time interval to admission and with worse Killip-Kimbal (Table 4) being independent predictors.

DISCUSSION
   The present study is a retrospective non randomized analysis of patients admitted in serial form in a single assistance center. We take the period starting from August of 1994 because it is then in that when we change our concept of primary success already not taking a TIMI 2-3 flow but a TIMI 3 flow (9-11) and not a residual obstruction < 50% but a < 30% (12) due to the routine incorporation of Stent inside the possible therapeutic arsenal for patient with AMI, for that that concomitantly changed our concept of failure.

   The difficulty in dilating the culprit vessel as cause of failure is extremely rare because habitually the plaque is soft, however this happened us here in one of the cases presented where a residual obstruction of 50% was achieved with TIMI 3 flow in a patient with multiple vessel disease in the one that decided elective revascularization surgery who evolved favorably; this situation could be solved by Cutting Balloon (13 -14) or High-Speed Rotational Atherectomy (15).

   The plaque accident is characterized among other things by the presence of spontaneous dissection for that that another of the causes possible of failure it is the secondary to impossibility of crossing the occlusion with the guide-wire; keeping in mind this possibility is that we should be very meticulous in the appropriate selection of the material (catheter, guide-wire, etc) and technique (radiological projections, etc) to use, since occasionally when the guide-wire is introduced in the dissection it is usually very difficult or impossible to win the true way; this eventuality happened here in the experience reported in 4 cases.

   Finally the most common causes of failure is given by the impossibility in obtaining TIMI 3 flow in spite of to get (16)a residual obstruction < 30% or with Stent near to the 0%;with this situation we found a relation with the greater time interval to admission and with worse Killip-Kimbal. The alterations in the microcirculation generated by the biggest time of occlusion and / or worsened by the worst clinical picture of admission and / or spontaneous or promote microembolus generated by the mechanical instrumentation are the responsible. Probably some pts could improve the flow by pharmacological means (17-19) (Verapamilo, Diltiazem, Inhibitors IIb-IIIa, Adenosine, etc) and/or the Intra Aortic Balloon Pump support; we believe that in this sense another studies should be made.

CONCLUSION

1) The worse Killip Kimbal and a delayed time interval to admission are related with an increased index of PTCA failures in AMI.
2) Another adjunctive therapeutics should be evaluated.

REFERENCES

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2. Zijlstra F, de Boer MJ, Hoorntje JCA, et al: A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328680-684.

3. Weaver WD, Simes J, Betriú A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction. A quantitative review. JAMA 1997;278:2093-2098.

4. García E, Elízaga J, Pérez N, et al. Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction. J Am Coll Cardiol 1999;33:605-611.

5. Leguizamón JH, Nauwerk R, Torresani EM ,y col: Angioplastia Coronaria en 115 pacientes cursando un IAM: 4 años de experiencia. Parte I: Angioplastia de Rescate. Rev Arg de Cardiol 1991; Vol.59, nº 5, TLP 5.

6. Torresani EM, Weisshein N, Martino G, et al: PTCA in Q Wave AMI. Predictors of In-Hospital Mortality. Am J of Cardiol, Vol 86 (Supp 8 A),TCT 236,92 i.

7. Moreno R, García E, Soriano J, y col: Angioplastia coronaria en el infarto agudo de miocardio:¿en que pacientes es menos probable obtener una reperfusión adecuada? Rev Esp Cardiol 2000;53:1169-1176.

8. TIMI Study Group. Thrombolysis in Myocardial infarction (TIMI) trial. N Engl J Med 1985;312 : 932-36 .

9. Fibrinolytic Therapy Trialist's (FIT) collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1.000 patients. Lancet 1993;342:759-766.

10. Lincoff AM, Ellis SG, Galeana A, et al for the TAMI Study Group: Is a coronary artery with TIMI grade 2 flow "patent"? Outcome in the Thrombolysis and Angiography in Myocardial Infarction (TAMI) Trial. Circulation 1992; 86 (Suppl 1):I-268.

11. GUSTO Angiographic Investigators: The effects plasminogen activator, streptokinase, or both on coronary artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993;329:1615 -1622.

12. Foley DP and Serruys PW. Provisional stenting - stent.like balloon angioplasty: evidence to define the continuing role of balloon angioplasty for percutaneous coronary revascularization. Semin Intervent Cardiol 1996;1:269-273.

13. Yamaguchi T, Nakamura M, Nishida T, et al: Update on Cutting Balloon Angioplasty. J Interven Cardiol 1998; 11 (Suppl.) S114-S119.

14. Asakura Y, Furukawa Y, Ishikawa S, et al: Successful Predilatation of a Resistant, Heavily Calcified Lesion With Cutting Balloon for Coronary Stenting. A Case Report. Cathet. Cardiovasc. Diagn. 44:420-422, 1998.

15. García Eulogio. Conferencia sobre Aterectomía Rotacional. Congreso Internacional Cardiología para el Consultante 2000.In Memorian Dr. René G.Favaloro. Noviembre 3-5,2000-Buenos Aires -Argentina.

16. Lincoff AM and Topol EJ. Illusion of Reperfusion: Does Anyone Achieve Optimal Reperfusion During Acute Myocardial Infarction? Circulation 1993;88:1361-1374.

17. Abbo KM, Dooris M, Glazier S, et al. No-reflow after percutaneous coronary intervention: Clinical and angiographic characteristics, treatment and outcome. Am J Cardiol 1995;75:778-782.

18. Piana RN, Paik GY, Moscucci M, et al. Incidence and treatment of no-reflow after percutaneous coronary intervention. Circulation 1994;89:2514-2518.

19. Van den Brand M and Ronner EF. The use of platelet glycoprotein IIb /IIIa receptor antagonists during the acute phase of myocardial infarction. Semin Intervent Cardiol 1999;4:85-87.

 

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2nd Virtual Congress of Cardiology

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