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