Predictors of no-reflow in patients with myocardial infarction and ST-segment elevation treated with primary angioplasty

Introduction

The no-reflow phenomenon is a serious complication of coronary intervention, especially in primary angioplasty and effective preventive measures are unknown.

Methods

Retrospective study of all patients treated by primary angioplasty in a single center through 4 years. We define no-reflow as the absence of flow immediately after stent angioplasty. The variables associated with this phenomenon were analyzed using binary logistic regression. The delay to primary angioplasty was calculated as the sum of the time to the first medical contact, activation, transfer until arterial puncture.

Results

We included 1453 patients, mean age 64.1 years, 21% women, 16.1% Killip >1. The mean delay to primary angioplasty was 180 minutes (interquartile range 125–323). No-reflow was recorded in 81 (5.57%) patients and these patients had a higher mean age (69.37±12.51 vs. 63.76±13.52; p<0.001), higher delay to primary angioplasty (770.93±2056.91 vs. 348.80±749.73; p<0.001), presentation with Killip grade >1 (29.0% 15.36%; p=0.002), in addition to lower systolic blood pressure (121.18±28.63 vs. 113.37±28.22; p=0.021). Regarding coronary angiography, patients who developed no-reflow presented more frequently TIMI-0 (88.89% vs. 70.32%; p<0.001) and a tendency to being the left anterior descending the culprit vessel (46.91% vs. 36.88, p=0.07). In 59.3% of the patients who presented no-reflow, a final TIMI 3 was achieved, with the measurements carried out, compared to (94.9%) of the patients who did not have no-reflow (p<0.001).

Multivariate analysis identified the following variables associated with no-reflow: age (OR: 1.03 95% CI 1.01–1.05; p=0.008), delay to primary angioplasty >120 min (OR: 2.70, 95% CI 1.21–6.00; p=0.015), initial TIMI-0 (OR: 3.22, 95% CI 1.57–6.58; p=0.001). In fact, patients aged >40 had a very low incidence of no-reflow (1.72%), regardless of delay to primary angioplasty; however, in patients >70 years of age, the incidence was much higher (figure)

Hospital mortality was 9.25% (125 patients) and was almost 4 times higher in patients who presented no-reflow (23.68% vs. 8.39%; p<0.001). Adjusted for age, sex, delay to primary angioplasty diabetes and final TIMI flow, the no-reflow phenomenon was associated with higher hospital mortality (OR: 2.34 95% CI 1.02 4.25; p=0.030)

Conclusions

The no-reflow phenomenon has a low incidence but high mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty. Age, delay to primary angioplasty and initial TIMI 0 flow are the main predictors of no-reflow.

Funding Acknowledgement

Type of funding sources: None.

The use of the acute Pd/Pa drop after intracoronary nitroglycerin infusion to rule out significant FFR: CANICA (Can intracoronary nitroglycerin predict fractional flow reserve without adenosine?) multicenter study

OBJECTIVE

Functional assessment of coronary artery stenosis is performed by measuring the fractional flow reserve (FFR) under hyperemic conditions (Adenosine). However, the use of adenosine portends limitations.

OBJECTIVE

We sought to investigate the relationship and correlation between FFR and the Pd/Pa value obtained just after the intracoronary infusion (acute drop) of nitroglycerin (Pd/Pa-NTG) and if this parameter enhances diagnostic accuracy for FFR prediction compared to the resting baseline Pd/Pa.

METHODS

We conducted a multicenter study including prospectively patients presenting intermediate coronary artery stenosis (30-70%) evaluated with pressure wire. Resting baseline Pd/Pa, Pd/Pa-NTG and FFR were measured.

RESULTS

283 patients (335 lesions) were included. Resting baseline Pd/Pa value was 0.72 to 1.0 (0.93 ± 0.04), Pd/Pa-NTG was 0.60 to 1.0 (0.87 ± 0.07) and FFR 0.55 to 1.0 (0.83 ± 0.08). The ROC curves for resting baseline Pd/Pa and for Pd/Pa-NTG, using a FFR ≤ 0.80 showed an AUC of 0.88 (95% CI: 0.84-0.92, P < 0.001) and 0.94 (95% CI: 0.92-0.96, P < 0.001) respectively. The optimal cutoff values of resting baseline Pd/Pa and Pd/Pa-NTG for an FFR > 0.80, were >0.96 and >0.88, respectively. These values were present in a 29.8% (n = 100) and a 47.1% (n = 158), of the total lesions. Scatter plots showed a better correlation and agreement points with Pd/Pa-NTG than resting baseline Pd/Pa. The cutoff value of Pd/Pa-NTG > 0.88 showed an excellent NPV (96.2% for FFR > 0.8 and 100% for FFR > 0.75) and sensitivity (95% for FFR > 0.8 and 100% for FFR > 0.75) which were consistently high across all the subgroups analysis.

CONCLUSION

The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions.

[A case of Carney syndrome]

The Carney complex is an autosomal dominant syndrome characterised by multiple neoplasies, including myxomas at various sites (cardiac, cutaneous, mammary), spotty pigmentation, endocrine overactivity (Cushing's syndrome, acromegalia), testicular tumours and schwannomas. This report describes the case of a 43-year-old woman with an acute inferior myocardial infarction, probably due to coronary embolization from a large left atrial myxoma and who presented this association. A brief review of the Carney complex is provided after discussion of this rare case that required an screening of family members.

Benign intracardiac teratoma detected prenatally. Case report and review of the literature

Primary cardiac tumors are rare and, until recently, were mostly incidental postmortem findings. Nowadays, due to the widespread use of prenatal ultrasound scans, we are able to diagnose them in utero. We present a case of an intracardiac teratoma diagnosed at 38 weeks, menstrual age. Previous scans had been normal. Labor was induced, and a female infant with an Apgar score of 9 and 4, at 1 and 5 min, was delivered. Her condition worsened rapidly. She died 16 h after birth. Necropsy was performed, and a cystic, mature teratoma of 4 cm was found in the interventricular septum, growing into the right ventricle. No other anomalies were found. This probably represents the first case of an intracardiac, benign teratoma diagnosed prenatally.

A comparison of two neurologic scoring instruments for multiple sclerosis

We examined the degree of association between two neurologic impairment scales, the Extended Disability Status Scale (EDSS) and the Scripps Neurologic Rating Scale (SNRS), with data from a randomized, double-blind, placebo-controlled clinical trial assessing the safety and efficacy of cladribine as treatment for chronic progressive multiple sclerosis (MS). We found that the EDSS and SNRS were not strongly correlated within individual patients, contrary to expectation; moreover, in 9 of the 48 evaluable patients, the directions of their changes from baseline values were not mutually consistent. The scales were differentially sensitive to clinical changes over time, with the EDSS indicating a more abrupt, and the SNRS a more gradual, change in the clinical course of disease. The validity of different impairment scales, and their sensitivity to detect clinical changes, should be formally assessed in future clinical trials using these scales as outcome measures.

[Papillary muscle rupture during subaortic membrane balloon dilatation]

A 37 year-old female patient underwent catheter-balloon dilation for discrete subaortic stenosis. During the procedure severe mitral regurgitation was produced requiring emergency surgery. Transesophageal and intraoperative findings were posteriormedial papillary muscle rupture. Retrospective viewing of the cineangiogram during balloon inflation revealed distal balloon indentation, corresponding to the injured papillary muscle. This severe complication of the left ventricular outflow tract angioplasty should be avoided by careful positioning of the guidewire and balloon before inflation.

Discrimination between the ulcerous and the nonulcerous forms of interstitial cystitis by noninvasive findings

PURPOSE

We determined whether the classification of interstitial cystitis cases into ulcer and nonulcer categories from cystoscopic findings could be corroborated with epidemiological data relating to demographics, risk factors, symptoms, pain and psychosocial factors.

MATERIALS AND METHODS

We surveyed 565 interstitial cystitis patients (111 with and 454 without ulcer), and from univariate analyses we found 10 noninvasive variables to be significantly associated with the presence of Hunner's ulcers. The 3 multivariate statistical methodologies of discriminant analysis, logistic regression and recursive partitioning were used to classify ulcer versus nonulcer cases from these variables. The retrospective and prospective performances from each methodology were also analyzed.

RESULTS

Retrospectively, resubstitution error rates of all 3 methodologies were small, with overall misclassification rates of 19.1% with linear discriminant, 14.7% with logistic regression and 8.0% with recursive partitioning. Prospectively, the overall misclassification rates increased slightly to 20.0% with linear discriminant, 15.8% with logistic regression, and 15.9% with recursive partitioning.

CONCLUSIONS

The classification of interstitial cystitis into distinct categories of Hunner's ulcer (classic interstitial cystitis) and nonulcer based on cystoscopic findings can be corroborated with epidemiological evidence. The 2 categories may represent different manifestations of the underlying disease pathophysiology.

Situs inversus and myocardial revascularization. Case report

This report describes an internal mammary artery by-pass grafting to the anterior descending coronary artery in a man with an unstable postinfarction angor pectoris and a "situs inversus totalis" condition. The association of "situs inversus totalis" and atherosclerotic coronary artery disease has the same incidence as in normal people. To the authors' knowledge, this is the second case in medical literature of coronary artery by-pass surgery with internal mammary artery graft in a patient with "situs inversus totalis".

Normal transcutaneous oxygen pressure in skin after radiation therapy for cancer

BACKGROUND

Chronic deleterious changes in human skin after radiation therapy often have been ascribed to progressive ischemia (decreased blood supply and oxygenation). Recent studies suggest, however, that damaged irradiated skin is not ischemic. Transcutaneous oxygen pressure (TCPO2), that accurately reflects skin oxygenation, was studied in 100 patients who had undergone prior extensive radiation therapy for cancer.

METHODS

In the 100 patients, the mean time since radiation was 7.86 +/- 10.56 years (mean, +/- SD) (range, 1-58 years). Radiation skin effects were graded (0-4+), and TCPO2 was measured in irradiated and control nonirradiated sites, with patients first breathing room air, then 100% O2 6 l/min for 10 minutes. Data were stratified according to skin grades, sex, time since irradiation, site, type, and dose of radiation.

RESULTS

The mean TCPO2 in patients breathing room air was 52.0 17.8 mm Hg (mean +/- SD) for all irradiated skin, compared with 131.8 +/- 51.1 at the same irradiated sites in response to oxygen breathing (P < 0.0001); the mean TCPO2 for normal, nonirradiated skin was 56.5 +/- 12.6 when patients were breathing room air, compared with 151.5 +/- 48.1 when breathing 100% oxygen (P < 0.0001). Higher skin damage grades correlated with increasing time after radiation therapy. However, neither increasing time after irradiation nor grade of skin damage correlated with TCPO2, which was normal in 88% of the patients.

CONCLUSIONS

Human skin, even many decades after radiation therapy, retains normal tissue oxygenation and TCPO2 response to inspired oxygen. Postradiation scarring, poor healing, and rare ulceration are not solely due to ischemia and may be caused by other radiation effects, such as permanent changes in fibroblasts.

[The clinical and echocardiographic factors predictive of bioprosthetic leaflet rupture. The clinical tolerance for prosthetic malfunction]

OBJECTIVE

The objective of this research was to determine the existence of predictors of bioprosthetic valve disruption depending on the echocardiographic characteristic of the biologic prosthesis. It also determines the factors that provoke a need of emergency surgery and a bad clinical tolerance to the prosthetic dysfunction.

METHODS

Clinical and echocardiographic features of two groups of 28 and 21 patients, all of them carrying bioprosthesis, were compared. The groups were homogeneous in sex, age, location and durability of the prosthesis. The first group showed leaflet disruption in a period of 6 months to 1 year after the study, not in the second group. Calcification, thickness and mobility of leaflets, prosthetic function were studied. An echocardiographic score was given between 4 and 10 points. Left ventricular function and pulmonary pressure were also studied.

RESULTS

Valve thickness was statistically different in both groups (95% of the first group vs 71.3% of the second, p = 0.0281). There was no significant difference in calcification (52% vs 38.7%), nor in leaflet mobility (71.5% normal in the first group vs the 80% of the second group), nor in the prosthetic function (52.3% vs 76.6%, respectively). It was not found in the echocardiographic score either. Left ventricular function and pulmonary pressure were 91.6% and 55% normal respectively in the first group. They were 80% and 45.83% normal in the second group. Clinical onset of disruption was: 5 asymptomatic patients, 2 patients noticed a change in prosthetic click, 14 cases with progressive dyspnea, 6 patients with acute pulmonary edema and 1 patient with cardiopulmonary arrest and effective resuscitation. Symptoms were kept under control with medical treatment in 22 patients (78.55%) and 6 patients were referred to surgery. These latter suffered from pulmonary hypertension and two of them had left ventricular dysfunction. Surgical mortality was 3% (1 patient).

CONCLUSIONS

No echocardiographic features were found as being predictors of imminent bioprosthetic disruption. However, leaflet thickness is the most common finding. Symptoms of disruption in patients without high surgical risk factors (left ventricular dysfunction or pulmonary hypertension) are kept under control with medical treatment. Therefore, "prophylactic" surgery is not needed in bioprosthesis with signs of degeneration and normal hemodynamic performance.

[Palliative interatrial septostomy in severe pulmonary hypertension]

Three patients with severe pulmonary hypertension underwent palliative atrial septostomy by dilating the interatrial septum with valvuloplasty catheter-balloons. In two cases successful dilation improved cardiac index and symptoms of cardiac failure (13 and 11 months follow-up). One patient died immediately post-septotomy due to severe hypoxemia. Severe pulmonary hypertension with low cardiac output and high right ventricular filling pressures has a very poor short-term prognosis. Atrial septostomy is a useful palliative procedure and can serve as a bridge to heart and/or lung transplantation. It is not free of risk and the resultant systemic hypoxemia can lead to dead; that is why we recommend progressive balloon diameters, stopping the procedure when improvement of cardiac index is achieved with the minimal systemic oxygen desaturation.

[Acute posttraumatic myocardial infarct: the necessity of an early interventionist posture]

We describe five cases of posttraumatic anterior acute myocardial infarction in young patients, without previous heart disease. One case was treated with intracoronary thrombolysis and angioplasty, 3 cases received systemic thrombolysis, and the last one did not have any re-permeabilization therapy, having arrived to the hospital 72 hours after the episode. The coronary angiograms showed at the left anterior descending artery: thrombosis in 3 cases, coronary dissection in one case, and slow flow with no morphological lesions in the other. The case which not received thrombolytic therapy developed a severe left ventricular dysfunction. In conclusion we emphasize an early angiographic study, in order to decide the re-permeabilization therapy.

Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention

We describe four cases of acute myocardial infarction in young patients, secondary to blunt chest trauma. One case was treated with intracoronary thrombolysis and angioplasty, two cases received systemic thrombolysis, and the last one did not have any reperfusion therapy. The coronary angiograms of the left anterior descending artery showed thrombosis in two cases, coronary dissection in one case, and no morphological lesions in the other. We encourage the early performance of angiographic studies in these patients, adjusting the therapy to their pathophysiologic mechanism.

[Silent ischemia after myocardial infarct]

The Framingham study demonstrated that 25% of all episodes of acute myocardial infarction (AMI) do not present clinical symptoms, and are later recognized in a routine ECG. Silent ischaemia is frequently found after acute myocardial infarction, and has been identified in 25-60% of the patients according to the results of different studies and the different criteria employed for diagnosis. Silent ischaemia after AMI, as well as angina, is related with the presence and extent of severe coronary lesions located in the infarct related coronary artery or in other vessel not responsible for the acute episode of necrosis. The prognostic significance of silent ischaemia after AMI has not been well established. In some studies the painless ST segment depression during an exercise test soon after AMI presented the same prognostic value that the ST segment depression accompanied by angina, but in others the symptomatic episodes were a better predictor of major events and long term survival after the infarct. Several studies employing ambulatory ECG monitoring (Holter) also seem to indicate that the painless and transient episodes of ST segment depression identify a group of patients with worse prognosis, but in these studies the patients were selected, introducing a clear bias in the results of these investigations. Finally, asymptomatic transient perfusion defects in thallium studies clearly identify a group of high risk patients with a higher incidence of complications and higher mortality rate than the patients with negative thallium studies. The efficacy of anti-ischaemic drugs or myocardium revascularization procedures, including surgery, has not been studied in patients with silent ischaemia after acute myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rupture of the mitral posteromedial papillary muscle associated with myxomatous mitral valve]

We report a 52 year old man, who without previous thoracic trauma, cardiac diseases or cardiovascular risk factors presented after mild epigastric discomfort acute pulmonary oedema. He did not present clinical, electrocardiographic and biochemical manifestation of acute myocardial infarction. He was hospitalized and 15 days later he was sent to our hospital intubated and with assisted respiration. Haemodynamic studies showed severe acute mitral regurgitation and absence of significant obstructing lesions in the coronaries arteries. He was operated few hours after admission. The surgeon found a dysplasic mitral valve and rupture of a head of the posteromedial papillary muscle. The anatomopathological studies discovered mitral myxoid degeneration and ischemic lesion of the papillary muscle. We review the literature of the exclusive infarction of the papillary muscles and their possible relationships with the mitral prolapse syndrome.