Preditores de insucesso de tromboaspiração em pacientes submetidos à intervenção coronária percutânea primária / Predictors of failed thrombus aspiration in patients undergoing primary percutaneous coronary intervention

INTRODUÇÃO: A tromboaspiração é recomendada como método adjunto à intervenção coronária percutânea (ICP) primária, mas o insucesso em recuperar trombos é relativamente frequente. O objetivo deste estudo foi avaliar as taxas de insucesso de tromboaspiração e identificar seus preditores, em uma série contemporânea de pacientes. MÉTODOS: Estudo de coorte prospectivo que incluiu pacientes consecutivos atendidos com infarto agudo do miocárdio com elevação do segmento ST e submetidos à ICP primária com tromboaspiração no período de dezembro de 2009 a dezembro de 2011. Os procedimentos de tromboaspiração foram realizados por decisão do operador, e o sucesso foi definido como aspiração efetiva de trombo pelo cateter dedicado, com recuperação do fluxo coronário (fluxo TIMI > 0). RESULTADOS: Foram realizadas 1.055 ICPs primárias, sendo que a tromboaspiração foi utilizada em 37% dos casos, com taxa de sucesso de 70%. Foram identificados 254 pacientes com sucesso e 107 com insucesso da tromboaspiração. Insucesso de tromboaspiração foi associado a: idade, hipertensão, diabetes mellitus, dislipidemia, ICP prévia, escore de risco TIMI, Killip IV, contagem de leucócitos, fibrinogênio sérico, diâmetro de referência do vaso-alvo e TIMI 3 pré-procedimento. Pacientes com insucesso da tromboaspiração apresentaram tendência a maior mortalidade (11,6% vs. 5,9%; P = 0,09). CONCLUSÕES: Insucesso de tromboaspiração durante ICP primária ocorreu em 30% dos casos e esteve associado a tendência de maior mortalidade. A identificação de preditores clínicos, laboratoriais e angiográficos pode auxiliar no aprimoramento desses dispositivos e em sua técnica, além da escolha de pacientes mais adequados para seu emprego.

BACKGROUND: Aspiration thrombectomy is recommended as an adjunctive method in patients undergoing primary percutaneous coronary intervention (PCI), however, thrombus aspiration failure is relatively frequent. The objective of this study was to evaluate the rate and identify predictors of failed thrombus aspiration in a contemporaneous series of patients. METHODS: Prospective cohort study including consecutive patients with acute ST-segment elevation myocardial infarction undergoing primary PCI with thrombus aspiration from December 2009 to December 2011. Aspiration thrombectomy was performed at the operator's discretion and success was defined as effective thrombus aspiration by a dedicated catheter with the achievement of a final TIMI flow > 0. RESULTS: 1,055 primary PCIs were performed and aspiration thrombectomy was used in 37% of cases with a success rate of 70%. Aspiration thrombectomy success was observed in 254 patients whereas failure was observed in 107 patients. Aspiration thrombectomy failure was associated with age, hypertension, diabetes mellitus, dyslipidemia, previous PCI, TIMI risk score, Killip IV, leukocyte count, serum fibrinogen, target vessel reference diameter and preprocedural TIMI 3 flow. Patients with failed thrombus aspiration had a trend towards higher mortality (11.6% vs. 5.9%; P = 0.09). CONCLUSIONS: Aspiration thrombectomy failure during primary PCI was observed in 30% of the cases and was associated with a trend towards higher mortality. The identification of clinical, laboratory and angiographic predictors may help improve these devices and the technique and enable better patient selection.

Intervenção coronária pelas vias radial ou femoral no infarto agudo do miocárdio com supradesnivelamento do segmento ST: um, a visão da prática clínica contemporânea / Coronary intevention by radial or femoral access in acute St-Segment elevation myocardial infarction: the real-world clinical practice

Introdução: A via radial é um acesso seguro para procedimentos percutâneos e reduz as complicações vasculares locais. Neste estudo comparou-se a evolução hospitalar de pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) submetidos a intervenção coronária percutânea primária (ICPp) por via radial vs. via femoral. Métodos: Estudo de coorte prospectivo com pacientes consecutivamente atendidos entre dezembro de 2009 e maio de 2011. Resultados: Foram incluídos 794 pacientes, 82 (10,3%) tratados por via radial e 712 (89,7%), por via femoral. Pacientes do grupo radial eram mais jovens (56,2 ± 10,7 anos vs. 61,2 ± 11,9 anos; P < 0,01), mais frequentemente do sexo masculino (78% vs. 68%; P = 0,06), com menor prevalência de diabetes (9,8% vs. 20%; P = 0,02) e maior fração de ejeção do ventrículo esquerdo (61,2 ± 11,8% vs. 55,5 ± 12,1%; P = 0,05). Não houve diferença em relação à maior parte das características angiográficas. Tromboaspiração (44% vs. 31%; P = 0,01) e administração de glicoproteína IIb/IIIa (41% vs. 26%; P = 0,004) foram mais utilizadas no grupo radial. O fluxo TIMI 3 final (93% vs. 88%; P = 0,47) e o blush miocárdico 3 (70% vs. 66%; P = 0,87) foram semelhantes entre os grupos. Não foram observadas diferenças em relação a óbito (7,5% vs. 8,4%; P = 0,78), reinfarto (4,9% vs. 4,4%; P = 0,77), revascularização de urgência (3,7% vs. 4,1%; P > 0,99), trombose do stent (2,4% vs. 3%; P > 0,99), sangramento maior (0 vs. 1,6%; P = 0,61) ou sangramento menor (5,3% vs. 7,3%; P = 0,81). Conclusões: A abordagem transradial mostrou-se segura e efetiva, com resultados semelhantes aos da abordagem transfemoral em pacientes com IAMCSST.

BACKGROUND: Radial access is a safe approach for percutaneous procedures and reduces local vascular complications. This study compared the hospital outcomes of patients with ST-elevation acute myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (pPCI) using the radial vs. femoral approaches. METHODS: Prospective cohort study with consecutive patients treated between December 2009 and May 2011. RESULTS: Seven hundred and ninety-four patients were included, 82 (10.3%) treated by radial access and 712 (89.7%) treated by femoral access. Radial access patients were younger (56.2 ± 10,7 years vs. 61,2 ± 11,9 years; P < 0.01), more often male (78% vs. 68%; P = 0.06), had a lower prevalence of diabetes (9.8% vs. 20%; P = 0.02) and higher left ventricle ejection fraction (61.2 ± 11.8% vs. 55.5 ± 12.1%; P = 0.05). There was no difference for most angiographic characteristics. Thromboaspiration (44% vs. 31%; P = 0.01) and glycoprotein IIb/IIIa administration (41% vs. 26%; P = 0.004) were used more often in the radial group. The final TIMI 3 flow (93% vs. 88%; P = 0.47) and myocardial blush grade 3 (70% vs. 66%; P = 0.87) were similar between groups. There were no differences for death (7.5% vs. 8.4%; P = 0.78), reinfarction (4.9% vs. 4.4%; P = 0.77), emergency revascularization (3.7% vs. 4.1%; P > 0.99), stent thrombosis (2.4% vs. 3%; P > 0.99), major bleeding (0 vs. 1.6%; P = 0.61) or minor bleeding (5.3% vs. 7.3%; P = 0.81) rates. CONCLUSIONS: The transradial approach has proven to be safe and effective with similar results to transfemoral approach in patients with STEMI.

Effectiveness of acetylcysteine in prevention of contrast nephropathy.

BACKGROUND: Acetylcysteine may provide prophylaxis against contrast nephropathy (CN) in some patients. Its benefit may vary according to the characteristics of patients and contrast used. The objective is to evaluate the effectiveness of oral acetylcysteine in preventing CN after coronary procedures in our practice. METHODS: We prospectively studied 397 patients with a creatinine level equal to or above 1.3 mg/dl, diabetes mellitus, or 70+ years of age who underwent a coronary procedure. Patients were randomly assigned to receive either acetylcysteine or placebo and 0.9% saline before and after the contrast agent. High- or low-osmolality contrast was used according to the discretion of the interventional cardiologist. Serum creatinine was measured before and 24 to 48 hours after the procedure. RESULTS: An increase of greater than or equal to 25% in the baseline creatinine level 24 to 48 hours after the procedure occurred in 14 (7.1%) of 196 acetylcysteine patients and in 17 (8.4%) of 201 placebo patients (p=0.62). In the acetylcysteine group, the mean baseline serum creatinine concentration was 1.30+/-0.56 mg/dl and increased 0.076+/-0.21 mg/dl 24 to 48 hours after administration of contrast, whereas in the placebo group, it was 1.27+/-0.51 mg/dl and increased 0.101+/-0.28 mg/dl (p=0.33). In the subgroup with estimated baseline creatinine clearance <60 ml/minute, no difference was found in the incidence of CN (9.1% in the acetylcysteine group; 11.7% in the placebo; p=0.66). By multivariate analysis, left ventricular ejection fraction less than or equal to 40%, volume of contrast >200 ml, and estimated creatinine clearance (but not acetylcysteine) were related to CN. CONCLUSIONS: Oral acetylcysteine was not effective as a prophylactic treatment against CN for patients with a potential risk and submitted to coronary angiographic procedures with predominantly high-osmolality contrast.