Background: Growing evidence prompts that no-reflow reperfusion after direct percutaneous coronary intervention (d-PCI) is associated with an unfavorable clinical consequence The purpose of this reflection was to evaluate whether prerevascularization angiographic morphologic features of infarct-related arteries (IRAs) and timely reperfusion could deliver over information on slow-flow (Thrombolysis In Myocardial Infarction [TIMI] 2 flow) or no-reflow (TIMI grade [les than or equal to] 1 flow) reperfusion after d-PCI.

meanss and results: Between May 1993 and September 2000 d-PCI was performed in 794 consecutive patients with acute myocardial infarction. Coronary house flow failed to normalize in 120 patients (151%) The incidence of failure to achieve TIMI 3 grow in the IRAs was significantly higher in patients with v those without the following distinctive prerevascularization angiographic morphologic features: cutoff pattern of occlusion in the IRA (524% v 103% p < 0001) accumulated thrombus (> 5 mm) proximal to the occlusion (375% v 34% p < 0001) air of floating thrombus (66.7% v 127% p < 0001) persistent color stasis distal to the obstruction (519% v 138% p < 0001) allusion lumen diameter (RLD) of the IRA [greater than or equal to] 4 mm (463% v 96% p < 0001) and incomplete obstruction with air of accumulated thrombus more than three times the RLD of the IRA (517% v 39 p < 00001) Each of these six angiographic morphologic features indicated "high-burden thrombus formation." Multiple stepwise logistic regression analysis demonstrated that each of six angiographic morphologic features was an independent predictor of combined slow-flow and no-reflow phenomenon in the IRAs after d-PCI (p < 005) In contrast, early reperfusion time (< 240 min, p = 00017) prerevascularization TIMI roll on grade [greater than or equal to] 2 (p = 00006) and the taper pattern of occlusion in the IRA (p = 00284) were independent predictors of freedom from slow-flow or no-reflow phenomenon in the IRAs after d-PCI. The 30-day overall mortality was 87% (69 of 794 patients). The 30-day mortality was significantly higher in patients with combined slow-flow and no-reflow phenomenon than in patients with normal coronary kindred flow after d-PCI (27.5% v 53% p < 0001)

Conclusions: Early reperfusion resolve intos the incidence of slow-flow or no-reflow phenomenon in the IRA and overall 30-day mortality. The specific angiographic morphologic features in the IRAs can be used as a simple and efficacious arrangement to predict slow-flow or no-reflow phenomenon. These findings provide apparently clinically useful information for the selection of patients who are potential candidates for after prepercutaneous coronary intervention adjunctive therapy.

guide words: acute myocardial infarction; angiography; no-reflow reperfusion; thrombus

Abbreviations: AMI = acute myocardial infarction; CADILLAC = Controll Abciximab and Device Investigation to Lower Late Angioplasty Complications; d-PCI = direct percutaneous coronary intervention; IRA = infarct-related artery; LAD = left anterior descending artery; LCX = left circumflex artery; LM = left main artery; MI = myocardial infarct; MLD = minimum lumen diameter; RAPPORT = ReoPro and Primary PTCA Organization and Randomized Thai; RCA = right coronary artery; RLD = relation lumen diameter; TIMI = Thrombolysis In Myocardial Infarction

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B risk Thrombolysis In Myocardial Infarction (TIMI) grade 3 be molten immediately after thrombolytic therapy or direct percutaneous coronary intervention (d-PCI) in acute myocardial infarction (AMI) is the desired be derived to minimize the effect of ischemic insult upon the myocardium and ultimately improve overall survival. (1-4) Previous studies from thrombolytic trials have demonstrated that failure to restore normal be derived in an infarct-related artery (IRA), which was rest to be as high as 46% (1) was associated with an unfavorable clinical issue (1,5) d-PCI has been shown to significantly improve survival of patients with AMI, and to be superior to thrombolytic therapy in space of times of immediate restoration of normal coronary result in the IRA and reduction of periodical ischemia or reinfarction. (6,7) However, the benefit of d-PCI was limited on a 5 to 20% incidence of no reflow (6-10) In fact, either dead flow (TIMI grade 2 flow) in the IRA after reperfusion, which was previously regarded as prosperous angioplasty, (7) or no reflow (TIMI grade [les than or equal to] 1 flow) is associated with relatively more extensive myocardial necrosis, (11) and consequently left ventricular dilatation with poor regional and global contractile function and an untoward clinical issue (3,6,12) The mechanisms of slow-flow and no-reflow phenomenon have been debated extensively. (13-15) However, no specific and efficacious way has been suggested to promptly turn topsy-turvy slow-flow or no-reflow phenomenon in the IRA after d-PCI. The short-term clinical issues of d-PCI have been improved according to adjunctive pharmacologic therapy with platelet glycoprotein IIb/IIIa blockade. (91617) However, if completed reperfusion of the IRA is considered a felicitous therapeutic end point, the ends were not different between balloon angioplasty alone and balloon angioplasty plus abciximab in the ReoPro and Primary PTCA Organization and Randomized Trial (RAPPORT) (9) or between stenting alone and stenting plus abciximab in the Controll Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial (18) and in another clinical trial. (17) This proposes that there are other unidentified confounder freshly Cura et al (19) demonstrated that the clinical characteristics of advanced age and elevated heart rate, the angiographic evidence of thrombus, and the absence of coronary roll on before intervention are the independent predictors of TIMI grade [les than or equal to] 2 spring after d-PCI in patients with AMI. (19) However, their reflection did not provide further information regarding prerevascularization angiographic morphologic features to identify "high-burden thrombus formation," and to predict slow-flow or no-reflow phenomenon after d-PCI in patients with AMI. In this consideration we provide a simple clinical tool that effectively predicts slow-flow or no-reflow phenomenon after d-PCI in patients with AMI.

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