Author + information
- Alejandro Gutierrez-Barrios1,
- Dolores Cañadas2,
- Enrique Diaz-Retamino3,
- German Calle Perez4 and
- Rafael Vázquez-García1
We hypothesized that good coronary collateral circulation(CCC) may be related to myocardial viability and left ventricular ejection fraction (LVEF) in late presenter myocardial infarction (MI) patients (>24h).
Ambispective multicenter study on 190 patients with a late presentation MI and angiographic evidence of a thrombotic occlusion (TIMI 0) of a major coronary artery from 2009 to 2016.The Rentrop and Werner score were used for the angiographic categorization of CCC. Two experienced cardiologists retrospectively evaluated the angiographies in a blinded manner to classify the CCC into grades.12 patients were prospectively followed up and left ventricular(LV) wall motion score(WMS) was assessed for each of the 17 segments of the LV with a visual scoring system in which 1=normal, 2=hypokinetic, 3=akinetic, and 4=dyskinetic. WMS was performed at baseline and at follow-up. Scoring was carried out by two experiences cardiologists.
The median follow up was 3.4 years(IR 1.1-5.5 years). The Kappa indices of agreement for CCC classification was good (k = 0.88) and the Pearson correlation coefficient of WMS at baseline and at follow up showed an excellent interobserver concordance(r=0.99,p=0.001 and r=0.98,p=0.0001) respectively. Culprit vessel revascularization was attempted in 83% of the patient (129/155) and successfully recanalized in 84%(108/129). Successful PCI of culprit vessel was not associated neither with LVEF at baseline (46±13vs50±10 p=0.06) nor with increase in LVEF, WMS at baseline and at follow up (p>0.1 for all). LVEF was significantly higher in patients with good CCC at baseline (53±8 vs 45±12, p<0.001) and at follow-up (56.7±11vs 44±11,p=0.01). Qualitative assessment of culprit vessel territory motion showed significant differences between patients with poor and good CCC(p=0.019): dyskinesia (15%vs3%); akynesia (41%vs12%), Hipokynesia ( 22%vs59%) and normokynesia (22%vs25%) respectively. Myocardial viability in the culprit vessel territory was confirmed in 56.6% of patients (90/159), 4.5% of them had akinesia and viability was assessed by a stress echocardiogram. Viability was significantly higher in good compare to poor CCC patients (76.5%vs33.8%, p<0.001). Rentrop and Werner classification were respectively correlated to: LVEF (r=0.38, p=0.001 and r=0.32, p=0.005);WMS at baseline (r=-0.605, p0.049 and r=-0.55, p=0.07) and WMS at follow-up (r=-0.66 p=0.01 and r=-0.47, p=0.11) and both classifications were significantly higher in patients with myocardial viability: 1.77±0.9vs0.9±0.9 p<0.001 for Rentrop and 1±0.6vs0.49±0.5, p<0.001 for Werner. Rentrop and Werner were also correlated with follow-up EKG: Number of leads with persistent ST segment elevation (r=-0.78, p=0.004 and r=-0.63, p=0.03) and number of leads with Q waves (r=-0.72, p=0.01 and r=-0.57, p=0.06) respectively.
Good CCC was related to myocardial viability and LVEF in late presenter MI patients. These patients could benefit from revascularization even late in the course of a MI. A randomized trial should be encouraged to confirm these findings.
CORONARY: Acute Myocardial Infarction