Combined Revascularization Strategy for Acute Myocardial Infarction in Patients With Intracoronary Thrombus

Abstract

rimary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) is a superior revascularization technique over systemic 1-4 or intracoronary 5 thrombolysis, although several limitations still remain, including a high reocclusion rate 6 or flow disturbance, 7,8 which influence the short 9,10 and long-term prognosis. 11 As is well known, the culprit lesion of AMI is usually a composite of atherosclerotic plaque and thrombus. [12][13][14] The thrombus burden varies from case to case, and large thrombus is resistant to systemic thrombolysis and frequently triggers distal embolization or 'no reflow' after mechanical revascularization. [15][16][17] Intracoronary thrombolysis (ICT) is a method of treating thrombus with a higher concentration of thrombolytic agent and potentially could enhance flow restoration when combined with PTCA. In the present study, we investigated this treatment method by comparing primary PTCA without preceding thrombolysis in AMI patients with intracoronary thrombus, focusing on acute phase flow restoration. Methods Study PopulationAmong 426 patients who received emergency PTCA for AMI between January 1988 and December 1996 in Kumamoto Central Hospital, 80 with an intracoronary thrombus Japanese Circulation Journal Vol.65, April 2001 on initial coronary angiography were enrolled in this retrospective analysis (Table 1). Patients who received systemic thrombolysis or who exhibited Thrombolysis in Myocardial Infarction (TIMI) grade 2/3 flow were excluded.Patients were also excluded if they displayed (1) stenosis of the left main coronary artery of more than 75%; or (2) critical 3-vessel disease. The diagnosis of AMI was based on typical chest pain lasting for at least 30 min, the appearance of ST-segment elevation of more than 2 mm in at least 2 contiguous ECG leads, and a greater than 3-fold increase in serum creatine kinase.Written informed consent for the need of revascularization had been obtained from each patient or from the family of the subject. DefinitionsIntracoronary thrombus was defined as a localized filling defect surrounded by contrast medium or as luminal staining at the site of a high-grade stenosis, which was visualized in multiple views clearly occupying more than 50% of the coronary artery lumen and more than 15 mm in length measured by the digital caliper method (DBAC-1000 NEOTEC Co, Ltd). In the case of total occlusion, the intracoronary thrombus was evaluated after crossing the occluded site with a 0.014-inch guidewire and/or noninflated balloon catheter. Preinfarction angina pectoris was defined as episodes of chest oppression/pain within 2 weeks of AMI onset. Cardiogenic shock at admission was defined as systolic blood pressure less than 80 mmHg that was unresponsive to volume expansion and necessitating immediate intraaortic balloon pump (IABP) therapy. Lesion success after PTCA was defined as residual stenosis less than 50% in the American Heart Association (AHA) classification

Serum NT-proBNP on admission can predict ST-segment resolution in patients with acute myocardial infarction after primary percutaneous coronary intervention

“…Although the efficacies of embolic protection and mechanical thrombectomy devices [29,30] are vague, other preventive measures aimed at improving myocardial reperfusion at the microvascular level may be initiated prospectively and prove beneficial. Administration of a glycoprotein IIB/IIIA inhibitor, an intracoronary thrombolytic agent, or a high-dose adenosine infusion before pPCI was shown to be beneficial in some studies [31][32][33]. Additionally, ischemic postconditioning, circulatory support, and an earlier re-opening of the IRA and restoration of blood flow may produce noticeable positive results.…”

Serum B-type natriuretic peptide on admission can predict the ‘no-reflow’ phenomenon after primary drug-eluting stent implantation for ST-segment elevation myocardial infarction

“…Although preventive effects of embolic protection and some mechanical thrombectomy devices have been disappointing in setting of STEMI [27][28][29], preventive administration of some drugs before PCI may be helpful. The use of GPI reduced the rate of no-reflow [30,31], and intracoronary thrombolytics or adenosine infusion prior to PCI showed to be beneficial in prevention of no-reflow in small studies [32,33]. Furthermore, the TAPAS study recently suggested that the adjunct of thrombectomy using 6-French Export Aspiration Catheter was associated with improvement of myocardial reperfusion, which translated into substantial improvement of the clinical outcome at 12-month follow-up as compared with conventional primary PCI [34,35].…”

Distal Shower Embolization During Directional Coronary Atherectomy and Stenting for Diffuse Stenosis of Right Coronary Artery-Current Limitations of Intravascular Ultrasonography for Evaluating Fragile Plaque-

“…In cases of acute coronary syndrome (ACS), this phenomenon also occurs with considerable frequency even in native coronary arteries. 11,12 However, the frequency of embolized debris in routine PCI of native vessel has not been evaluated. The first clinical results of the effectiveness and safety of the AngioGuard Emboli Capture Guidewire (Cordis, Johnson and Johnson) was recently reported in a study by Eberhard et al 13 in which not only 11 SVG lesions, but also 15 native vessel lesions were enrolled and all cases were electively treated.…”