Multi-vessel coronary artery disease is quite a common state, which is often diagnosed by coronary angiography in patients with both stable coronary artery disease and acute coronary syndromes. Major difficulties in percutaneous coronary intervention include stent thrombosis and the need for antiplatelet therapy (aspirin and a P2Y12 inhibitor). Stent thrombosis leads to the recurrence of myocardial infarction and may occur within the first few hours after percutaneous coronary intervention. The use of dual antiplatelet therapy, especially that combined with low-molecular-weight heparin in the first days after myocardial infarction, poses a risk of bleeding, which often occurs in real clinical practice. Among P2Y12 inhibitors, ticagrelor causes bleeding somewhat more frequently than clopidogrel. A case of multi-vessel coronary artery disease is described in this paper. Coronary angiography revealed right-dominant circulation; occlusion of the proximal and medial segments of the right coronary artery, thrombolysis in myocardial infarction flow grade 0; stenosis of the left main coronary artery (50-60%), thrombolysis in myocardial infarction flow grade 2; diffuse stenosis of the medial and distal segments of the left anterior descending artery, thrombolysis in myocardial infarction flow grade 1; stenosis of the proximal segment of the left circumflex artery (> 75%), thrombolysis in myocardial infarction flow grade 1. The patient underwent percutaneous coronary intervention; the stents were implanted in the infarct-dependent right coronary artery. The clinical course was complicated by early stent thrombosis with subsequent thrombus extraction; a day later melena developed. Bleeding was stopped, the intensity of antithrombotic therapy was reduced: the combination of aspirin and ticagrelor was replaced by the combination of aspirin and clopidogrel. Six weeks after stenting of the infarct-dependent coronary artery, complete myocardial revascularization (hybrid intervention) was performed: coronary artery bypass grafting [the left internal mammary artery → the left anterior descending artery], coronary autogenous bypass grafting [the aorta → the right coronary artery and the aorta → the left circumflex artery]. The role of fractional flow reserve or instantaneous wave-free ratio-controlled complete myocardial revascularization techniques is discussed. The following algorithm for myocardial revascularization was used: percutaneous coronary intervention for the right coronary artery + coronary artery bypass grafting-3: the left internal mammary artery → the left anterior descending artery, the aorta → the left circumflex artery, the aorta → the right coronary artery.
It has been established that successful repefusion of ocluded infarct-dependent coronary artery (IDCA) during percutaneous coronary intervention does not mean restoration of myocardial perfusion. This «no-reflow» phenomenon is known from the studies of R. Kloner, C. Ganote, R. Jennings (1974). They were among the first to note only a partial restoration of coronary blood flow after the reperfusion of mechanically occluded for 90-180 minutes coronary artery in dogs. The authors considered damage to the capillary endothelium, edema of the damaged wall and extravasal tissues, and protrusion into the capillary cavity to be the cause of this phenomenon. The frequency of the phenomenon of «no-reflow» after the successful restoration of coronary blood flow in the IDCA varies between 5 - 40% of all cases. The development of this phenomenon was an unfavorable prognostic factor, primarily in terms of mortality and deterioration of the functional state of the left ventricle. The pathophysiology of the «no-reflow» phenomenon remains poorly understood. Obviously, it has a multifactorial nature and cannot be described by any one mechanism. Analyzing the phenomenon of «no-reflow», it is noted that in spite of the reperfusion of IDCA, there are pronounced pathophysiological changes in the microcirculatory tract, the essence of which is to block myocardial perfusion in the area of myocardial infarction. During the COVID-19 pandemic, the number of patients with myocardial infarction increased, including an increase in the number of diagnosed «no-reflow» and «slow-flow» phenomena, which is associated with the impact of SARS СOVID-19 virus on the myocardium, namely the development of microvascular damage. There is currently no specific therapy for the prevention and treatment of «no-reflow» phenomen that would be recommended for patients with STEMI. This article presents a clinical case of the phenomenon of «no-reflow» in patient B., 56 years old, who complained of severe chest pain, irradiation in the left shoulder and lower jaw, shortness of breath, general weakness. History of hypertension, coronavirus PCR +. Troponin I - 5.4 ng/ml. According to the electrocardiogram: elevation of the ST segment in II. III, aVF leads. At the time of contrast infusion during stenting of infarct-dependent right coronary artery, its slow filling was recorded - the phenomenon of «no-reflow» TIMI 0, MBG-0. The patient was discharged from the hospital in satisfactory condition under the supervision of a family doctor. Conclusions: The phenomenon of «no-reflow» is a topical and unresolved issue of myocardial revascularization in real clinical practice. The most common prerequisite for the development of the phenomenon of «no-reflow» after myocardial revascularization is late hospitalization, and aggravating circumstances - comorbid pathology (COVID-19, hypertension, diabetes). This clinical case is interesting because the patient with lesions of the lower left ventricular wall PCI was complicated by the phenomenon of «no-reflow», as evidenced by the slowing of ST segment resolution, lack of myocardial perfusion, parietal thrombosis throughout the RCA. Further search for ways to prevent and treat irreversible blood flow syndrome after successful reperfusion of infarct-dependent coronary artery is needed.
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