Further insights into the no-reflow phenomenon after primary angioplasty in acute myocardial infarction: The role of microthromboemboli

Sakuma, Tadamichi; Leong‐Poi, Howard; Fisher, N.; Goodman, Norman C.; Kaul, Sanjiv

doi:10.1067/mje.2003.44

Cited by 73 publications

(39 citation statements)

References 17 publications

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“…In addition to microvascular reperfusion damage, mounting interests have emerged on distal embolization. 10,18 In the present study, we observed a higher rate of distal embolization in patients with advanced Killip class, which may partially explain the poor perfusion observed in these patients. Thus, adjunctive pharmacological or mechanical therapy should be used to protect the microcirculation from distal embolization during mechanical reperfusion, particularly in patients with signs of heart failure at presentation.…”

Section: Discussionsupporting

confidence: 51%

Impaired Myocardial Perfusion Is a Major Explanation of the Poor Outcome Observed in Patients Undergoing Primary Angioplasty for ST-Segment–Elevation Myocardial Infarction and Signs of Heart Failure

Luca¹,

Hof²,

Boer³

et al. 2004

Circulation

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Background-The aim of the present study was to investigate the prognostic implication of myocardial perfusion in patients with ST-segment-elevation myocardial infarction (STEMI) and signs of heart failure, treated with primary angioplasty. Methods and Results-Our population is represented by 1548 consecutive patients undergoing primary angioplasty for STEMI. Congestive heart failure was defined as Killip class Ͼ1 at admission. Killip class was linearly associated with myocardial perfusion, enzymatic infarct size, predischarge ejection fraction, and 1-year mortality rate. Myocardial blush was an independent predictor of 1-year mortality (RR [95% CI]ϭ2.92 [1.37 to 6.23], Pϭ0.005) in patients with advanced Killip class at presentation. Conclusions-Our study shows that patients with heart failure complicating STEMI have impaired myocardial perfusion, which accounts for the poor outcome observed in these patients. Further efforts should be aimed at improving myocardial perfusion, beyond epicardial recanalization, to further improve the outcome of these high-risk patients.

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Section: Discussionsupporting

confidence: 51%

Impaired Myocardial Perfusion Is a Major Explanation of the Poor Outcome Observed in Patients Undergoing Primary Angioplasty for ST-Segment–Elevation Myocardial Infarction and Signs of Heart Failure

Luca¹,

Hof²,

Boer³

et al. 2004

Circulation

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“…However, epicardial recanalization does not guarantee optimal myocardial perfusion, that remains suboptimal in a relatively large proportion of patients [3,4]. Large interest has been focused in recent years on the role of distal embolization as major determinant of impaired reperfusion [5][6][7]. However, few data have been reported among patients treated with Gp IIb-IIIa inhibitors [8].…”

mentioning

confidence: 99%

Impact of distal embolization on myocardial perfusion and survival among patients undergoing primary angioplasty with glycoprotein IIb–IIIa inhibitors: insights from the EGYPT cooperation

Luca¹,

Gibson

Bellandi

et al. 2009

J Thromb Thrombolysis

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Even though primary angioplasty is able to obtain TIMI 3 flow in the vast majority of STEMI patients, epicardial recanalization does not guarantee optimal myocardial perfusion, that remain suboptimal in a relatively large proportion of patients. Large interest has been focused in recent years on the role of distal embolization as major determinant of impaired reperfusion. The aim of the current study was to investigate in a large cohort of STEMI undergoing primary angioplasty with Gp IIb-IIIa inhibitors the impact of distal embolization on myocardial perfusion and survival. Our population is represented by patients undergoing primary angioplasty for STEMI included in the EGYPT database. Distal embolization was defined as an abrupt ''cutoff'' in the main vessel or one of the coronary branches of the infarct-related artery, distal to the angioplasty site. Myocardial perfusion was evaluated by angiography or ST-segment resolution, whereas infarct size was estimated by using peak CK and CK-MB. Follow-up data were collected between 30 days and 1 year after primary angioplasty. Data on distal embolization were available in a total of 1182 patients (71% of total population). Distal embolization was observed in 132 patients (11.1%). Patients with distal embolization were older (P < 0.001), with larger prevalence of diabetes (P = 0.01), previous MI (P = 0.048) and advanced Killip class at presentation (P = 0.018), abciximab administration (P < 0.001), with a lower prevalence of smoking (P = 0.04). Patients with distal embolization had more often poor preprocedural recanalization (P = 0.061), less often postprocedural TIMI 3 flow (P < 0.001), postprocedural MBG 2-3 (P < 0.001), complete ST-segment resolution (P = 0.021) and larger infarct size (CK-MB: 328 +/- 356 U/l vs. 259 +/- 226 U/l, P = 0.012). The impact of distal embolization on myocardial perfusion was confirmed after correction for baseline confounding factors as evaluated by MBG 2-3 (adjusted OR [95% CI] = 3.14 [2.06-4.77], P < 0.0001) but not complete ST-segment resolution (adjusted OR [95% CI] = 1.23 [0.84-1.92], P = 0.26). At 208 +/- 160 days follow-up, distal embolization was associated with a significantly higher mortality (9.2% vs. 2.7%, HR [95% CI] = 3.41 [1.73-6.71], P < 0.0001), that was confirmed after correction for baseline confounding factors (adjusted HR [95% CI] = 2.23 [1.1-4.7], P = 0.026). This study showed among STEMI patients treated with Gp IIb-IIIa inhibitors, that distal embolization is independently associated with impaired myocardial perfusion and survival.

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“…[2][3][4][5] Microthrombi, originating from upstream clot fragmentation or formed in situ, have been shown to play pivotal roles in the development of the no-reflow phenomenon. [6][7][8] These microthrombi can exhibit a range of histological patterns and may be platelet or erythrocyte rich.…”

mentioning

confidence: 99%

Microbubble-Mediated Sonothrombolysis Improves Outcome After Thrombotic Microembolism-Induced Acute Ischemic Stroke

Wang

Huang

et al. 2016

Stroke

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Microbubble-mediated sonothrombolysis is a promising treatment for cerebral microthrombi and is based on ultrasound driven cavitation of microbubbles that accelerate thrombolysis via localized mechanical stress on the thrombi. 17Background and Purpose-Microthrombi originating from disintegrated clots or formed in situ may account for the poor clinical improvement of acute ischemic stroke after recanalization therapy. We attempted to determine whether microbubble-mediated sonothrombolysis could dissolve platelet-rich and erythrocyte-rich microthrombi, thereby reducing their brain injury-causing potential. Methods-Platelet-and erythrocyte-rich microthrombosis were induced by periadventitial application of 5% ferric chloride or thrombin to mesenteric microvessels in 75 Sprague-Dawley rats. Acute ischemic stroke was induced by intracarotid injection of platelet-or erythrocyte-rich microthrombi in another 50 rats. Rats were randomly divided into control (CON), ultrasound (US), ultrasound and microbubble (US+MB), recombinant tissue-type plasminogen activator (r-tPA), and US+MB+r-tPA groups. The post-treatment mesenteric microvessel recanalization rates, cerebral infarct volumes, and neurological scores were determined. Results-The recanalization rates of platelet-and erythrocyte-rich microthrombi in mesenteric microvessels were higher (P<0.05), and the cerebral infarct volumes and neurological scores of rats with either microthrombi were lower in the US+MB group than in the CON group (P<0.01). The infarct volumes and neurological scores were greater in the r-tPA group than in the US+MB and US+MB+r-tPA groups after treatment of rats with platelet-rich microthrombi (P<0.05).In contrast, after treatment of rats with erythrocyte-rich microthrombi, the infarct volumes and neurological scores were similar in the r-tPA and US+MB groups, but smaller in the US+MB+r-tPA group (P<0.05). Conclusions-Microbubble-mediated sonothrombolysis improved the outcomes of microthrombi-induced acute ischemic stroke. Thus, this method may serve as an attractive adjunct to recanalization therapy for acute ischemic stroke.

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Further insights into the no-reflow phenomenon after primary angioplasty in acute myocardial infarction: The role of microthromboemboli

Cited by 73 publications

References 17 publications

Impaired Myocardial Perfusion Is a Major Explanation of the Poor Outcome Observed in Patients Undergoing Primary Angioplasty for ST-Segment–Elevation Myocardial Infarction and Signs of Heart Failure

Impaired Myocardial Perfusion Is a Major Explanation of the Poor Outcome Observed in Patients Undergoing Primary Angioplasty for ST-Segment–Elevation Myocardial Infarction and Signs of Heart Failure

Impact of distal embolization on myocardial perfusion and survival among patients undergoing primary angioplasty with glycoprotein IIb–IIIa inhibitors: insights from the EGYPT cooperation

Microbubble-Mediated Sonothrombolysis Improves Outcome After Thrombotic Microembolism-Induced Acute Ischemic Stroke

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