Features and outcome of no-reflow after percutaneous coronary intervention

Intracoronary adenosine compared with adrenaline and verapamil in the treatment of no-reflow phenomenon following primary PCI in STEMI patients

BACKGROUND

no-reflow can complicate up to 25% of pPCI and is associated with significant morbidity and mortality. We aimed to compare the outcomes of intracoronary epinephrine and verapamil with intracoronary adenosine in the treatment of no-reflow after primary percutaneous coronary intervention (pPCI).

METHODS

108 STEMI patients had no-reflow during pPCI were assigned into four groups. Group 1, in which epinephrine and verapamil were injected through a well-cannulated guiding catheter. Group 2, in which same drugs were injected in the distal coronary bed through a microcatheter or perfusion catheter. Group 3, in which adenosine was injected through a guiding catheter. Group 4, in which adenosine was injected in distal coronary bed. Primary end point was the achievement of TIMI III flow and MBG II or III. Secondary end point was major adverse cardiovascular and cerebrovascular events (MACCEs) during hospital stay.

RESULTS

The study groups did not differ in their baseline characteristics. Primary end point was achieved in 15 (27.8%) patients in the guide-delivery arm compared with 34 (63%) patients in the local-delivery arm, p < 0.01. However, the primary end point did not differ between the epinephrine/verapamil group and the adenosine group (27 (50%) vs 22 (40.7%), p = 0.334). The secondary end points were similar between the study groups.

CONCLUSION

Local delivery of epinephrine, verapamil and adenosine in the distal coronary bed is more effective in achieving TIMI III flow with MBG II or III compared with their guide-delivery in patients who suffered no-reflow during pPCI. There was no difference between epinephrine/verapamil Vs. adenosine.

The Predictive Value of the Inflammatory Prognostic Index for Detecting No-Reflow in ST-Elevation Myocardial Infarction Patients

BACKGROUND

No-reflow (NR) is characterized by an acute reduction in coronary flow that is not accompanied by coronary spasm, thrombosis, or dissection. Inflammatory prognostic index (IPI) is a novel marker that was reported to have a prognostic role in cancer patients and is calculated by neutrophil/lymphocyte ratio (NLR) multiplied by C-reactive protein/albumin ratio.

OBJECTIVE

We aimed to investigate the relationship between IPI and NR in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI).

METHODS

A total of 1541 patients were enrolled in this study (178 with NR and 1363 with reflow). Lasso panelized shrinkage was used for variable selection. A nomogram was created based on IPI for detecting the risk of NR development. Internal validation with Bootstrap resampling was used for model reproducibility. A two-sided p-value <0.05 was accepted as a significance level for statistical analyses.

RESULTS

IPI was higher in patients with NR than in patients with reflow. IPI was non-linearly associated with NR. IPI had a higher discriminative ability than the systemic immune-inflammation index, NLR, and CRP/albumin ratio. Adding IPI to the baseline multivariable logistic regression model improved the discrimination and net-clinical benefit effect of the model for detecting NR patients, and IPI was the most prominent variable in the full model. A nomogram was created based on IPI to predict the risk of NR. Bootstrap internal validation of nomogram showed a good calibration and discrimination ability.

CONCLUSION

This is the first study that shows the association of IPI with NR in STEMI patients who undergo pPCI.

Development of Multi-Vessel Coronary No-Reflow Following Elective Percutaneous Intervention in One Vessel

Percutaneous coronary intervention (PCI) is a frequently performed procedure that can have minor or major complications. One of the more serious complications of PCI is the development of coronary no-reflow. No-reflow signifies reduced or absent coronary flow in the distal coronary circulation in the absence of flow-limiting lesions. We present a case of a middle-aged man who presented as an outpatient for elective coronary angiography due to angina pectoris and a high-risk exercise stress test. Coronary angiography demonstrated significant single-vessel disease with lesions in the proximal and mid-segments of the left anterior descending (LAD) coronary artery. Successful placement of drug-eluting stents in the LAD was followed by a severe drop in blood pressure, worsening chest pain, and ST elevation on telemetry. Immediate angiography showed the development of no-reflow in both the LAD and left circumflex coronary arteries. Ionotropic and intravenous anti-platelet agents were administered with simultaneous placement of an intra-aortic balloon pump, restoring normal flow in both arteries. No-reflow occurs most commonly following PCI in certain lesion subsets, and it is usually seen only in the vessel in which the PCI was performed (culprit vessel). It is important to realize that this phenomenon can occur in other circumstances since immediate recognition and treatment can be lifesaving.

Mitigating the risk of flow deterioration by deferring stent optimization in STEMI patients with large thrombus burden: Insights from a prospective cohort study

OBJECTIVES

It is uncertain, if omitting post-dilatation and stent oversizing (stent optimization) is safe and may decrease the risk for distal thrombus embolization (DTE) in STEMI patients with large thrombus burden (LTB).

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) with stenting, (DTE) and flow deterioration are common and increase infarct size leading to worse outcomes.

METHODS

From a prospective registry, 74 consecutive STEMI patients with LTB undergoing pPCI with stenting and intentionally deferred stent optimization were analyzed. Imaging data and outcomes up to 2 years follow-up were analyzed.

RESULTS

Overall, 74 patients (18% females) underwent deferred stent optimization. Direct stenting was performed in 13 (18%) patients. No major complications occurred during pPCI. Staged stent optimization was performed after a median of 4 (interquartile range (IQR) 3; 7) days. On optical coherence tomography, under-expansion and residual thrombus were present in 59 (80%) and 27 (36%) cases, respectively. During deferred stent optimization, we encountered no case of flow deterioration (slow or no-reflow) or side branch occlusion. Minimal lumen area (mm2) and stent expansion (%) were corrected from 4.87±1.86mm to 6.82±2.36mm (p<0.05) and from 69±18% to 91±12% (p<0.001), respectively. During follow-up, 1 patient (1.4%) required target lesion revascularization and 1 (1.4%) patient succumbed from cardiovascular death.

CONCLUSIONS

Among STEMI patients with LTB, deferring stent optimization in the setting of pPCI appears safe and potentially mitigates the risk of DTE. The impact of this approach on infarct size and clinical outcomes warrants further investigation in a dedicated trial.

Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review

ABSTRACT

Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

The Association of Serum Uric Acid/Albumin Ratio with No-Reflow in Patients with ST Elevation Myocardial Infarction

The goal of this investigation was to explore the relationship between serum uric acid/albumin ratio (UAR) and no-reflow (NR) in ST elevation myocardial infarction (STEMI) patients (n = 838) who underwent primary percutaneous coronary intervention (pPCI). Angiographic NR was defined as thrombolysis in myocardial infarction (TIMI) flows 0, 1, and 2 in the absence of coronary spasm or dissection. NR developed in 91 (10.9%) STEMI patients. Patients with NR had higher UAR and according to multivariable logistic regression models, a high UAR was an independent risk factor for NR. The area under the curve (AUC) value of the UAR was .760 (95%CI: .720-.801) in a receiver-operating characteristics curve (ROC) assessment. Notably, the UAR AUC value was greater than that of its components: albumin (AUC: .642) and serum uric acid (AUC: .637) (P < .05 for both comparisons). The optimum UAR value in detecting NR in STEMI patients was >1.21 with a sensitivity of 82% and a specificity of 67%. This was the first study to report that the UAR was independently associated with NR in STEMI patients who underwent pPCI.

No reflow phenomenon in CAD patients after percutaneous coronary intervention: A prospective hospital based observational study

The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length≥ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Clinical and electrocardiographic features in acute total left main coronary artery occlusion without collateral circulation

BACKGROUNDS

Study concerning the clinical features, electrocardiogram (ECG) findings and outcomes in patients presenting with acute total occlusion of left main coronary artery (LM) without collateral circulation is limited.

METHODS

25 patients with acute total LM occlusion without collateral circulation by emergency coronary angiography, from muti-center registry, were retrospectively studied. The clinical and angiographic characteristics, ECG and in-hospital mortality were reviewed.

RESULTS

Nineteen patients (76%) presented with cardiogenic shock. Twelve (60%, 12/20) patients had coronary slow flow or no reflow phenomenon after primary percutaneous coronary intervention (PCI). The in-hospital mortality rate was 88% (n = 22). All the patients presented with ST-segment elevation myocardial ischemia (STEMI) pattern, mostly involving leads I, aVL, V2, V3, V4, V5 and ST-segment depression in leads II, III and aVF.

CONCLUSIONS

Acute total LM occlusion without collateral circulation portends high in-hospital mortality. Anterior ST elevation in the precordial leads from V2 to V4 through V6, and ST elevation in leads I and aVL, accompanying with ST depression in the inferior leads is associated with acute total LM occlusion without collateral circulation.

Comparison of Two Different Rota-Flush Solutions in Patients Undergoing Rotational Atherectomy: A Randomized, Controlled, Triple-Blind Trial

INTRODUCTION

This prospective study accessed the feasibility and safety of the heparin rota-flush solution in patients undergoing rotational atherectomy (RA).

METHODS

Between August 2019 and November 2021, 200 patients who underwent RA were included in this study, among whom 103 (51.5%) were randomly allocated into the heparin rota-flush group and 97 (48.5%) into the traditional rota-flush group. The primary endpoint was the incidence of slow flow/no-reflow after RA; the secondary endpoints were procedural success, RA-related procedural complications, and in-hospital major adverse cardiovascular events (MACE).

RESULTS

There were no significant differences in baseline clinical and angiographic characteristics between the two groups. Thirty patients (29.1%) in the heparin rota-flush group and nineteen patients (19.6%) in the traditional rota-flush groups developed slow flow/no-reflow (P = 0.117), respectively, and procedural success was also comparable (97.1% vs. 93.8%, P = 0.320). Severe hypotension (systolic blood pressure < 90 mmHg) was not significantly different (15.5% vs. 16.5%, P = 0.841), but the incidence of coronary spasm was significantly higher in the heparin rota-flush group (42.7% vs. 22.7%, P = 0.003). MACE including stent-thrombosis (ST), target-lesion revascularization (TLR), and cardiac death were also comparable between the two groups; no stroke was observed.

CONCLUSIONS

The findings suggest that although continuous intracoronary infusion of heparin rota-flush solution does not increase the incidence of slow flow/no-reflow, traditional rota-flush solution without RotaGlide prevents coronary spasm more effectively compared to the heparin rota-flush without significant impact on severe hypotension. These results do not support a strategy of routine use of heparin rota-flush solution in patients receiving RA procedures.

Management of Coronary Complications

Coronary complications are increasingly rare but remain fatal if not managed promptly and effectively. We review the incidence, management, and prevention of the most serious coronary complications including acute vessel closure from dissection, no-reflow, thrombosis, and air embolism as well as mechanical complications including perforation, stent dislodgment, and atherectomy burr entrapment.

Intracoronary eptifibatide with vasodilators to prevent no-reflow in diabetic STEMI with high thrombus burden. A randomized trial

INTRODUCTION AND OBJECTIVES

To study the impact of injecting intracoronary eptifibatide plus vasodilators via thrombus aspiration catheter vs thrombus aspiration alone in reducing the risk of no-reflow in acute ST-elevation myocardial infarction (STEMI) with diabetes and high thrombus burden.

METHODS

The study involved 413 diabetic STEMI patients with high thrombus burden, randomized to intracoronary injection (distal to the occlusion) of eptifibatide, nitroglycerin and verapamil after thrombus aspiration and prior to balloon inflation (n=206) vs thrombus aspiration alone (n=207). The primary endpoint was post procedural myocardial blush grade and corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC). Major adverse cardiovascular events were reported at 6 months.

RESULTS

The intracoronary eptifibatide and vasodilators arm was superior to thrombus aspiration alone regarding myocardial blush grade-3 (82.1% vs 31.4%; P=.001). The local intracoronary eptifibatide and vasodilators arm had shorter cTFC (18.16±6.54 vs 29.64±5.53, P=.001), and better TIMI 3 flow (91.3% vs 61.65%; P=.001). Intracoronary eptifibatide and vasodilators improved ejection fraction at 6 months (55.2±8.13 vs 43±6.67; P=.005). There was no difference in the rates of major adverse cardiovascular events at 6 months.

CONCLUSIONS

Among diabetic patients with STEMI and high thrombus burden, intracoronary eptifibatide plus vasodilators injection was beneficial in preventing no-reflow compared with thrombus aspiration alone. Larger studies are encouraged to investigate the benefit of this strategy in reducing the risk of adverse clinical events.

Study on Correlation between Type 2 Diabetes and No-Reflow after PCI

Diabetes, a serious chronic disease globally, is often complicated with cardiovascular diseases for which percutaneous coronary intervention (PCI) is the mainstay. The no-reflow rate of diabetic patients after PCI is 2-4 times higher than that of nondiabetic patients, yet the specific mechanism is still unclear. This study was designed to investigate the correlation between the duration of diabetes, preoperative blood glucose level, coronary angiographic blood flow, coronary artery stenosis level, and no-reflow after PCI. A total of 131 patients with type 2 diabetes who underwent PCI in our hospital from 2019 to 2020 were divided into control group and observation group. The disease duration, preoperative blood glucose level, coronary angiographic blood flow, and coronary artery stenosis level of the two groups were calculated. There were differences in the duration of diabetes between the two groups; the blood glucose level of the control group was about 3.8%, which was lower than 5.8% of the observation group; the thrombolysis in myocardial infarction (TIMI) value of the control group was $18.46\pm 4.6$ , which was lower than $20.67\pm 3.9$ of the observation group; The degree of coronary stenosis in the control was $63\%\pm 2\%$ , which was lower than $76\%+3\%$ in the observation group. Binary logistic stepwise regression analysis was performed on these indicators and no-reflow after PCI to explore the correlation between these indicators and no-reflow after PCI in diabetic patients. The study found that the diabetes duration, higher preoperative blood glucose level, coronary angiography blood flow, and coronary artery were positively associated with no-reflow after PCI.

Comparison of the incidence of periprocedural myocardial infarction between percutaneous coronary intervention with versus without rotational atherectomy using propensity score-matching

Complications such as slow flow are frequently observed in percutaneous coronary intervention (PCI) with rotational atherectomy (RA). However, it remains unclear whether the high incidence of slow flow results in the high incidence of periprocedural myocardial infarction (PMI), reflecting real myocardial damage. The aim of this study was to compare the incidence of PMI between PCI with versus without RA using propensity score-matching. We included 1350 elective PCI cases, which were divided into the RA group (n = 203) and the non-RA group (n = 1147). After propensity score matching, the matched RA group (n = 190) and the matched non-RA group (n = 190) were generated. The primary interest was to compare the incidence of PMI between the matched RA and non-RA groups. Before propensity score matching, the incidence of slow flow and PMI was greater in the RA group than in the non-RA group. After matching, the incidence of slow flow was still greater in the matched RA group than in the matched non-RA group (16.8% vs. 9.5%, p = 0.048). However, the incidence of PMI was similar between the matched RA and matched non-RA group (7.4% vs. 5.3%, p = 0.528, standardized difference: 0.086). In conclusion, although use of RA was associated with greater risk of slow flow, use of RA was not associated with PMI after a propensity score-matched analysis. The fact that RA did not increase the risk of myocardial damage in complex lesions would have an impact on revascularization strategy for severely calcified coronary lesions.

Advances in the Post-coronary Artery Bypass Graft Management of Occlusive Coronary Artery Disease

Revascularisation of chronic total occlusion (CTO) represents one of the most challenging aspects of percutaneous coronary intervention, but advances in equipment and an understanding of CTO revascularisation techniques have resulted in considerable improvements in success rates. In patients with prior coronary artery bypass grafting (CABG) surgery, additional challenges are encountered. This article specifically explores these challenges, as well as antegrade methods of CTO crossing. Techniques, equipment that can be used and reference texts are highlighted with the aim of providing potential CTO operators adequate information to tackle additional complexities likely to be encountered in this cohort of patients. This review forms part of a wider series where additional aspects of patients with prior CABG should be factored into decisions and methods of revascularisation.

Long-term outcomes of percutaneous coronary interventions within coronary artery bypass grafts

INTRODUCTION

The long-term outcomes of percutaneous coronary interventions (PCIs) within coronary artery bypasses are still poor as compared to those within native coronary arteries. Thus, we aimed to assess predictors of long-term clinical outcomes after PCIs of coronary bypasses.

MATERIAL AND METHODS

We enrolled 194 patients after PCIs of coronary artery bypasses at the mean age of 69.5 ±8.3 years (73.2% male). The primary study endpoint was a combination of target-vessel revascularization (TVR), target-lesion revascularization (TLR), myocardial infarction (MI), stroke, coronary artery bypass grafting (CABG) and death. The mean follow-up was 964 ±799.1 days and was completed among 156 patients. Multivariate analysis was used to assess determinants of study endpoints during follow-up. Moreover, we compared survival curves according to the type of PCI and presence of anti-embolic protection.

RESULTS

The primary endpoint of the study occurred in 59.7% of patients after the mean time of 669.6 ±598.7 days. The TVR occurred in 37.9% of individuals, TLR in 24.2%, MI in 26.3%, stroke in 4.2%, CABG in 2.1% and death in 30.5% of patients. In Cox multivariate analysis, PCI of two or more bypasses (p < 0.01), post-dilatation (p < 0.05) and no-reflow (p < 0.05) were the independent determinants of the primary study endpoint. No significant impact of anti-embolic protection devices on long-term outcomes was observed.

CONCLUSIONS

Percutaneous coronary interventions of two or more bypasses, post-dilatation and no-reflow are predictors of worse outcome in patients undergoing PCI within coronary artery bypass grafts.

A Scoring System to Predict No-Reflow Phenomenon in Elective Percutaneous Coronary Intervention: The RECOVER Score

The RECOVER score system aimed to stratify the risk of no-reflow phenomenon in patients undergoing elective percutaneous coronary intervention. A total of 3967 patients with 5340 lesions were used for the construction and validating of the risk model and score system. In multivariable analyses, 3 variables were independently associated with the risk of no-reflow phenomenon (model C-statistic=0.746 (95% confidence interval [CI]: 0.690 to 0.803) with good calibration). No-reflow phenomenon rates in both construction and validation cohort increased significantly across different risk groups. The RECOVER score can help identify patients at risk for phenomenon during percutaneous coronary intervention.

The impact of lesion complexity on no-reflow phenomenon and predictors of reversibility in patients treated with primary percutaneous intervention

OBJECTIVES

Complex coronary lesions are more prone to complications; however, the relationship between complex coronary lesions and no-reflow phenomenon in patients undergoing primary percutaneous intervention (pPCI) is still not clarified. Previous studies reported the association of total coronary artery complexity with no-reflow; however, impact of culprit lesion complexity on no-reflow is not known. In this study, we aimed to investigate the impact of culprit lesion complexity on no-reflow phenomenon. Furthermore, we aimed to investigate the factors that are related to reversibility of no-reflow.

METHODS

We prospectively included 424 patients treated with pPCI. Patients' baseline characteristics and clinical variables were recorded. Reversibility of no-reflow was decided according to final angiography or ST resolution during the first hour following pPCI. There were 90 patients with a diagnosis of no-reflow constituted group 1 and patients without no-reflow constituted group 2. Complexity of coronary artery disease was assessed with SYNTAX score and culprit lesion complexity was assessed with both American College of Cardiology/Society of Cardiovascular Angiography and Interventions lesion classification and SYNTAX score.

RESULTS

Complexity of culprit lesion was significantly higher in group 1 patients (type C lesion 76.6 vs. 27.8%; P < 0.001 and SYNTAX score 8.7 ± 3.0 vs. 6.2 ± 2.6; P < 0.001, respectively, group 1 vs. 2). Multivariate analyses revealed that lesion complexity is independently associated with no-reflow. Among 90 patients of group 1, 43 patients were classified as reversible no-reflow. Logistic regression analysis revealed that only ischaemia duration is independently associated with reversibility of no-reflow.

CONCLUSION

Our study demonstrated that culprit lesion complexity is independently associated with no-reflow phenomenon and short ischaemic duration is significantly associated with reversibility of no-reflow.

Care of the Post-CABG Patient

An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the "no-reflow phenomenon," which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.

A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention

Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.

Long-term cardiovascular prognosis after rotational atherectomy in hemodialysis patients: Data from the J2T multicenter registry

BACKGROUND

Hemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era.

METHODS

This study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death.

RESULTS

During the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13-0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02-0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients.

CONCLUSION

In the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies.

Two-Stage Revascularization in Patients with Acute Myocardial Infarction and Massive Coronary Thrombosis

AIM

to investigate safety and angiographic efficacy of two-stage revascularization with percutaneous coronary intervention (PCI) with stenting delayed by one day in patients with acute myocardial infarction (MI) and massive coronary thrombosis.

MATERIALS AND METHODS

We included in this study 12 patients with massive infarct related coronary artery thrombus which length was greater than thrice the vessel diameter in the presence of TIMI grade II-III blood flow as detected by coronary angiography (CAG). The emergency PCI was not performed, and conservative antithrombotic therapy continued for 24 hours. After this day, CAG was repeated.

RESULTS

Repeat CAG in all patients showed thrombus regression which visually appeared as complete lysis in 8, and partial lysis - in 4 patients. Stenting of residual stenosis was performed in 11 patients without complications. In 1 patient residual stenosis was considered insignificant (&lt;50 %) therefore stenting was not performed. No-reflowphenomenon and recurrent MI were not observed.

CONCLUSION

These data suggest that in patients with massive coronary artery thrombosis conservative antithrombotic therapy for 24 hours followed by repeated CAG and, if required, by stenting of residual stenosis, is safe treatment tactics that might reduce the risk of the no-reflow phenomenon.

Saphenous graft atherosclerosis as assessed by optical coherence tomography data for stenotic and non-stenotic lesions from the OCTOPUS registry

Introduction

Coronary artery bypass grafting (CABG), although widely used for a long time in diffuse coronary artery disease (CAD), has serious limitations associated with graft aging and its degeneration.

Aim

The relationship between saphenous vein graft (SVG) plaque morphology assessed by optical coherence tomography (OCT) and clinical findings has not been elucidated yet.

Material and methods

We compared the morphology of SVG in stenotic vs. non-stenotic lesions using OCT imaging in 29 patients hospitalized in our center within the OCTOPUS registry.

Results

Stenotic lesions were characterized by higher incidence of thin-cap fibroatheroma (TCFA) (33% vs. 0%, p = 0.0048), thrombus (28% vs. 0%, p = 0.0008), lipid-rich plaque (LRP) (75% vs. 35%, p = 0.0013) and plaque within the SVG valve (19% vs. 0%, p = 0.0114) as compared to non-stenotic lesions. Patients with intimal tearing or rupture (ITR) were older (75.8% vs. 68.9 years, p = 0.047) and had lower left ventricular ejection fraction (LVEF) (32.0% vs. 49.7%, p = 0.001) and glomerular filtration rate (GFR) (36.0 vs. 73.6 ml/min/1.73 m², p = 0.010). Patients with calcified lesions vs. those without had lower high-density lipoprotein (HDL) cholesterol (33.2 vs. 44.1 mg/dl, p = 0.018), similarly to those with ruptured plaque vs. those without (28.3 vs. 41.7 mg/dl, p = 0.047).

Conclusions

Presence of ITR was associated with advanced age, decreased LVEF and renal insufficiency. Decreased concentration of HDL was associated with higher occurrence of calcified and ruptured plaque.

Clinical manifestations and basic mechanisms of myocardial ischemia/reperfusion injury

Acute myocardial ischemia/reperfusion (I/R) injury is a significant, unsolved clinical puzzle. In the disease context of acute myocardial infarction, reperfusion remains the only effective strategy to salvage ischemic myocardium, but it also causes additional damage. Myocardial I/R injury is composed of four types of damage, and these events attenuate the benefits of reperfusion therapy. Thus, inventing new strategies to conquer I/R injury is an unmet clinical need. A variety of pathological processes and mediators, including changes in the pH, generation of reactive oxygen radicals, and intracellular calcium overload, are proposed to be crucial in I/R-related cell injury. Among the intracellular events that occur during I/R, we stress the importance of protein phosphorylation signaling and elaborate its regulation. A variety of protein kinase pathways could be activated in I/R, including reperfusion injury salvage kinase and survivor-activating factor enhancement pathways, which are critical to cardiomyocyte survival. In addition to serine/threonine phosphorylation signaling, protein tyrosine phosphorylation is also critical in multiple cell functions and survival. However, the roles of protein kinases and phosphatases in I/R have not been extensively studied yet. By better understanding the mechanisms of I/R injury, we may have a better chance to develop new strategies for I/R injury and apply them in the clinical patient care.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

Predictors of no- reflow during primary angioplasty for acute myocardial infarction, from Medical College Hospital, Trivandrum

Background

Primary angioplasty (PCI) for acute myocardial infarction is associated with no-reflow phenomenon, in about 5–25% of cases. Here we analysed the factors predicting no reflow .

Methods

This was a case control study of consecutive patients with acute myocardial infarction who underwent Primary PCI from August 2014 to February 2015.

Results

Of 181 patients who underwent primary PCI, 47 (25.9%) showed an angiographic no-reflow phenomenon. The mean age was 59.19 ± 10.25 years and females were 11%.

Univariate predictors of no reflow were age >60 years (OR = 6.146, 95%CI 2.937–12.86, P = 0<0.001), reperfusion time >6 h (OR = 21.94, 95%CI 9.402–51.2, P = < 0.001), low initial TIMI flow (≤1) (OR = 12.12, 95%CI 4.117–35.65, P < 0.001), low initial TMPG flow (≤1) (OR = 36.19, 95%CI 4.847–270.2, P < 0.001) a high thrombus burden (OR = 11.04,95%CI 5.124–23.8, P < 0.001), a long target lesion (OR = 8.54, 95%CI 3.794–19.23, P < 0.001), Killip Class III/IV(OR = 2.937,95%CI 1.112–7.756,P = 0.025) and overlap stenting(OR = 3.733,95%CI 1.186–11.75,P = 0.017).

Multiple stepwise logistic regression analysis predictors were: longer reperfusion time > 6 h (OR = 13.844, 95%CI 3.214–59.636, P = <0.001), age >60 years (OR = 8.886, 95%CI 2.145–36.80, P = 0.003), a long target lesion (OR = 8.637, 95%CI 1.975–37.768, P = 0.004), low initial TIMI flow (≤1) (OR = 20.861, 95%CI 1.739–250.290, P = 0.017).

Conclusions

It is important to minimize trauma to the vessel, avoid repetitive balloon dilatations use direct stenting and use the shortest stent if possible.

Effect of Thrombus Composition and Viscosity on Sonoreperfusion Efficacy in a Model of Micro-Vascular Obstruction

Distal embolization of micro-thrombi during stenting for myocardial infarction causes micro-vascular obstruction (MVO). We have previously shown that sonoreperfusion (SRP), a microbubble (MB)-mediated ultrasound (US) therapy, resolves MVO from venous micro-thrombi in vitro in saline. However, blood is more viscous than saline, and arterial thrombi that embolize during stenting are mechanically distinct from venous clot. Therefore, we tested the hypothesis that MVO created with arterial micro-thrombi are more resistant to SRP therapy compared with venous micro-thrombi, and higher viscosity further increases the US requirement for effective SRP in an in vitro model of MVO. Lipid MBs suspended in plasma with adjusted viscosity (1.1 cP or 4.0 cP) were passed through tubing bearing a mesh with 40-μm pores to simulate a micro-vascular cross-section; upstream pressure reflected thrombus burden. To simulate MVO, the mesh was occluded with either arterial or venous micro-thrombi to increase upstream pressure to 40 mmHg ± 5 mmHg. Therapeutic long-tone-burst US was delivered to the occluded area for 20 min. MB activity was recorded with a passive cavitation detector. MVO caused by arterial micro-thrombi at either blood or plasma viscosity resulted in less effective SRP therapy compared to venous thrombi. Higher viscosity further reduced the effectiveness of SRP therapy. The passive cavitation detector showed a decrease in inertial cavitation when viscosity was increased, while stable cavitation was affected in a more complex manner. Overall, these data suggest that arterial thrombi may require higher acoustic pressure US than venous thrombi to achieve similar SRP efficacy; increased viscosity decreases SRP efficacy; and both inertial and stable cavitation are implicated in observed SRP efficacy.

Long-Term Clinical Outcomes of Transient and Persistent No Reflow Phenomena following Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

Background and Objectives

There is limited information on the transient or persistent no reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

Subjects and Methods

The study analyzed 4329 patients with AMI from a Korean multicenter registry who underwent PCI using coronary stents (2668 ST-elevation and 1661 non-ST-elevation myocardial infarction [MI] patients): 4071 patients without any no reflow, 213 with transient no reflow (no reflow with final thrombolysis in myocardial infarction [TIMI] flow grade 3), and 45 with persistent no reflow (no reflow with final TIMI flow grade≤2). The primary endpoint was all-cause mortality during 3-year follow-up. We also analyzed the incidence of cardiac mortality, non-fatal MI, re-hospitalization due to heart failure, target vessel revascularization, and stent thrombosis.

Results

The persistent no reflow group was associated with higher all-cause mortality (hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.08-3.65, p=0.028) and cardiac mortality (HR 3.28, 95% CI 1.54-6.95, p=0.002) compared with the normal reflow group. Transient no reflow increased all-cause mortality only when compared with normal reflow group (HR 1.58, 95% CI 1.11-2.24, p=0.010). When comparing transient and persistent no reflow, persistent no reflow was associated with increased all-cause mortality (46.7 vs. 24.4%, log rank p=0.033).

Conclusion

The persistent no reflow phenomenon was associated with a poor in-hospital outcome and increased long-term mortality mainly driven by increased cardiac mortality compared to the transient no reflow phenomenon or normal reflow.

Early Administration of Intracoronary Nitroprusside Compared with Thrombus Aspiration in Myocardial Perfusion for Acute Myocardial Infarction: A 3-Year Clinical Follow-Up Study

BACKGROUND

Intracoronary nitroprusside and thrombus aspiration have been demonstrated to improve myocardial perfusion during percutaneous coronary interventions (PCI) for ST-segment elevation acute myocardial infarction (STEMI) However, no long-term clinical studies have been performed comparing these approaches.

METHODS

A single medical center retrospective study was conducted to evaluate the effects of intracoronary nitroprusside administration before slow/no-reflow phenomena versus thrombus aspiration during primary PCI. Forty-three consecutive patients with STEMI were enrolled in the intracoronary nitroprusside treatment group. One hundred twenty-four consecutive STEMI patients who received thrombus aspiration were enrolled; ninety-seven consecutive STEMI patients who did not receive either thrombus aspiration or intracoronary nitroprusside treatment were enrolled and served as control subjects. Patients with cardiogenic shock, who had received platelet glycoprotein IIb/IIIa inhibitor, or intra-aortic balloon pump insertion were excluded. Thrombolysis in Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count and TIMI myocardial perfusion grade (TMPG) were assessed prior to and following PCI by two independent cardiologists blinded to the procedures. The rate of major adverse cardiac events (MACE) at 30 days, 1 year, and 3 years after study enrollment as a composite of recurrent myocardial infarction, target-vessel revascularization, and cardiac death were recorded.

RESULTS

The control group had a significantly lower pre-PCI TIMI flow (≤ 1; 49.5% vs. 69.8% vs. 77.4%; p = < 0.001) compared with the nitroprusside and thrombus aspiration groups. The thrombus aspiration group had a significantly higher pre-PCI thrombus score (> 4; 98.4% vs. 88.4% vs. 74.3%; p = < 0.001) and post-PCI TMPG (3; 39.5% vs. 16.3% vs. 20.6%; p = 0.001) compared with the nitroprusside and control groups. No significant differences were noted in the post-PCI thrombus score, 30-day, 1-year and 3-year MACE rate, and Kaplan-Meier curve among 3 groups of patients.

CONCLUSIONS

Although thrombus aspiration provided improved TMPG compared with early administration of intracoronary nitroprusside and neither of both during primary PCI, it did not have a significant impact on 30-day, 1-year and 3-year MACE rate.

KEY WORDS

Acute myocardial infarction; Intracoronary nitroprusside; Thrombus aspiration.

Short-Term Effects of Verapamil and Diltiazem in the Treatment of No Reflow Phenomenon: A Meta-Analysis of Randomized Controlled Trials

Currently, there is still a lack of an optimal treatment for no reflow phenomenon (NRP). We analyzed the efficacy and safety of using nondihydropyridine calcium channel antagonists (NDHP, verapamil/diltiazem) in patients suffering from NRP. Eight RCTs with 494 participants were eligible for analysis. The pooling analysis showed that intracoronary verapamil/diltiazem injection significantly decreased the occurrence of the coronary NRP (RR: 0.3, 95% CI: 0.16–0.57; P = 0.0002) and reduced corrected thrombolysis in myocardial infarction (TIMI) frame Count (WMD = −9.24, 95% CI −13.91–4.57; P = 0.0001) in patients with NRP. Moreover, verapamil/diltiazem treatment showed superiority in reducing wall motion index (WMI) compared to the control at day 1 (WMD = 0.11, 95% CI: 0.02–0.20; P = 0.02) (P < 0.05). There was also a significantly greater decline at occurrence of the major adverse cardiac events between verapamil/diltiazem and control groups (WMD: 0.4, 95% CI: 0.19–0.84; P = 0.02). However, using verapamil/diltiazem did not provide additional improvement of left ventricular ejection fraction post procedure (at 7 days, WMD, 0.1; 95% CI, −2.43–2.63; P = 0.94; at 30 days, WMD, 0.42; 95% CI, −2.09–2.92; P = 0.75). NDHP use is beneficial in attenuating NRP and reducing 6-month MACEs in patients with NRP.

Early and midterm major adverse cardiac events in patient with saphenous vein graft using direct stenting or embolic protection device stenting

Background:

The treatment of an occluded saphenous vein graft (SVG) with percutaneous coronary intervention may encounter major adverse cardiac events (MACE). MACE rates have been reduced significantly by using the embolic protection device (EPD).

Objectives:

The aim of this study was to clarify the risks and the benefits of embolic protection devices.

Patients and Methods:

In a prospective, non-randomized observational study, patients aged 33 to 85 years old who underwent elective percutaneous coronary intervention due to SVG stenosis at our tertiary care center were enrolled between 2009 and 2011. The incidence rates of adverse events, including MACE, were obtained during the patients’ hospitalization and at 30-day and 6-month follow-up. MACE included death, Q-wave and non-Q-wave myocardial infarction, in-stent thrombosis, target lesion revascularization, and target vessel revascularization.

Results:

From 150 patients enrolled to the study, 128 (85.3%) patients underwent direct stenting and the rest underwent the EPD procedure. In-hospital MACE occurred in 17.2% of the patients in the direct stenting group versus only 9.1% in the EPD group (P = 0.530). MACE incidence was gradually increased at one and 6-month follow-up periods in the direct stenting group (19.5% and 21.9%, respectively), and remained unchanged in the EPD group (9.1% at six-month follow-up). Multivariate logistic regression model showed that the stenting procedure type could not predict early and midterm MACE with the presence of baseline characteristics as cofounders.

Conclusions:

Despite the considerable lower early and midterm MACE rates, numerically following the EPD procedure compared to direct stenting, the difference in the MACE rates between the two groups was not significant.

Concordance of angiographic and electrocardiographic indexes of microvascular obstruction: myocardial haemorrhage role

BACKGROUND

Angiographic and electrocardiographic (ECG) indexes of microvascular obstruction (MVO) have been described. We aimed at assessing by cardiac magnetic resonance (CMR) anatomical features underlying concordance between them.

METHODS

Forty-one patients were enrolled. Patients presented with neither angiographic nor ECG indexes of MVO (without MVO) (44%), with either angiographic or ECG indexes of MVO (discordant with MVO) (22%) or with both angiographic and ECG indexes of MVO (concordant with MVO) (34%). All patients underwent in-hospital CMR. Echocardiographic data obtained after 6 months were compared with those obtained in hospital.

RESULTS

Concordant patients with MVO had larger infarct size, lower myocardial salvage index and higher rate of myocardial haemorrhage (all assessed by CMR) [33% (25-41%), 15% (10-29%) and 88%, respectively] as compared with patients without MVO [12% (9-16%), 66% (52-79%) and 0%; Bonferroni-adjusted P < 0.001, Bonferroni-adjusted P < 0.001 and P < 0.001, respectively], or with discordant ones [25% (21-39%), 35% (20-48%) and 7%; Bonferroni-adjusted P = 0.03, Bonferroni-adjusted P = 0.002 and P = 0.04, respectively]. After 6 months, ejection fraction significantly decreased in concordant patients with MVO (P < 0.001) without significant changes in the other groups.

CONCLUSIONS

Concordance of angiographic and ECG indexes of MVO reflects more severe myocardial damage translating into unfavourable left ventricular remodelling.

Innate immune response after acute myocardial infarction and pharmacomodulatory action of tacrolimus in reducing infarct size and preserving myocardial integrity

Background

This study investigated the association between innate immune reaction and myocardial damage after acute myocardial infarction (AMI) and anti-inflammatory role of tacrolimus in reducing infarct size. Male mini-pigs (n=18) were equally categorized into sham control (SC), untreated AMI (by ligation of left anterior descending coronary artery), and AMI-Tacrolimus (AMI-Tac) (0.5 mg intra-coronary injection 30 minutes post-AMI). Cardiac magnetic resonance imaging (MRI) was performed at post-AMI days 2, 5 and 21 before sacrificing the animals.

Results

By post-AMI day 21, left ventricular ejection fraction (LVEF) was lowest in untreated AMI animals, significantly higher in SC than in AMI-Tac group (all p<0.003). Infarct areas at basal, middle, and apical levels, numbers of CD14+ and iNOS+ cells in infarct area (IA) and peri-IA, and protein expression of CD14, CD68, and Ly6g from circulating inflammatory cells showed an opposite pattern compared with that of LVEF in all groups (all p<0.005). Protein expressions of MCP-1, MIP-1, TNF-α, NF-κB, iNOS, and IL-12 in IA and peri-IA exhibited an identical pattern compared to that of CD14, CD68, and Ly6g from circulating inflammatory cells (all p<0.01). Expressions of myocardial damage biomarkers in IA and peri-IA [γ-H2AX, β-myosin heavy chain (MHC), Smad3, TGF-β] were highest in AMI and higher in AMI-Tac than in SC, whereas expressions of myocardial integrity biomarkers (connexin43, mitochondrial cytochrome-C, α-MHC, BMP-2, Smad1/5) were opposite to those of damage biomarkers (all p<0.001).

Conclusion

Innate immune responses were markedly augmented and LVEF was significantly reduced after AMI but were remarkably improved after tacrolimus treatment.

Acute Profound Thrombocytopenia after Using Abciximab for No-Reflow during Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Glycoprotein IIb/IIIa antagonists are well established for their effectiveness in improving clinical outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention. Acute profound thrombocytopenia is a rare complication of abciximab. We present a case which was managed successfully for the rare complication of acute profound thrombocytopenia after using abciximab and an intra-aortic balloon pump for the treatment of a no-reflow phenomenon and consecutive cardiogenic shock during primary percutaneous coronary intervention.

Impact of lesion location on intravascular ultrasound findings and short-term and five-year long-term clinical outcome after percutaneous coronary intervention for saphenous vein graft lesions

BACKGROUND

Little is known about intravascular ultrasound (IVUS) findings and acute post-percutaneous coronary intervention (PCI) outcome and long-term clinical outcome between aorto-ostial lesion and shaft lesion after PCI for saphenous vein graft (SVG) lesions.

METHODS

Aorto-ostial lesion was defined as those arising within 3mm of the origin of SVG and shaft lesion was defined as those arising in remaining portion of SVG. We evaluated pre- and post-PCI IVUS images of 311 SVG lesions and compared IVUS findings and acute post-PCI outcome and 5-year clinical outcome between aorto-ostial lesion (n=64) and shaft lesion (n=247).

RESULTS

The presence of positive remodeling (40% vs. 22%, p=0.026), hypoechoic plaque (47% vs. 36%, p=0.035), plaque rupture (23% vs. 8%, p=0.008), multiple plaque rupture (9% vs. 2%, p=0.038), and an intraluminal mass (54% vs. 25%, p<0.001) were significantly more common in shaft lesion than in aorto-ostial lesion. Post-PCI no-reflow (15% vs. 5%, p=0.033), post-PCI tissue prolapse (TP) (40% vs. 23%, p=0.014), and post-PCI creatine kinase-MB elevation more than 3 times normal (14% vs. 8%, p=0.047) were observed more frequently after PCI for shaft lesion than for aorto-ostial lesion. At 5-year clinical follow-up, the incidences of death (25% vs. 13%, p=0.036) and myocardial infarction (24% vs. 11%, p=0.028), but not the rate of target vessel revascularization (36% vs. 25%, p=0.096), were significantly higher in patients with shaft lesion compared with those with aorto-ostial lesion.

CONCLUSIONS

SVG shaft lesion has more unstable plaque morphology and this may contribute to the worse acute PCI outcomes and long-term outcomes.

Telmisartan protects against microvascular dysfunction during myocardial ischemia/reperfusion injury by activation of peroxisome proliferator-activated receptor γ

Background

We investigated the potential of telmisartan to improve microvascular dysfunction induced by myocardial ischemia/reperfusion (I/R) injury by activating the peroxisome proliferator-activated receptor gamma (PPARG) pathway.

Methods

Forty-eight male rabbits were randomly allocated into sham-operated, I/R, GW9662, telmisartan, telmisartan–GW9662, or candesartan groups. Rabbits were anesthetized, and the left anterior descending coronary artery (LAD) was ligated for 60 minutes. Following reperfusion for 6 hours, angiotensin II content of the heart was determined using radioimmunoassay. Myocardial neutrophil accumulation and microvessel cross-sectional area were examined histologically. Myocardial capillaries were examined with transmission electron microscopy. Intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in the myocardium were measured using enzyme-linked immunosorbent assay. Western blot was utilized for investigating the expression of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and PPARG.

Results

Angiotensin II concentration was significantly increased in all treatment groups compared with the sham-operated group (P < 0.05, all). Accumulation of polymorphonuclear neutrophils was significantly lower, while microvessel cross-sectional area was significantly higher in the telmisartan, telmisartan-GW9662, and candesartan groups compared with the I/R group (P < 0.05). ICAM-1 and VCAM-1 levels were also significantly lower, and correlated with lower NF-κB expression in these groups. The effects were the most significant in the telmisartan group compared with the telmisartan–GW9662 and candesartan groups. Telmisartan significantly increased PPARG protein expression compared with all other groups (P < 0.05, all).

Conclusions

Except for the typical effects of angiotensin II-receptor blocker, telmisartan improved microvascular dysfunction during myocardial I/R injury via the PPARG pathway.

Complications of coronary intervention: device embolisation, no-reflow, air embolism

The introduction of drug-eluting stents, better equipment, stronger antiplatelet drugs, and higher levels of operator experience has led to markedly improved patency rates for complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate complications. However, rigorous preventive measures pre-empt the appearance of complications. During traversal of severely diseased coronary arteries and manipulating equipment, particularly devices with detachable components, the opportunity for loss or embolisation of material in the coronary circulation presents itself. Device embolisation is associated with periprocedural myocardial infarction and emergent referral to surgery, particularly if the device is not retrieved. The coronary no-reflow phenomenon is a feared complication of PCI. It is associated with a worse prognosis and has been shown to be an independent predictor of death, myocardial infarction and impaired left ventricular function. Air embolism can be prevented by flushing of catheters during equipment exchanges.

Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead?

Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.

No-Reflow Phenomenon

No-reflow is responsible for 40% of the primary percutaneous coronary intervention without complete myocardial reperfusion despite successful reopening of the infarct-related artery. This review describes the main pathophysiological mechanisms of no-reflow, its clinical manifestation, including the strong association with increased in-hospital mortality, malignant arrhythmias, and cardiac failure as well as the diagnostic methods. The latter ranges from simple angiographic thrombolysis in myocardial infarction grade score to more complex angiographic indexes, imaging techniques such as myocardial contrast echo or cardiac magnetic resonance, and surrogate clinical end points such as ST-segment resolution. This review also summarizes the strategies of prevention and treatment of no-reflow, considering the most recent studies results regarding medical therapy and devices.