Analysis of vessel wall morphology, blood flow velocity, and the hemostatic system in a patient with a large intracoronary thrombus

A patient with AMI caused by a large thrombus in the proximal LAD was successfully treated with PTCA and an intracoronary lysis combined with the platelet-receptor antagonist c7E3. Analysis of cellular hemostasis after 1 and 6 months revealed a sustained platelet activation despite combined anti-platelet therapy with ASA and ticlopidine. A progredient slow-flow phenomenon appeared during control angiographies, confirmed by intracoronary Doppler examination.

[Treatment of a large intracoronary thrombus with urokinase and a chimeric monoclonal platelet aggregation inhibitor]

HISTORY AND CLINICAL FINDINGS

7 days after an operation for intervertebral disc prolapse a 43-year-old man was referred with the clinical and ECG signs of an acute posterior wall myocardial infarction.

INVESTIGATIONS

Creatine kinase (CK) activity was raised to 204 U/I (myocardial-specific isoenzyme CKMB of 23.6 U/I, 11.6% of total) and glutamic-oxalate transferase (GOT) activity to 37 U/I. Emergency cardiac catheterisation, performed 4 hours after renewed onset of precordial pain showed no abnormal findings in the right coronary artery, despite the ECG signs, but a definite filling defect in the anterior interventricular branch, which on intravascular ultrasound was an echo-dense noncalcified structure.

TREATMENT AND COURSE

After percutaneous transluminal coronary angioplasty in the area of the obstructing structure a free-floating mass was identified in the proximal part of the anterior interventricular branch, most likely a thrombus. Intercoronary thrombolysis was therefore undertaken with urokinase (bolus of 1 mill. IU) together with the chimeric monoclonal antibody c7E3, which inhibits platelet aggregation by blocking the platelet glycoprotein surface receptor IIb/IIIa. Coronary angiography 12 hours later revealed almost complete dissolution of the previously obstructing mass.

CONCLUSION

Combining the platelet aggregation inhibitor c7E3 with a thrombolytic agent is an alternative treatment to the current management of intracoronary thrombi. Intravascular ultrasound is a suitable method for demonstrating angiographically inconspicuous or unclear but pathogenetically significant vessel changes.

Senile amyloidoses of the pituitary and adrenal glands. Morphological and statistical investigations

The pituitary and adrenal glands are a functional endocrine unit affected by local or organ-limited senile amyloid syndromes. These occur as interstitial (pituitary only) or intracellular (pituitary and adrenal) varieties. The pituitary and right adrenal glands of each of 108 consecutive autopsy cases of individuals aged 85 years and over were investigated for the prevalence, distribution and immunostaining characteristics of local amyloid. Intracellular amyloid was detected in 77 (71%) pituitaries and 73 (68%) adrenals. Interstitial amyloid was found in 86 pituitaries (80%). Immunohistochemical studies, investigating different amyloid fibril proteins, amyloid P component, ubiquitin, intermediate filaments and pituitary hormones, failed to demonstrate any similarities, and a common origin is unlikely. Statistical analyses demonstrated significant correlations between the occurrences of all three local amyloids. The clinical and histopathological significance of local pituitary and adrenal amyloid remains obscure. The results suggested that the pathogenesis of the local senile amyloidoses of the pituitary and adrenals may be influenced by a common, still uncharacterized variable. It is not clear whether this variable also contributes to the pathogenesis of other senile amyloid syndromes, such as those associated with Alzheimers' disease.

[Normalization of myocardial perfusion reserve after coronary stent implantation in comparison with balloon angioplasty alone]

Stents scaffold coronary arteries after angioplastic treatment and inhibit elastic recoil resulting in a larger and more circular focal lumen. In 25 patients with significant stenoses of the left anterior descending coronary artery, presenting no collaterals or myocardial infarction, EKG-gated digital subtraction angiograms were recorded at baseline and during hyperemia induced by intracoronary injection of 12 mg papaverine before and after balloon angioplasty, and after adjunct implantation of a single Palmaz-Schatz stent. Densitometric evaluation revealed the time parameters contrast medium appearance time (MCAT) rise time (RT) and mean transit time (MTT) and maximum intensity (Imax). Myocardial perfusion reserve (MPR1) was calculated as the ratio of baseline MCAT and hyperemic MCAT multiplied by the ratio of hyperemic Imax and baseline Imax while MPR2 was calculated as the ratio of baseline RT and hyperemic RT. Maximum flow ratio (MaxFR) was calculated as the ratio of preprocedural hyperemic MTT and postprocedural hyperemic MTT. Post-stenotic MPR1 increased from 1.36 +/- 0.28 to 2.50 +/- 1.20 and to 3.40 +/- 0.58 (ANOVA p < 0.05), while reference MPR1 remained unchanged with 3.40 +/- 0.60. Post-stenotic MPR2 increased from 1.57 +/- 0.14 to 2.59 +/- 0.86 after balloon angioplasty and to 3.10 +/- 0.41 after stenting (ANOVA p < 0.05), while reference MPR2 remained unchanged with 3.10 +/- 0.40. MaxFR was 2.13 +/- 0.53 after balloon angioplasty and 2.83 +/- 0.35 after stenting (p < 0.05). A good correlation was found between minimal stenosis diameter and MPR1 or MPR2 (MPR1: r = 0.94; MPR2: r = 0.87) and between luminal gain and MaxFR (r = 0.75). A negative correlation was measured between recoil, defined as the difference between inflated balloon diameter and resulting minimal stenosis diameter, and MPR1 and MPR2 and MaxFR (MPR1: r = -0.86; MPR2 r = -0.80; MaxFR r = -0.83). In conclusion, adjunct coronary stent implantation normalized post-stenotic myocardial perfusion immediately in contrast to balloon angioplasty alone resulting from a larger postprocedural lumen and a more pronounced inhibition of elastic recoil.