The no-reflow phenomenon associated with percutaneous coronary intervention: its mechanisms and treatment
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REVIEW ARTICLE
The no-reflow phenomenon associated with percutaneous coronary intervention: its mechanisms and treatment Hiroshi Ito
Received: 28 June 2010 / Published online: 9 October 2010 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2010
Abstract In patients with acute coronary syndrome (ACS), the immediate therapeutic goal is to establish patency of the infarct-related artery and to achieve optimal myocardial tissue reperfusion. Coronary microvasculatures, however, are often damaged irreversibly due to myocardial ischemia and reperfusion, and flow to the previously ischemic myocardium is markedly reduced, a phenomenon known as the ‘‘no-reflow phenomenon’’. In clinical settings, percutaneous coronary intervention (PCI) may accelerate embolization of plaque gruels and microthrombi to the microvessels, which further reduces tissue perfusion. The microvascular dysfunction attenuates the beneficial impact of PCI. The extent of the no-reflow phenomenon correlates with infarct size, and it has additional prognostic information. Patients with the no-reflow phenomenon have poor functional and clinical outcomes. Recent advances in imaging modalities have enabled diagnosis of the no-reflow phenomenon and assessment of the mechanisms of the microvascular dysfunction in patients. Use of pharmacological interventions and catheter-based devices to retrieve embolic materials have been proposed, and some of them are associated with improvement in clinical outcomes. Thus, we should keep in mind that only the achievement of successful myocardial perfusion is associated with better functional and clinical outcomes in patients with ACS.
H. Ito (&) Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, 2-5-1 Kita-ku, Shikata-cho, Okayama 700-8558, Japan e-mail: [email protected]
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Keywords Coronary intervention Microcirculation Myocardial infarction Reperfusion Cardiac function
Introduction The goal of direct angioplasty for treatment of acute myocardial infarction (MI) is not only restoration of normal epicardial flow but also achievement of optimal myocardial tissue reperfusion. Although the epicardial artery appears to have gained sufficient luminal diameter after stent implantation, some patients with acute MI show coronary slow flow and are inadequately washed out during coronary angiography. This is caused by structural damage of the coronary microvasculature [1–3], called the no-reflow phenomenon [4]. The no-reflow phenomenon is defined as reduced epicardial blood flow without apparent vessel obstruction in clinical settings. The no-reflow phenomenon significantly attenuates the beneficial impact of percutaneous coronary intervention (PCI) in patients with acute MI. With the advancement of imaging modalities, the incidence of the no-reflow phenomenon has been increasing. The coronary slow flow is also observed during PCI in patients with unstable angina, and it is not necessarily associated with MI. Embolization of plaque and thrombus debris, eith
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