Rheolytic thrombectomy with AngioJet catheter during transluminal coronary revascularization in patients with acute myocardial infarction

BACKGROUND: Although balloon angioplasty and stenting are effective in the treatment of acute myocardial infarction (M1), reduced coronary flow and distal embolization frequently complicate interventions when thrombus is present. Adjunctive treatment with mechanical thrombectomy devices was suggested to reduce these complications. METHODS: We evaluated immediate angiographic, in-hospital and 30-day follow-up clinical outcomes of 185 patients with acute MI and angiographically evident thrombus who were treated with AngioJet rheolytic thrombectomy followed by immediate definitive treatment. RESULTS: Procedural success (residual diameter stenosis <50% and thrombolysis in myocardial infarction [TIMI] flow >2 after final treatment) was 97%. Rheolytic thrombectomy success was achieved in 7% of patients. Subsequent definitive treatment included stenting in 67% and balloon angioplasty alone in 26% of patients. Final TIMI 3 flow was achieved in 89%. AngioJet treatment resulted in mean thrombus area reduction from 69.6 mm(2) at baseline to 17.3 mm(2) post-thrombectomy (p<0.001). Procedural complications included distal embolization (7.6%) and perforation (1.1%). Clinical success (procedure success without major in-hospital cardiac events) rate was 88%, in-hospital mortality - 7.0%. There were no further major adverse events during 30-day follow-up. CONCLUSION: Rheolytic thrombectomy can be performed safely and effectively in patients with acute MI, allowing for immediate definitive treatment of thrombus-containing lesions.     

AngioJet流体溶血栓吸引术对急性心肌梗死血栓性病变的疗效

目的　AngioJet流体溶血栓吸引术是通过流体击碎并吸引冠状动脉内血栓而将其移出体外的一种新的冠状动脉介入治疗技术。本研究以TIMI心肌灌注级别作为疗效指标评价该技术对急性心肌梗死血栓性病变的疗效。方法　选择澳大利亚皇家珀斯医院 2 0 0 0年 1月至 2 0 0 1年 1月所有冠状动脉造影明确显示血栓性病变的急性心肌梗死患者共 2 8例作为研究对象。其中 1 3例患者于支架置入术前进行了AngioJet流体溶血栓吸引术 (AngioJet组 ) ,而另 1 5例患者只行直接支架置入术(支架组 )。重点比较两组患者之间治疗前后心表面冠状动脉TIMI血流及TIMI心肌灌注级别 (后者与预后有强烈的相关性 )的变化。结果　支架组术后心表面冠状动脉TIMI血流及TIMI心肌灌注级别均明显优于AngioJet组 (分别为 2 60± 0 0 9vs 2 2 3± 0 1 6 ,P =0 0 4 2及 2 50± 0 1 1vs 1 92± 0 2 3 ,P=0 0 2 4 )。AngioJet组冠状动脉穿孔的例数显著多于支架组 (分别为 3例及 0例 ,P =0 0 4 9)。结论对于急性心肌梗死血栓性病变 ,支架置入术治疗可获得良好疗效 ;支架置入前采用AngioJet流体溶血栓吸引术并不增加疗效 ,甚至可能存在潜在的不良作用     

Rheolytic thrombectomy during percutaneous revascularization for acute myocardial infarction: experience with the AngioJet catheter

BACKGROUND: Although balloon angioplasty and stenting are effective in the treatment of acute myocardial infarction (MI), reduced coronary flow and distal embolization frequently complicate interventions when thrombus is present. Adjunctive treatment with mechanical thrombectomy devices may reduce these complications. METHODS AND RESULTS: We evaluated the angiographic and clinical outcomes of 70 patients with acute MI (16% with cardiogenic shock) and with angiographically evident thrombus who were treated with AngioJet rheolytic thrombectomy followed by immediate definitive treatment. Procedure success (residual diameter stenosis <50% and Thrombolysis in Myocardial Infarction [TIMI] flow > or =2 after final treatment) was achieved in 93.8%. Clinical success (procedure success without major in-hospital cardiac events) was achieved in 87.5%, with an in-hospital mortality rate of 7.1%. Final TIMI 3 flow was achieved in 87.7%. AngioJet treatment resulted in a mean thrombus area reduction from 73.2 +/- 64.6 mm(2) at baseline to 15.5 +/- 30.1 post-thrombectomy (P <.001). Subsequent definitive treatment included stenting in 67% and balloon angioplasty alone in 26% of patients. Procedural complications included distal embolization in six patients and perforation in two patients. There were no further major adverse events during 30-day follow-up. CONCLUSION: Rheolytic thrombectomy can be performed safely and effectively in patients with acute MI, allowing for immediate definitive treatment in thrombus-containing lesions.     

Treatment of coronary aneurysm in acute myocardial infarction with AngioJet thrombectomy and JoStent coronary stent graft

A 54-year-old male with a history of coronary artery disease with a percutaneous transluminal coronary angioplasty and stenting presented to the emergency with an acute myocardial infarction. The patient underwent angiography which showed in-stent thrombosis of the right coronary artery along with 2 aneurysms proximal to the lesion. The right coronary artery was treated with AngioJet rheolytic thrombectomy and the JoStent coronary stent graft. To our knowledge, this is the first report of the use of the AngioJet rheolytic thrombectomy and the JoStent coronary stent graft in acute myocardial infarction.     

Acute myocardial infarction in patients with normal coronary arteries after acute ethanol intoxication

Three cases are presented where acute myocardial infarction occurred in young individuals after an episode of heavy alcohol intake. Subsequent coronary arteriograms demonstrated normal coronary arteries. Several mechanisms by which acute ethanol intoxication might precipitate myocardial infarction are discussed. To our knowledge, no similar cases have been reported.     

Cocaine-induced myocardial infarction in patients with normal coronary arteries

OBJECTIVE: To review the reported cases of myocardial infarction temporally related to recreational and topical anesthetic use of cocaine, with special regard for underlying etiologic factors in patients subsequently found to have normal coronary arteries. DATA SOURCES: Personal records of three cases and a comprehensive literature review using MEDLINE and supplemented by Index Medicus and the bibliographies of case reports. DATA SYNTHESIS: A total of 114 cases of cocaine-induced myocardial infarction were identified. The coronary anatomy was defined by angiography or autopsy in 92 patients, 38% of whom had normal coronary arteries. In these 35 patients (average age, 32; range, 21 to 60 years), myocardial infarction typically involved the anterior left ventricular wall (77%). Moderate cigarette smoking with one or fewer associated coronary risk factors was prevalent (68%). Focal coronary vasospasm was shown convincingly in only two cases. Intracoronary thrombus was initially found on 9 of 11 angiograms (82%) done within 12 hours of the myocardial infarction. Experimental evidence suggests that cocaine has direct and indirect sympathomimetic effects on vascular smooth muscle, attenuates endothelium vasodilator capacity, exerts a potent depressant effect on cardiac myocytes, and promotes atherogenesis. CONCLUSIONS: Cocaine-induced myocardial infarction in patients with normal coronary arteries probably involves adrenergically mediated increases in myocardial oxygen consumption, vasoconstriction of large epicardial arteries or small coronary resistance vessels, and coronary thrombosis. Accelerated atherosclerosis and impairment of endothelium vasodilator function may occur after chronic cocaine use.     

Normal coronary arteries are rare in young patients with acute myocardial infarction.

OBJECTIVE: To delineate the angiographic extent of coronary atherosclerosis in young patients (<45 years) with acute myocardial infarction (MI). BACKGROUND: Prior studies suggest 20% of young patients with acute MI have normal coronary arteries. However, most such studies defined "normal" as absence of stenoses >50% luminal diameter, ignoring the presence of nonflow limiting disease that may harbor culprit plaques. METHODS: We retrospectively analyzed 131 patients <45 years old with ST-segment elevation MI undergoing emergency catheterization. Angiograms were analyzed for the presence and extent of disease, including lesion "complexity" indicative of plaque instability. "Normal" vessels were defined as absence of any disease. RESULTS: Mean patient age was 40 +/- 7 years. The infarct related artery and an obvious complex culprit lesion was identified in all (100%) cases (left anterior descending 44%, right coronary 38%, and circumflex 18%). Single vessel disease involving the culprit vessel only was identified in 60% of cases, whereas additional disease was found in 40% of others (two-vessel in 29% and three-vessel disease in 11% of patients). CONCLUSION: These findings demonstrate that young patients with acute MI typically manifest an identifiable complex culprit atherosclerotic coronary lesion. Furthermore, they often have multivessel atherosclerosis.     

Selective thrombolytic patency of the coronary arteries in patients with acute myocardial infarction

Urgent selective coronarography followed by intracoronary infusion of nitroglycerin and streptokinase (2000-4000 U/min) was performed in 24 patients with acute myocardial infarction. Mechanical recanalization of an occluded coronary artery was also performed in two patients. The coronary artery supplying the infarcted area was occluded in 22 patients while 2 patients had third-degree stenosis. Following intracoronary drug infusion, antegrade flow was recovered completely in 16 of 22 occluded coronary arteries (72.7%). All patients, however, retained acute coronary arterial stenosis around former occlusions. Aortal-coronary shunting was performed within 1 to 20 days in 6 patients.     

Thrombectomy during PCI for acute myocardial infarction

Macro and microembolization during percutaneous coronary intervention (PCI) in ST elevation acute myocardial infarction (STEAMI) is frequent and may result in obstruction of the microvascular network with subsequent reduction in efficacy of reperfusion. Numerous mechanistic studies have shown that the presence and size of the culprit thrombus is the most powerful predictor of incidence of embolization and slow flow/no reflow. Techniques that have been used to reduce the incidence of these events include thrombectomy devices and embolic protection devices. Although numerous prospective randomized clinical trials have been performed to evaluate the role of thrombectomy devices in patients with STEAMI, the results of these trials are conflicting and they speak to both sides of the controversy. The Achilles heal of the majority of these trials is the premise that thrombectomy devices should be routinely used in all patients presenting with STEAMI even irrespective of the presence and size of the thrombus. Such a hypothesis is naively optimistic and it ignores the basic knowledge available to us regarding the relationship between thrombus burden and embolization. Nonetheless, clinicians are faced every day with the reality of making difficult decisions on how to best treat patients presenting with STEAMI and large thrombus burden. The current available “evidence‐based medicine” cannot and should not be generalized to these patients because only a minority of these patients was included in these randomized clinical trials. In these patients, thrombectomy devices should be strongly considered as an integral part of the armamentarium available to reduce thrombus burden prior to definitive treatment. Whether a future clinical trial will provide a definitive answer in terms of clinical outcome difference is doubtful because such a trial will need to include large number of selected patients with STEAMI who both have large amount of myocardium at jeopardy and large thrombus burden, a difficult and possibly undoable study. © 2008 Wiley‐Liss, Inc.     

急性心肌梗死后近期病情稳定患者的冠状动脉造影特点

目的通过回顾性分析患者的冠状动脉造影特点,探讨是否应对急性心肌梗死后近期病情稳定的患者常规行冠状动脉造影。方法回顾性分析50例首次急性心肌梗死发病后病情稳定的患者,在1周至2个月行冠状动脉造影的结果,并与61例病情不稳定的患者对照。结果病情稳定患者冠状动脉造影检出≥70%冠状动脉狭窄性病变的比率为90%,病情不稳定患者的检出率为93.4%。差异无显著性(P=0.755)。结论急性心肌梗死后近期病情稳定的患者,大多数冠状动脉有严重狭窄,应考虑常规行冠状动脉造影检查。     

冠状动脉造影正常的急性心肌梗死患者临床预后的研究

目的　通过对冠状动脉 (冠脉 )造影正常的急性心肌梗死 (MINC)患者的随访 ,探讨其临床预后 ,并分析发病危险因素。方法　 1987至 2 0 0 1年北京大学第一医院 4 0例 (A组 )首次急性心肌梗死后冠脉造影正常 (冠脉造影狭窄程度小于 2 0 % )患者。同时随访了 12 9例 (B组 )年龄、性别、梗死部位与A组相匹配的冠脉造影严重狭窄 (梗死相关血管狭窄程度 >5 0 % )的急性心肌梗死患者 ,比较分析两组患者急性期、远期预后及发病危险因素。结果　高血压史、危险因素个数、梗死后心绞痛发生率A组明显低于B组。住院期间LVEFA组明显高于B组。两组患者平均随访时间相似 (6 7± 4 0比 6 8± 34月 )。复合心血管事件发生率A组明显少于B组。结论　MINC患者急性期、远期预后明显好于MICS患者 ,冠心病危险因素明显少于后者     

Acute myocardial infarction in juvenile patients with normal coronary arteries

Three patients below 21 years of age presented with typical symptoms, electrocardiographic pattern, and levels of enzymes suggestive for acute myocardial infarction. Various risk factors for coronary artery disease were present in all three patients. Coronary angiography showed normal coronary arteries in all. Thus, acute myocardial infarction may be experienced even in very young patients. Clinical and angiographic findings are discussed on the basis of the existing reports in the literature.     

Functional disorders in non-culprit coronary arteries and their implications in patients with acute myocardial infarction

Approximately 30-50% of patients with ST-segment elevation acute myocardial infarction have multivessel disease. The physiology of the non-culprit artery (NCA) is complex and represents a challenge to physicians as, while these plaques are presumably stable, clinical data show that they frequently lead to major adverse cardiovascular events. In addition the presence of microvascular and endothelial dysfunction may have prognostic implications and interfere with current physiological indices for stenosis severity assessment. In this review we aim to summarize current methods to study the microcirculation, discuss the evidence available regarding the endothelium and the microvascular compartment of the NCA; the best strategies to perform a complete revascularization based on proven ischemia; real limitations associated to hyperemic stenosis indices; and the potential role of novel resting-indices in this specific acute context.     

Characteristics and outcomes of patients with acute myocardial infarction and angiographically normal coronary arteries

This study on patients undergoing coronary angiography for acute myocardial infarction demonstrated that 2.8% of patients had angiographically normal coronary arteries and that these patients have a better prognosis than patients with angiographically verified coronary artery disease. The trend toward a higher prevalence of malignancy in this unique patient group raises the possibility of malignancy-induced hypercoagulability or inflammation as an underlying etiologic factor.     

Multicentric inflammation in epicardial coronary arteries of patients dying of acute myocardial infarction

OBJECTIVES: We sought to test the hypothesis of whether inflammatory cell infiltration in patients dying of an acute myocardial infarction (MI) is a multifocal event involving multiple coronary branches. BACKGROUND: Coronary instability is thought to reflect local disruption of a single vulnerable plaque. However, previous postmortem studies have not addressed the question of whether activation of inflammatory cells, particularly T lymphocytes, is limited to the culprit lesion only or rather diffuse in the coronary circulation. METHODS: We performed a systematic flow cytometric study in three groups of autopsied patients (group 1 = acute MI; group 2 = old MI; group 3 = no ischemic heart disease). Cell suspensions of enzymatically digested coronary arteries were stained for flow cytometry with CD3, CD68, alpha-smooth muscle actin, and human leukocyte antigen (HLA)-DR antibodies. RESULTS: The coronary plaques showed: 1) a higher proportion of inflammatory cells in groups 1 and 2 than in group 3; 2) a higher percentage of T lymphocytes in group 1 than in group 2 (11.67 +/- 0.70% vs. 5.67 +/- 0.74%, p = 0.001) and in group 2 than in group 3 (p = 0.008); and 3) diffuse cell activation in the whole coronary tree of group 1, but not of group 2 subjects. CONCLUSIONS: Our study suggests that lymphocytes may play a key role in coronary instability by determining activation of various cellular types throughout the coronary circulation. Activated T lymphocytes and their products may well represent a new target in both the treatment and prevention of acute coronary syndromes.     

Multivessel percutaneous coronary intervention in Chinese patients with acute myocardial infarction and simple nonculprit arteries

BACKGROUND: Multivessel percutaneous coronary intervention (PCI) for patients during acute myocardial infarction (AMI) is currently controversial. In this study, we investigated the significance of multivessel PCI in Chinese patients with ST-segment elevation AMI and relatively simple lesions in nonculprit arteries. METHODS: We reviewed all consecutive primary PCI of ST-segment elevation AMI in our hospital between 2002 and 2005. The patients with multivessel disease and ACC/AHA type A/B1 lesions in nonculprit arteries who underwent multivessel PCI were identified (n = 105, multivessel PCI group), and 120 patients with single-vessel disease and treatment with primary PCI were enrolled as control subjects (single-vessel PCI group). The primary end points were the occurrences of 6-month major adverse cardiac events (cardiogenic death, nonfatal reinfarction, and target vessel revascularization). The secondary end points included procedure time, angiographic success rate, TIMI grade, reperfusion arrhythmia, ST-segment resolution, and left ventricular ejection fraction. RESULTS: All patients with multivessel PCI tolerated the operations well and had similar TIMI 3 and angiographic success rates but longer procedure times than those patients with single-vessel PCI. There were no significant differences in reperfusion arrhythmia, ST-segment resolution, left ventricular ejection fraction, or 6-month MACEs between both groups. CONCLUSIONS: This study suggests that multivessel PCI is effective and safe for Chinese patients with ST-segment elevation AMI and simple lesions in nonculprit arteries.     

Distal protection in native coronary arteries during primary angioplasty in acute myocardial infarction: single-center experience.

Distal embolization of plaque or thrombotic debris is one of the mechanisms involved in the ischemia/reperfusion injury during primary percutaneous intervention for acute occlusion of a native coronary artery. We tested the clinical application of maximal antiplatelet therapy with abciximab combined with one of two different systems of mechanical distal protection: balloon occlusion and aspiration (PercuSurge) in 24 cases and a distal filter (FilterWire Ex) in 10 cases. Feasibility, technical limitations, and pitfalls are described.