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The pathogenesis and treatment of no-reflow in patient with ACS

The pathogenesis and treatment of no-reflow in patient with ACS. Jian Liu, MD Chief Physician, Associate Professor of Medicine Cardiology Department, Peking University People’s Hospital, Beijing. Contents. Case report. 1. 2. Epidemiology of no reflow. Definition and classification.

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The pathogenesis and treatment of no-reflow in patient with ACS

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  1. The pathogenesis and treatment of no-reflow in patient with ACS Jian Liu, MD Chief Physician, Associate Professor of Medicine Cardiology Department, Peking University People’s Hospital, Beijing

  2. Contents Case report 1 2 Epidemiology of no reflow Definition and classification 3 Pathophysiology of no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  3. Female, 55yr. • “ Chest pain 5 months，aggravated for 1 week” . • Risk factors: Hypertension 6years；Hyperlipidaemia 10years. • CTA: LAD, RCA severe stenosis and soft plaque. • Diagnosis: Acute coronary syndrome.

  4. ECG at rest, pre PCI

  5. Left Coronary Artery Angiogram

  6. Right Coronary Artery Angiogram

  7. After balloon predilation

  8. After DES deployed

  9. No-reflow • Severe chest pain • Blood pressure dropped • Heart rate dropped

  10. Blood flow recover • Nitroglycerin ( IC) • Atropine ( IV ) • Dopamine ( IV )

  11. Final result

  12. ECG 2 days later • Myocardial injury biomarker：TNI 4.62ng/ml

  13. Contents Case report 1 Epidemiology of no reflow 2 Definition and classification 3 Pathophysiology of no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  14. Incidence Influence Epidemiology • Overall incidence was 2%; • 10%-15% in patients undergoing PCI of SVGs; • 30% in AMI undergoing direct PCI; • The hospital mortality and recurrent MI increased 5-10 times; • Associated with increased malignant arrhythmias,cardiac failure and poor long-term prognosis; • A large area of microvascular injury might impair the healing of the infarct area and could prevent the delivery of pharmacologic agents into that area;

  15. Contents Case report 1 Epidemiology of no reflow 2 Definition and classification 3 Pathophysiologyof no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  16. No-reflow (NR) was known as "primary percutaneous coronary intervention (PPCI) achieves epicardial coronary artery reperfusion but not myocardial reperfusion"; The term “no-reflow” has been increasingly used in published medical reports to describe microvascular obstruction and reduced myocardial flow after opening an occluded artery; Manifested as stagnant contrast and myocardial ischemia symptoms. Definition

  17. Classification according to the different situation

  18. Structural no-reflow - microvessels confined within necrotic myocardium exhibit irreversible damage of the cellular components of their wall. Functional no-reflow - patency of anatomically intact microvessels is compromised because of spasm and/or microembolisation. Classification according to morphological and functional studies

  19. Classification according to the duration of the preceding myocardial ischemia • Reperfusion NR • Ischemia-reperfusion injury • Myocardial edema • Endothelial swelling • Capillary obstruction • Vasospasm • Inflammatory response • Distal coronary embclization Interventional NR • Distal coronary embolization - Microvascular obstruction - Inflammatory response - Secondary Duration of Preceding ischemia seconds-minutes hours Circulation. 2008;117:3152-3156

  20. Contents Case report 1 Epidemiology of no reflow 2 Definition and classification 3 Pathophysiologyof no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  21. Mechanical obstruction from embolization Vascular autoregulation Extrinsic coagulation pathway Leukocyte adherence, platelet thrombi, and free radicals Microvascular ischemia and edema Vasoconstrictor mediators Individual susceptibility Pathophysiology

  22. Coronary microembolization Debris + Thrombotic material + Soluble factors Plaque rupture/fissure Microembolization Acute ischemia Protection Infarctlets TNFα Inflammatory reaction Serotonin TXA2 Adhesin NO, TNF, ROS Arrhythmia Myocardial dysfunction Coronary reserve

  23. Summarizing different mechanisms Heart 2002; 87: 162–8

  24. Contents Case report 1 Epidemiology of no reflow 2 Definition and classification 3 Pathophysiology of no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  25. The course of ACS and reperfusion time Characteristics of coronary artery lesions Pathological vessels and interventions Influencing factors of NR • Acute phase of ACS (<2w) • Reperfusion time<6h • Plaque rupture • Ulcerative lesions • Rich lipid,etc • SVG • Rotational atherectomy

  26. Evaluation methods

  27. Coronary angiography No-reflow Reflow • The sensitivity of TIMI flow grade is rather low as no-reflow occurs even in patients showing TIMI flow grade 3. • MBG provides a semi-quantitative evaluation of tissue perfusion after injection of contrast media in the epicardial vessel,represents a newer and more sensitive method.

  28. ECG Reflow No-reflow • Electrocardiographic STR is assessed 1 h after PCI,represents the most widely used technique, both in experimental studies and in clinical practice. • Sustained elevation of the ST segment after successful PCI is also associated with unfavorable functional and clinical outcomes. • Almost 30% of patients with TIMI flow grade 3 and MBG 2 or 3 do not exibit STR.

  29. Myocardial contrast echocardiography No-reflow Reflow • MCE uses ultrasound to detect the presence of microbubbles in myocardial microvessels; • Microvascular obstruction is detectable as a perfusion defect during myocardial contrast echocardiography and represents the extent of no-reflow; • AMICI study indicated the extent of no-reflow was the best predictor of adverse left ventricular remodeling after STEMI, being superior to STR and MBG among patients with a TIMI flow grade 3.

  30. Cardiac magnetic resonance Reflow No-reflow • No-reflow can be diagnosed as a lack of gadolinium enhancement during first pass or a lack of gadolinium enhancement within a necrotic region, identified by late gadolinium hyperenhancement; • CMR evaluation of microvascular perfusion has been shown to strictly correlate with MBG; • The detection of hypoenhancement zones on first-pass perfusion CMR,is associated with permanent dysfunction at follow-up

  31. Contents Case report 1 2 Epidemiology of no reflow Definition and classification 3 Pathophysiologyof no reflow 4 Influencing factors and diagnostic methods 5 Prevention and treatment of no reflow 6

  32. Prevention and treatment of no reflow • Medical therapy • Anti-platelet therapy: Abciximab • Vasodilators: Nitroglycerine, Adenosine, Calcium channel blockers, Nicorandil,Sodium nitroprusside • Intracoronary thrombolytics: Streptokinase • New drugs: Cyclosporine,Statins,Endothelin-1 and Thromboxane-A2 receptor antagonists

  33. Evidence Concerning Medical Prevention and Treatment of No-Reflow

  34. Prevention and treatment of no reflow • Mechanical therapies • Embolic protection devices 1. Distal or proximal protection 2. Thrombectomy devices • PCI techniques : 1. Minimization of balloon inflations 2. Stent deployment without predilation 3. Pre- and postconditioning methods

  35. Manual thrombectomy devices 1.Export [Medtronic Corporation, Minneapolis,MN, USA] 2. Driver CE [Invatec, Brescia, Italy] 3. Pronto [Vascular solutions, Minneapolis, MN, USA] Mechanical thrombectomy devices 1. Angiojet [MEDRAD Interventional/Possis Medical Inc., Minneapolis,MN, USA] 2. X-Sizer [eV3, White Bear Lake, MN,USA] Thrombectomy devices

  36. Manual thrombectomy devices a. The Diver CE device.b. The Pronto catheter. c. The Export catheter. d. The Hunter catheter. e. The VMax catheter.

  37. Mechanical thrombectomy devices The Rinspirator system The Angiojet System The X-sizer system

  38. Effect of Thrombectomy Devices on Surrogate End Points of Myocardial Reperfusion

  39. Both manual and mechanical were associated with better STR, albeit manual thrombectomy demonstrated a clear superiority.Manual thrombectomy device suggest that it is associated with a benefit in terms of death, stroke, and MI compared to standard PCI.Mechanical thrombectomy, on the other hand, does not seem to improve outcome over standard PCI. Therefore, current evidence suggests the routine use of manual thrombectomy in primary PCI Costopoulos C, Gorog DA, Di Mario C, Kukreja N. Use of thrombectomydevices in primary percutaneous coronary intervention:a systematic review and meta-analysis [published online December11, 2011]. Int J Cardiol. 2011.

  40. Prevention and treatment of no reflow • Mechanical therapies • Embolic protection devices 1. Distal or proximal protection 2. Thrombectomy devices • PCI techniques : 1. Minimization of balloon inflations 2. Stent deployment without predilation 3. Pre- and postconditioning methods

  41. Prevention and treatment of no reflow • Others • Oxygen intracoronary administration • Therapeutic hypothermia

  42. Thank you for your attention ！

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