International Journal of Cardiology, 36 (1992) 236-239 0 1992 Elsevier Science Publishers B.V. AH rights reserved 0167~5273/92/$05.00
236
CARD10 14995
Successful coronary atherectomy during acute myocardial infarction Siguemituzo Arie, Carlos Vicente Serrano, Jr. and JosC Antonio Franchini Ramires Heart Institute, Faculty of Medicine, Unirrersiry of .%io Paulo, Sio Paula, SP, Brazil
(Received 2 January 1992; revision accepted
Immediate angiographic results and early follow-up of a patient initial phase of acute myocardial infarction are evaluated. Key words:
Coronary
atherectomy;
Coronary
angioplasty;
Introduction Recently, there has been a particular concern in mechanical coronary reperfusion by percutaneous transluminal coronary angioplasty in the early treatment of acute myocardial infarction. Hence, primary coronary angioplasty has been considered for rescuing the ischemic myocardium at risk. However, two main limitations of this procedure must be considered: abrupt reocclusion and occurrence of restenosis [l]. Therefore, directional coronary atherectomy, a new percutaneous technique, has been developed in an attempt to overcome these limitations of balloon angioplasty [l]. By permitting controlled removal of the atheromatous plaque, it usually results in an angiographically smooth surface or in a minimal residual stenosis. In this case report a patient was submitted to successful primary coronary angioplasty. During the subacute phase, he presented with total reocclusion of the infarct-related artery. He was then treated, within the hyperacute phase, with a successful coronary atherec-
Correspondence to: Dr. C.V. Serrano, Jr., Heart Institute, Clinical Division, Faculty of Medicine, University of Slo Paulo, Av. Dr. Eneas Carvalho de Aguiar, 44, Sb Paulo, SP 05403, Brazil. Fax 55-11-282-2354.
Myocardial
16 March 1992)
treated
with coronary
atherectomy
during
the
infarction
tomy which removed filling defects consequent to balloon angioplasty.
from the vessel wall
Case Report F.O.L., a 49-yr-old man, with poorly controlled arterial hypertension, smoker of more than two packs of cigarettes per day and hypercholesterolemia, experienced an intense, prolonged chest pain. He was referred to the hospital within 90 min and physical examination on admission revealed arterial pressure of 100/60 mmHg and discrete jugular venous distension; there were no other abnormalities. With the diagnosis of acute inferior myocardial infarction, probably complicated by right ventricular infarction, he underwent cardiac catheterization. The right coronary artery was totally occluded at its proximal portion (Fig. lA), and the left coronary artery revealed no stenosis (Fig. 1B); no collaterals were visualized. Primary coronary angioplasty was then indicated with successful result, and effective coronary reperfusion occurred within 3 h of the onset of chest pain (Fig. 10. Left ventriculography showed mild hypokinesia of the inferior wall (Fig. 1Dl. An early rise of creatinine kinase MB peaking at 61 U/l occurred within 12 h of chest pain. Standard electrocardiogram after coronary reperfusion revealed negative T waves in leads D3 and aVF. The patient was treated with isosorbide dinitrate, calcium channel blocker, aspirin and subcutaneous
237
Fig. 1. Angiograms during right coronary artery angioplasty. Proximal right coronary occlusion (lA, arrow) was successfully dilated within 15 min (1B). Left coronary artery revealed no stenosis (1C). Left ventriculography showed mild hypokinesia of the inferior wall (1D).
heparin. He was discharged from the hospital on the 6th day post myocardial infarction. He remained asymptomatic for a lo-day period, after which he presented with a new severe oppressing chest pain. At the hospital, 1 h later, another inferior infarction was diagnosed. Positive physical examination abnormalities consisted of arterial pressure of 90/50 mmHg, presence of moderate jugular venous distension and impaired periferic pressure. He was therefore taken to the cardiac catheterization laboratory and reocclusion of the right coronary artery was confirmed (Fig. 2A). Owing to the existence of hemodynamic impairment, aggressive intervention was once more immediately recommended. Repeated balloon dilatations of the coronary stenosis did not produce good results because of successive coronary artery spasms
and filling defects in the lumen despite the administration of an intracoronary infusion of nitroglycerine and of 100,000 U of streptokinase (Fig. 2B). We then opted for coronary atherectomy (Fig. 20. The resulting angiographic outcome was satisfactory within 2 h of onset of pain, with an approximate 20% residual stenosis but without any of the previously seen filling defects (Fig. 2D). Left ventriculography was unaltered and no complications occurred during this approach. The serum creatinine kinase MB level rose to 16 U/l after 21 h of pain. All other blood determinations were normal. The electrocardiogram immediately post-coronary atherectomy showed nonspecific ST-segment and T-wave changes in the inferior wall leads. Afterwards, the patient was managed with intravenous nitroglycerine and heparin, calcium channel
238
Fig. 2. Coronary angiograms of right coronary artery during coronary atherectomy. Reocclusion of the right coronary artery occurred after 10 days of coronary angioplasty (2A, arrow). Repeated balloon dilatations were unsuccessful after 15 min because of presence of coronary artery spasms and filling defects in the lumen (2B, arrow). Coronary atherectomy was then indicated (2C, arrow) and the resulting angiographic outcome was satisfactory within 2 h, with an approximate 20% residual stenosis but without any filling defects (2D).
blocker, beta-blocker, aspirin and dipyridamole. He was discharged from the hospital on the 6th day of post-myocardial infarction. After 2 months of follow-up evaluation, he is without any cardiac symptoms. Discussion In the present case, the patient was first admitted to the hospital with an acute inferior myocardial infarction, probably complicated by mild right ventricular ischemic dysfunction. Aggressive management by primary coronary angioplasty was considered in order to produce early reperfusion of the infarct-related coronary artery. However, complete coronary reocclusion was present in the subacute phase. In virtue of hemo-
dynamic impairment complicating reinfarction, mechanical intervention was once more immediately recommended, but repeated balloon dilatations of the coronary stenosis produced incomplete results. To overcome this dilemma, an emergency coronary atherectomy was performed. An immediate beneficial angiographic result was followed by an uneventful post-myocardial infarction outcome for this patient. Since the development of coronary angioplasty in 1977, an increasing concern in mechanical coronary reperfusion for the early treatment of acute myocardial infarction has been developed to salvage the jeopardized, ischemic myocardium at risk and limit the extent of injury (primary coronary angioplasty ). This technique is especially considered when a large amount of
239 myocardium is at risk and/or the patient is evolving with cardiogenic shock or pump failure within 18 h of acute infarction [2]. Therefore, a beneficial effect on left ventricular function takes place when a successful primary coronary angioplasty is obtained in these circumstances [3]. However, there are two main limitations of primary coronary angioplasty, namely abrupt vessel occlusion and restenosis [1,4]. Therefore, a variety of new interventional catheter technologies (e.g., stents, lasers, atherectomy catheters) have been introduced in the hope of addressing the residual problems of conventional balloon dilatation. Directional coronary atherectomy was therefore developed in an attempt to provide a safer and more predictable method of treating obstructive coronary artery disease [5]. While both coronary angioplasty and coronary atherectomy enlarge the coronary lumen, there are several important differences between the two techniques. On the one hand, balloon angioplasty cracks and disrupts atherosclerotic plaque and separates plaque from the media to allow stretching of the vessel wall [4,5]. On the other hand, the fundamental mechanism of coronary atherectomy was conceived to be excision and removal of atherosclerotic plaque with a low incidence of intimal flaps and dissection [5]. This case is unique in the literature as it describes the application of coronary atherectomy as a primary
approach to yield prompt coronary reperfusion in a patient presenting acute myocardial infarction due to complicated coronary angioplasty. Therefore, coronary atherectomy may be of value in the early, short-term management of patients with acute myocardial infarction due to unsuccessful coronary angioplasty and fulfill the criteria for coronary reperfusion. References Kerensky R, Kutcher M, Mumma M, Applegate RJ, Little WC. Cause of acute myocardial infarction after successful coronary angioplasty. Am J Cardiol 1991;68:967-970. Guidelines for the early management of patients with acute myocardial infarction: A report of the ACC/AHA Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Develop Guidelines for the Early Management of Patients With Acute Myocardial Infarction). Circulation 1990;82:664-706. Hartzler GO, Rutherford BD, McConahay DR. Percutaneous transluminal coronary angioplasty with and without thrombolytic therapy for treatment of acute myocardial infarction. Am Heart J 1983;106:965-973. Safian RD, Gelbfish JS, Erny RE, Stuart JS, Schmidt DA,
Bairn DS. Coronary atherectomy: clinical, angiographic, and histological findings and observations regarding potential mechanisms. Circulation 1990;82:69-79. Kaufman UP. Garratt KN. Vlietstra RE, Jr. Coronary atherectomy: first 50 patients Proc 1989;64:747-752.
at the Mayo Clinic. Mayo Clin
236
CARD10 14995
Successful coronary atherectomy during acute myocardial infarction Siguemituzo Arie, Carlos Vicente Serrano, Jr. and JosC Antonio Franchini Ramires Heart Institute, Faculty of Medicine, Unirrersiry of .%io Paulo, Sio Paula, SP, Brazil
(Received 2 January 1992; revision accepted
Immediate angiographic results and early follow-up of a patient initial phase of acute myocardial infarction are evaluated. Key words:
Coronary
atherectomy;
Coronary
angioplasty;
Introduction Recently, there has been a particular concern in mechanical coronary reperfusion by percutaneous transluminal coronary angioplasty in the early treatment of acute myocardial infarction. Hence, primary coronary angioplasty has been considered for rescuing the ischemic myocardium at risk. However, two main limitations of this procedure must be considered: abrupt reocclusion and occurrence of restenosis [l]. Therefore, directional coronary atherectomy, a new percutaneous technique, has been developed in an attempt to overcome these limitations of balloon angioplasty [l]. By permitting controlled removal of the atheromatous plaque, it usually results in an angiographically smooth surface or in a minimal residual stenosis. In this case report a patient was submitted to successful primary coronary angioplasty. During the subacute phase, he presented with total reocclusion of the infarct-related artery. He was then treated, within the hyperacute phase, with a successful coronary atherec-
Correspondence to: Dr. C.V. Serrano, Jr., Heart Institute, Clinical Division, Faculty of Medicine, University of Slo Paulo, Av. Dr. Eneas Carvalho de Aguiar, 44, Sb Paulo, SP 05403, Brazil. Fax 55-11-282-2354.
Myocardial
16 March 1992)
treated
with coronary
atherectomy
during
the
infarction
tomy which removed filling defects consequent to balloon angioplasty.
from the vessel wall
Case Report F.O.L., a 49-yr-old man, with poorly controlled arterial hypertension, smoker of more than two packs of cigarettes per day and hypercholesterolemia, experienced an intense, prolonged chest pain. He was referred to the hospital within 90 min and physical examination on admission revealed arterial pressure of 100/60 mmHg and discrete jugular venous distension; there were no other abnormalities. With the diagnosis of acute inferior myocardial infarction, probably complicated by right ventricular infarction, he underwent cardiac catheterization. The right coronary artery was totally occluded at its proximal portion (Fig. lA), and the left coronary artery revealed no stenosis (Fig. 1B); no collaterals were visualized. Primary coronary angioplasty was then indicated with successful result, and effective coronary reperfusion occurred within 3 h of the onset of chest pain (Fig. 10. Left ventriculography showed mild hypokinesia of the inferior wall (Fig. 1Dl. An early rise of creatinine kinase MB peaking at 61 U/l occurred within 12 h of chest pain. Standard electrocardiogram after coronary reperfusion revealed negative T waves in leads D3 and aVF. The patient was treated with isosorbide dinitrate, calcium channel blocker, aspirin and subcutaneous
237
Fig. 1. Angiograms during right coronary artery angioplasty. Proximal right coronary occlusion (lA, arrow) was successfully dilated within 15 min (1B). Left coronary artery revealed no stenosis (1C). Left ventriculography showed mild hypokinesia of the inferior wall (1D).
heparin. He was discharged from the hospital on the 6th day post myocardial infarction. He remained asymptomatic for a lo-day period, after which he presented with a new severe oppressing chest pain. At the hospital, 1 h later, another inferior infarction was diagnosed. Positive physical examination abnormalities consisted of arterial pressure of 90/50 mmHg, presence of moderate jugular venous distension and impaired periferic pressure. He was therefore taken to the cardiac catheterization laboratory and reocclusion of the right coronary artery was confirmed (Fig. 2A). Owing to the existence of hemodynamic impairment, aggressive intervention was once more immediately recommended. Repeated balloon dilatations of the coronary stenosis did not produce good results because of successive coronary artery spasms
and filling defects in the lumen despite the administration of an intracoronary infusion of nitroglycerine and of 100,000 U of streptokinase (Fig. 2B). We then opted for coronary atherectomy (Fig. 20. The resulting angiographic outcome was satisfactory within 2 h of onset of pain, with an approximate 20% residual stenosis but without any of the previously seen filling defects (Fig. 2D). Left ventriculography was unaltered and no complications occurred during this approach. The serum creatinine kinase MB level rose to 16 U/l after 21 h of pain. All other blood determinations were normal. The electrocardiogram immediately post-coronary atherectomy showed nonspecific ST-segment and T-wave changes in the inferior wall leads. Afterwards, the patient was managed with intravenous nitroglycerine and heparin, calcium channel
238
Fig. 2. Coronary angiograms of right coronary artery during coronary atherectomy. Reocclusion of the right coronary artery occurred after 10 days of coronary angioplasty (2A, arrow). Repeated balloon dilatations were unsuccessful after 15 min because of presence of coronary artery spasms and filling defects in the lumen (2B, arrow). Coronary atherectomy was then indicated (2C, arrow) and the resulting angiographic outcome was satisfactory within 2 h, with an approximate 20% residual stenosis but without any filling defects (2D).
blocker, beta-blocker, aspirin and dipyridamole. He was discharged from the hospital on the 6th day of post-myocardial infarction. After 2 months of follow-up evaluation, he is without any cardiac symptoms. Discussion In the present case, the patient was first admitted to the hospital with an acute inferior myocardial infarction, probably complicated by mild right ventricular ischemic dysfunction. Aggressive management by primary coronary angioplasty was considered in order to produce early reperfusion of the infarct-related coronary artery. However, complete coronary reocclusion was present in the subacute phase. In virtue of hemo-
dynamic impairment complicating reinfarction, mechanical intervention was once more immediately recommended, but repeated balloon dilatations of the coronary stenosis produced incomplete results. To overcome this dilemma, an emergency coronary atherectomy was performed. An immediate beneficial angiographic result was followed by an uneventful post-myocardial infarction outcome for this patient. Since the development of coronary angioplasty in 1977, an increasing concern in mechanical coronary reperfusion for the early treatment of acute myocardial infarction has been developed to salvage the jeopardized, ischemic myocardium at risk and limit the extent of injury (primary coronary angioplasty ). This technique is especially considered when a large amount of
239 myocardium is at risk and/or the patient is evolving with cardiogenic shock or pump failure within 18 h of acute infarction [2]. Therefore, a beneficial effect on left ventricular function takes place when a successful primary coronary angioplasty is obtained in these circumstances [3]. However, there are two main limitations of primary coronary angioplasty, namely abrupt vessel occlusion and restenosis [1,4]. Therefore, a variety of new interventional catheter technologies (e.g., stents, lasers, atherectomy catheters) have been introduced in the hope of addressing the residual problems of conventional balloon dilatation. Directional coronary atherectomy was therefore developed in an attempt to provide a safer and more predictable method of treating obstructive coronary artery disease [5]. While both coronary angioplasty and coronary atherectomy enlarge the coronary lumen, there are several important differences between the two techniques. On the one hand, balloon angioplasty cracks and disrupts atherosclerotic plaque and separates plaque from the media to allow stretching of the vessel wall [4,5]. On the other hand, the fundamental mechanism of coronary atherectomy was conceived to be excision and removal of atherosclerotic plaque with a low incidence of intimal flaps and dissection [5]. This case is unique in the literature as it describes the application of coronary atherectomy as a primary
approach to yield prompt coronary reperfusion in a patient presenting acute myocardial infarction due to complicated coronary angioplasty. Therefore, coronary atherectomy may be of value in the early, short-term management of patients with acute myocardial infarction due to unsuccessful coronary angioplasty and fulfill the criteria for coronary reperfusion. References Kerensky R, Kutcher M, Mumma M, Applegate RJ, Little WC. Cause of acute myocardial infarction after successful coronary angioplasty. Am J Cardiol 1991;68:967-970. Guidelines for the early management of patients with acute myocardial infarction: A report of the ACC/AHA Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Develop Guidelines for the Early Management of Patients With Acute Myocardial Infarction). Circulation 1990;82:664-706. Hartzler GO, Rutherford BD, McConahay DR. Percutaneous transluminal coronary angioplasty with and without thrombolytic therapy for treatment of acute myocardial infarction. Am Heart J 1983;106:965-973. Safian RD, Gelbfish JS, Erny RE, Stuart JS, Schmidt DA,
Bairn DS. Coronary atherectomy: clinical, angiographic, and histological findings and observations regarding potential mechanisms. Circulation 1990;82:69-79. Kaufman UP. Garratt KN. Vlietstra RE, Jr. Coronary atherectomy: first 50 patients Proc 1989;64:747-752.
at the Mayo Clinic. Mayo Clin
