Circulation, Vol 89, 2514-2518, Copyright © 1994 by American Heart Association
RN Piana, GY Paik, M Moscucci, DJ Cohen, CM Gibson, AD Kugelmass, JP Carrozza Jr, RE Kuntz and DS Baim
BACKGROUND: Profound reduction in antegrade epicardial coronary flow with
concomitant ischemia is seen occasionally during percutaneous coronary
intervention despite the absence of evident vessel dissection, obstruction,
or distal vessel embolic cutoff. In a prior small series of cases, this
"no-reflow" phenomenon appeared to be promptly reversed by the
intra-coronary administration of verapamil. METHODS AND RESULTS: To further
understand the prevalence of this syndrome and its responsiveness to the
proposed therapy, we reviewed 1919 percutaneous interventions performed
between January 1991 and April 1993. During the study period, 39 patients
(2.0%) met our criteria for no reflow, 37 of whom were treated with
intracoronary nitroglycerin followed by intracoronary verapamil and 2 of
whom received intracoronary nitroglycerin alone. An additional 16 patients
(0.8%) were given verapamil as part of the management of a flow-limiting
dissection or distal embolus (mechanical obstruction). Intracoronary
verapamil (50 to 900 micrograms, total dose) improved TIMI flow grade in
89% of no- reflow patients and markedly reduced the number of cineframes
between contrast injection and opacification of a selected distal landmark
(from 91 +/- 56 to 38 +/- 21 frames, P < .001). By contrast, only 19% of
patients with epicardial mechanical obstruction showed improvement in TIMI
flow grade after verapamil, with minimal reduction in frames to
opacification (from 107 +/- 42 to 101 +/- 69, P = .73). CONCLUSIONS: The
no-reflow phenomenon--reduction in distal flow without apparent dissection
or distal embolization--occurs in 2% of coronary interventions. It
generally responds promptly to intracoronary verapamil administration,
suggesting that distal microvascular spasm may be its etiology.
ARTICLES
Incidence and treatment of 'no-reflow' after percutaneous coronary intervention
Charles A. Dana Research Institute, Boston, MA.
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