Nadelson, Jeffrey D.

Vidovich, Mladen I.

English

Via Medica Journals

IMAGES IN CARDIOLOGYCardiology Journal2012, Vol. 19, No. 3, pp. 328–32910.5603/CJ.2012.0060Copyright © 2012 Via MedicaISSN 1897–5593328 www.cardiologyjournal.orgAddress for correspondence: Mladen I. Vidovich, MD, FACC, FSCAI, Division of Cardiology, Department of Medicine,University of Illinois at Chicago, 840 South Wood Street, MC 715, Suite 935, Chicago, IL 60612, USA, tel: 312 996 6730,fax: 312 413 2948, e-mail: miv@uic.eduReceived: 11.05.2011 Accepted: 09.08.2011‘No-reflow’ phenomenonJeffrey D. Nadelson, Mladen I. VidovichDivision of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USAA 57-year-old man presented with new angi-nal symptoms nine years after three-vessel coro-nary artery bypass grafting. Cardiac catherizationrevealed severely and diffusely diseased saphenousvein graft to the obtuse marginal coronary artery.Percutaneous coronary intervention was complicat-ed by the ‘no-reflow’ phenomenon.  The patientsuffered a periprocedural myocardial infarction(peak troponin 26.3 ng/mL) and died from low-out-put cardiogenic shock four days after the procedure.Gross autopsy findings demonstrated myone-crosis of the posterolateral wall (Fig. 1, black arrow).The infarction is in the distribution of the obtuse mar-ginal coronary artery and extends further than the dis-tribution of the obtuse marginal coronary artery se-condary to low perfusion resulting from cardiogenicshock. Histopathologic examination revealed massivemyonecrosis and abundant polymorphonuclear leuko-cytes consistent with recent myocardial infarction(Fig. 2). It is highly unusual and interesting that thehematoxylin and eosin stain demonstrated merely theinflammatory cells and necrosis, rather than debrisresulting from procedure-related embolization.The ‘no-reflow’ phenomenon is defined as in-adequate myocardial perfusion through a given seg-ment of the coronary circulation without evidenceof vessel obstruction. After placement of an embo-lic filter protection device, the graft was success-fully recannalized with a bare metal stent. Imme-diately after the stent was placed, the ‘no-reflow’ phe-Figure 1. Gross autopsy findings of posterolateral wall ofthe myocardium — arrow demonstrates extensive myo-necrosis of the posterolateral wall of the myocardium onautopsy in the distribution of the obtuse marginal artery.Figure 2. Hematoxylin and eosin stain demonstrating thedamaged posterolateral wall of the myocardium — mas-sive myonecrosis and abundant polymorphonuclear leu-kocytes are consistent with recent myocardial infarction.329Jeffrey D. Nadelson, Mladen I. Vidovich, ‘No-reflow’ phenomenonwww.cardiologyjournal.orgnomenon was observed despite initial filter protec-tion and subsequent administration of intracoronaryvasodilators. The underlying pathophysiology is notcompletely understood, but it may occur as a resultof vessel microembolization or microcirculatoryspasm and edema. The ‘no-reflow’ phenomenon isassociated with increased hospital mortality andperiprocedural myocardial infarction.  Pathologicchanges in the myocardium are similar to those seenin atherothrombotic acute myocardial infarction.AcknowledgementsFunding support: Division of Cardiology,University of Illinois at Chicago.Conflict of interest: Jeffrey D. Nadelson, MD:none; Mladen I. Vidovich, MD, FACC, FSCAI:Speakers Bureau — Eli Lilly and Dai Ichi Sankyo;Research Support — HCRI, DCRI, Sanofi-Aventis,The Medicines Company; Honoraria — Abiomed,Teleflex Medical.

No-reflow phenomenon

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No-reflow phenomenon

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