Clinical Implications of Distal Embolization During Coronary Interventional Procedures in Patients With Acute Myocardial InfarctionQuantitative Study With Doppler Guidewire
Atsunori Okamura, MD,
Hiroshi Ito, MD, FACC*,
Katsuomi Iwakura, MD,
Toshiya Kurotobi, MD,
Yasushi Koyama, MD,
Motoo Date, MD,
Yoshiharu Higuchi, MD,
Koichi Inoue, MD,
Kenshi Fujii, MD
Division of Cardiology, Sakurabashi Watanabe Hospital, Kita-ku, Japan.
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Figure 2 Detectable Size of Microspheres With the DGW
Representative coronary blood flow velocity spectra of the Doppler guidewire (DGW) at the concentration at which 100 microspheres passed the tip of the DGW in 1 s without (control) or with injection of microspheres 15, 50, or 80 µm in diameter.
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Figure 3 Accuracy of the Number of Embolic Particles Detected With the DGW
Correlations between the number of high-intensity transient signals (HITS) detected with the Doppler guidewire (DGW) in 1 s and the number of microspheres that passed the tip of the DGW in 1 s in the study with microspheres 50 or 80 µm in diameter.
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Figure 4 Representative Coronary Blood Flow Velocity Spectra During the 4 PCI Procedures
(A) The numbers of high-intensity transient signals (HITS) were 12 immediately after first balloon angioplasty (BA), and (B) only 2 after second BA, but increased to 17 after stenting. (C) Only 1 HITS was found after post-dilation. (D) These HITS were only observed within the initial 3 beats after balloon deflation.
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Figure 5 Liberation Timing and Prediction of the Number of Embolic Particles during the 4 PCI Procedures
(A) Comparison of the number of high-intensity transient signals (HITS) and their liberation timing throughout the subsequent percutaneous coronary intervention (PCI) procedures: first balloon angioplasty (BA), second BA, stenting, and post-dilation. (B) Correlation between the number of HITS after first BA and that after stenting.
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Figure 6 A Case in Which a Cluster of Embolic Particles Was Associated With Angiographic No-Reflow
(A) Coronary angiography (left anterior oblique projection) showed the complete occlusion of the proximal portion of the right coronary artery. (B) Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was achieved after thrombectomy and first and second balloon angioplasty (BA). (E) The average peak velocity detected by the intracoronary Doppler guidewire (DGW) was 6 cm/s. (C) We deployed a 3.0 x 25-mm stent into the culprit lesion. (F) The coronary blood flow velocity waveform showed a large number of HITS within 3 heartbeats after stent-balloon deflation. (G) The coronary blood flow disappeared except for transient antegrade flow in systole 4 beats after balloon deflation. (D) Coronary angiography showed angiographic no-reflow (TIMI flow grade 0), and we performed additional coronary thrombectomy and repeated intracoronary injections of nicorandil and nitroprusside. Ten minutes later, radiocontrast runoff was improved (TIMI flow grade 2). (H and I) Myocardial contrast echocardiography (short-axis view) showed good contrast enhancement (good reflow) at this stage.
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