Circulation. 2006;113:e21-e23
doi: 10.1161/CIRCULATIONAHA.105.551705
(Circulation. 2006;113:e21-e23.)
© 2006 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Architecture of Intracoronary Thrombi in ST-Elevation Acute Myocardial Infarction
Time Makes the Difference
Farzin Beygui, MD, PhD;
Jean-Philippe Collet, MD, PhD;
Chandrasekaran Nagaswami, MD;
John W. Weisel, PhD;
Gilles Montalescot, MD, PhD
From the Department of Cardiology, Pitié-Salpêtrière University Hospital, Paris, France (F.B., J.-P.C., G.M.), and Department of Cell and Developmental Biology, University of Pennsylvania School of Medicine, Philadelphia (C.N., J.W.W.).
Correspondence to Dr Gilles Montalescot, Department of Cardiology, Institut de Cardiologie, Bureau 2–236, Hôpital Pitié-Salpêtrière, 47 Bd de l’Hôpital, 75013 Paris, France. E-mail gilles.montalescot{at}psl.aphp.fr
Patient 1, a 46-year-old man, and patient 2, a 53-year-old man, both current smokers, were admitted to our center 60 minutes and 6 hours, respectively, after the onset of a first episode of ST-elevation inferior wall acute myocardial infarction. Neither of the patients had a prior history of heart disease or any risk factor for coronary artery disease other than a history of smoking. Both underwent coronary angiography with a transradial approach, revealing single-vessel disease consisting of a TIMI grade 0 occlusion of the proximal right coronary artery (Figure 1A and Figure 2A). Both patients received 500 mg IV aspirin, 300 mg oral clopidogrel, 0.5 mg/kg IV enoxaparine, and 0.25-mg/kg intravenous bolus, followed by 0.125-µg · kg–1 · min–1 intravenous infusion of abciximab, started 30 minutes before primary percutaneous coronary intervention (PCI). PCI was performed 90 minutes and 6.5 hours after the onset of the chest pain in patients 1 and 2, respectively. The thrombotic occlusion was easily crossed by the guidewire, and angiography before stenting revealed a TIMI grade 1 flow and an intracoronary floating thrombus in both cases (Figure 1B and Figure 2B). A nonocclusive distal protection Spider filter (ev3) was placed downstream from the thrombus. Direct stenting was performed successfully in both cases. Post-PCI angiography revealed a TIMI grade 3 flow and trapped thrombi in the filters (Figure 3A and 3B). The filters containing thrombi were easily removed. Macroscopically, the thrombus was white and friable in patient 1 but red and compact in patient 2 (Figure 4A and 4B). Scanning electron microscopy of the thrombus showed a platelet-rich thrombus with a small amount of fibrin in patient 1 and a highly organized, fibrin-rich thrombus with erythrocytes in patient 2 (Figure 5 and Figure 6). Both patients were discharged on day 3 after an uneventful stay, with similar prescriptions. These ex vivo findings may have important implications for the efficacy of drugs and/or mechanical devices used in the field of myocardial reperfusion.
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Figure 1. A and B, Initial angiograms revealing occlusion of the mid right coronary artery in patients 1 and 2, respectively.
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Figure 2. A and B, Angiograms showing intracoronary thrombus after the lesions were crossed by the guidewires in patients 1 and 2, respectively.
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Figure 3. A and B, Angiograms showing intracoronary thrombus trapped in the distal filter after direct stenting of the lesions in patients 1 and 2, respectively.
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Figure 5. A and B, Scanning electron microscopy at low (x500; a) and high (x2000; b) magnification showing a platelet-rich thrombus without fibrin or erythrocytes (patient 1).
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Figure 6. Scanning electron microscopy at low (x500; A) and high (x2000; B) magnification showing a fibrin-rich thrombus with erythrocytes and almost no platelets (patient 2). Additional data of an angiogram showing intracoronary thrombus trapped in the distal filter in patients 1 and 2 can be found in Movie I and Movie II.
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Footnotes
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The online-only Data Supplement, which contains Movie I and Movie II, can be found with this article at http://circ.ahajournals.org/cgi/content/full/113/2/e21/DC1.
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