The SALINE Technique for the Treatment of the No-Reflow Phenomenon during Percutaneous Coronary Intervention in STEMI

Background: Primary percutaneous coronary intervention (pPCI) performed for STEMI may be complicated by the “no-reflow” phenomenon. Aims: A super-selective intracoronary injection of saline solution through a thrombus aspiration catheter (SALINE technique), was investigated for the treatment of no-reflow as compared with the standard care of therapy (SCT). Methods: Among the 1471 patients with STEMI undergoing pPCI between May 2015 and June 2020, 168 patients developed no-reflow. Primary endpoints were the incidence of ST-segment resolution (STR) ≥ 70% at 90 min after PCI and the rate of flow restoration (TIMI flow grade 3 with an MBG > 1). The secondary endpoint was the incidence of major adverse cardiac and cerebrovascular events at 3 years follow-up. Results: After propensity score matching analysis, patients treated with SALINE showed STR ≥ 70% in twelve out of the sixteen patients (75.0%), compared to only three patients out of the sixteen in the SCT control group (19.0%), (p < 0.004). SALINE was associated with a higher probability of final TIMI flow grade 3 with an MBG > 1, as shown in fourteen out of sixteen patients (87.5%), as compared to only seven out of sixteen patients in the SCT group (43.8%), (p < 0.03). MACCE at 3 years follow-up occurred in only one patient (6.3%) in the SALINE group, as compared to eight patients (50%) in the SCT group (p = 0.047). Conclusions: The SALINE technique showed to be a safe and effective strategy to reduce “no-reflow” in STEMI patients as assessed by significant STR, improvement of TIMI flow grade, and better 3-year outcomes.

[1]  A. Candreva,et al.  Saline-induced coronary hyperemia with continuous intracoronary thermodilution is mediated by intravascular hemolysis. , 2022, Atherosclerosis.

[2]  A. Candreva,et al.  Simplified Assessment of the Index of Microvascular Resistance , 2021, Journal of interventional cardiology.

[3]  A. Candreva,et al.  Basics of Coronary Thermodilution. , 2021, JACC. Cardiovascular interventions.

[4]  A. Candreva,et al.  Thermodilution-Derived Volumetric Resting Coronary Blood Flow Measurement in Humans. , 2021, EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology.

[5]  J. Bartunek,et al.  Duration of Hyperemia With Intracoronary Administration of Papaverine , 2021, Journal of the American Heart Association.

[6]  P. Bruneval,et al.  Intracoronary Saline‐Induced Hyperemia During Coronary Thermodilution Measurements of Absolute Coronary Blood Flow: An Animal Mechanistic Study , 2020, Journal of the American Heart Association.

[7]  D. Kandzari,et al.  Efficacy and safety of intracoronary epinephrine versus conventional treatments alone in STEMI patients with refractory coronary no‐reflow during primary PCI: The RESTORE observational study , 2020, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[8]  G. Cimmino,et al.  Antiplatelet therapy in Acute Coronary Syndromes. Lights and shadows of platelet function tests to guide the best therapeutic approach. , 2020, Current vascular pharmacology.

[9]  I. Porto,et al.  Index of Microcirculatory Resistance as a Tool to Characterize Microvascular Obstruction and to Predict Infarct Size Regression in Patients With STEMI Undergoing Primary PCI. , 2019, JACC. Cardiovascular imaging.

[10]  F. Crea,et al.  The coronary circulation in acute myocardial ischaemia/reperfusion injury: a target for cardioprotection. , 2018, Cardiovascular research.

[11]  Kristian Thygesen,et al.  Fourth Universal Definition of Myocardial Infarction (2018). , 2018, Journal of the American College of Cardiology.

[12]  Marco Valgimigli,et al.  2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). , 2018, European heart journal.

[13]  M. Penicka,et al.  Saline-Induced Coronary Hyperemia: Mechanisms and Effects on Left Ventricular Function , 2017, Circulation. Cardiovascular interventions.

[14]  K. Abrams,et al.  The REFLO-STEMI (REperfusion Facilitated by LOcal adjunctive therapy in ST-Elevation Myocardial Infarction) trial: a randomised controlled trial comparing intracoronary administration of adenosine or sodium nitroprusside with control for attenuation of microvascular obstruction during primary percut , 2016 .

[15]  G. Heusch The Coronary Circulation as a Target of Cardioprotection. , 2016, Circulation research.

[16]  E. Ohman,et al.  Relationship Between Infarct Size and Outcomes Following Primary PCI: Patient-Level Analysis From 10 Randomized Trials. , 2016, Journal of the American College of Cardiology.

[17]  Harlan M Krumholz,et al.  2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infa , 2016, Journal of the American College of Cardiology.

[18]  F. Van de Werf,et al.  Evolving therapies for myocardial ischemia/reperfusion injury. , 2015, Journal of the American College of Cardiology.

[19]  E. Romagnoli,et al.  Open-label, randomized, placebo-controlled evaluation of intracoronary adenosine or nitroprusside after thrombus aspiration during primary percutaneous coronary intervention for the prevention of microvascular obstruction in acute myocardial infarction: the REOPEN-AMI study (Intracoronary Nitropruss , 2013, JACC. Cardiovascular interventions.

[20]  M. Nijsten,et al.  Computer-assisted myocardial blush quantification after percutaneous coronary angioplasty for acute myocardial infarction: a substudy from the TAPAS trial. , 2009, European heart journal.

[21]  F. Zijlstra,et al.  Thrombus aspiration during primary percutaneous coronary intervention. , 2008, The New England journal of medicine.

[22]  F. Burzotta,et al.  Thrombus-aspiration: a victory in the war against no reflow , 2008, The Lancet.

[23]  F. Zijlstra,et al.  Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study , 2008, The Lancet.

[24]  G. Schuler,et al.  Influence of time-to-treatment, TIMI-flow grades, and ST-segment resolution on infarct size and infarct transmurality as assessed by delayed enhancement magnetic resonance imaging. , 2006, European heart journal.

[25]  Hiroshi Ito No-reflow phenomenon and prognosis in patients with acute myocardial infarction , 2006, Nature Clinical Practice Cardiovascular Medicine.

[26]  Steven A. Julious,et al.  Sample size of 12 per group rule of thumb for a pilot study , 2005 .

[27]  E. Antman,et al.  Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. , 2005, JAMA.

[28]  R. Schröder Prognostic Impact of Early ST-Segment Resolution in Acute ST-Elevation Myocardial Infarction , 2004, Circulation.

[29]  E. Braunwald,et al.  Relationship of the TIMI Myocardial Perfusion Grades, Flow Grades, Frame Count, and Percutaneous Coronary Intervention to Long-Term Outcomes After Thrombolytic Administration in Acute Myocardial Infarction , 2002, Circulation.

[30]  K. Okumura,et al.  Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. , 2000, Journal of the American College of Cardiology.

[31]  Y. Taniyama,et al.  Beneficial effect of intracoronary verapamil on microvascular and myocardial salvage in patients with acute myocardial infarction. , 1997, Journal of the American College of Cardiology.

[32]  D. Baim,et al.  Incidence and treatment of 'no-reflow' after percutaneous coronary intervention. , 1994, Circulation.