Catheterization and Cardiovascular Diagnosis 39:119 (1 996) Editorial Comment No-Reflow No More? Joel K. Kahn, MD, and Steven L. Almany, MD William Beaumont Hospital Royal Oak, Michigan The ultimate goal of all coronary interventions is to achieve maximal vessel patency with excellent coronary flow. Many mis- haps can occur in the course of achieving that goal but few are as disappointing as seeing, on the one hand, a widely patent vessel and, on the other hand, diminished or absent antegrade flow. With more coronary interventions performed in the setting of acute ischemic syndromes and patients after saphenous vein bypass grafting, no-reflow is being seen more commonly. Therapies that have been tried in the past with generally little success have included guidewire agitation, aspiration, vigorous contrast or saline imga- tion, and intraaortic balloon counterpulsation. The contribution of Kaplan and colleagues from our institution is an important one [ 11. They prospectively looked at two treatment regimens for the no-reflow phenomenon following interventions in deteriorated vein grafts and found that intracoronary verapamil was far superior to intracoronary nitroglycerin which was relatively useless. Only a small number of patients suffered a non-Q wave myocardial infarction from the no-reflow. It is interesting that while 15 of 36 vein graft interventions resulted in the no-reflow phenomenon, a total of 32 separate episodes of no-reflow were recorded. Recurrent no-reflow has not been emphasized before. It may be that most prior episodes of serious no-reflow were untreatable and resulted in termination of the procedure. After effectively administrating verapamil, Kaplan and coworkers were able to proceed with the procedures only to observe the event again. It is also interesting that no adverse events were noted to be due directly to the use of intracoronary verapamil. Concern over heart block has slowed down the introduction of verapamil for wider usage and this may be an overreaction. The most pressing question raised by Kaplan et al. [I] is whether no-reflow can be prevented some or all of the time by the more liberal use of prophylactic intracoronary verapamil in high- risk patients and vessels. This question can only be answered by a randomized trial in a sufficient large number of patients as to empower the statistical analysis. This question would also have relevance for patients undergoing mechanical rotational atherec- tomy. The role of adjunctive intraaortic balloon pumping after intracoronary verapamil therapy of no reflow also needs clarifica- tion. We are excited by the findings from our colleagues at William Beaumont Hospital and believe they represent an important contribution to patient care. These findings need to be reproduced at other centers and but will likely be validated as a low cost, acces- sible way to avoid a potential ischemic catastrophe. REFERENCES 1. Kaplan BM, Benzuly KH, Kinn JW, Bowers TR, Tilli FV, Grines CL, O’Neill WW, Safian RD: Treatment of no-reflow in degen- erated saphenous vein graft interventions: Comparison of intracoronary verapamil and nitroglycerin. Cathet Cardiovasc Diagn 39:113-118, 1996. 0 1996 Wiley-Liss, Inc.

Editorial comment: No-reflow no more?

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Catheterization and Cardiovascular Diagnosis 39:119 (1 996)

Editorial Comment

No-Reflow No More?

Joel K. Kahn, MD, and Steven L. Almany, MD William Beaumont Hospital Royal Oak, Michigan

The ultimate goal of all coronary interventions is to achieve maximal vessel patency with excellent coronary flow. Many mis- haps can occur in the course of achieving that goal but few are as disappointing as seeing, on the one hand, a widely patent vessel and, on the other hand, diminished or absent antegrade flow. With more coronary interventions performed in the setting of acute ischemic syndromes and patients after saphenous vein bypass grafting, no-reflow is being seen more commonly. Therapies that have been tried in the past with generally little success have included guidewire agitation, aspiration, vigorous contrast or saline imga- tion, and intraaortic balloon counterpulsation.

The contribution of Kaplan and colleagues from our institution is an important one [ 11. They prospectively looked at two treatment regimens for the no-reflow phenomenon following interventions in deteriorated vein grafts and found that intracoronary verapamil was far superior to intracoronary nitroglycerin which was relatively useless. Only a small number of patients suffered a non-Q wave myocardial infarction from the no-reflow.

It is interesting that while 15 of 36 vein graft interventions resulted in the no-reflow phenomenon, a total of 32 separate episodes of no-reflow were recorded. Recurrent no-reflow has not been emphasized before. It may be that most prior episodes of serious no-reflow were untreatable and resulted in termination of

the procedure. After effectively administrating verapamil, Kaplan and coworkers were able to proceed with the procedures only to observe the event again.

It is also interesting that no adverse events were noted to be due directly to the use of intracoronary verapamil. Concern over heart block has slowed down the introduction of verapamil for wider usage and this may be an overreaction.

The most pressing question raised by Kaplan et al. [ I ] is whether no-reflow can be prevented some or all of the time by the more liberal use of prophylactic intracoronary verapamil in high- risk patients and vessels. This question can only be answered by a randomized trial in a sufficient large number of patients as to empower the statistical analysis. This question would also have relevance for patients undergoing mechanical rotational atherec- tomy. The role of adjunctive intraaortic balloon pumping after intracoronary verapamil therapy of no reflow also needs clarifica- tion.

We are excited by the findings from our colleagues at William Beaumont Hospital and believe they represent an important contribution to patient care. These findings need to be reproduced at other centers and but will likely be validated as a low cost, acces- sible way to avoid a potential ischemic catastrophe.

REFERENCES

1. Kaplan BM, Benzuly KH, Kinn JW, Bowers TR, Tilli FV, Grines CL, O’Neill WW, Safian RD: Treatment of no-reflow in degen- erated saphenous vein graft interventions: Comparison of intracoronary verapamil and nitroglycerin. Cathet Cardiovasc Diagn 39:113-118, 1996.

0 1996 Wiley-Liss, Inc.