Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction

Abstract

AIMS: Although recognized as an important feature of atherosclerotic coronary disease, little is known about the frequency and prognostic importance of distal embolization during primary angioplasty for acute myocardial infarction. METHODS AND RESULTS: As part of a randomized trial of thrombolysis vs primary angioplasty, 178 patients with acute myocardial infarction were treated with primary angioplasty. In these patients the occurrence of distal embolization after angioplasty was assessed. Embolization was defined as a distal filling defect with an abrupt 'cutoff' in one of the peripheral coronary artery branches of the infarct-related vessel, distal to the site of angioplasty. We analysed myocardial blush grade, ST-T segment elevation resolution, enzymatic infarct size and left ventricular ejection fraction in patients with and without distal embolization. Clinical information was collected for a mean of 5 years. Distal embolization was present in 27 patients (15.2%). Mean age and gender were not different from patients without distal embolization. Angiographic success (thrombolyis in myocardial infarction flow grade 3 and residual stenosis <50%) after primary angioplasty was less frequently observed in patients with distal embolization (70% vs 90%, P<0.01). Myocardial blush and ST-T segment elevation resolution after angioplasty were reduced when distal embolization was present. Patients with distal embolization had a larger enzymatic infarct size (mean cumulative lactate dehydrogenase measured over 72 h, 1612 vs 847, P<0.05) and a lower left ventricle ejection fraction at discharge (42% vs 51%, P<0.01). Long-term mortality was higher in patients with distal embolization (44% vs 9%, P<0.001). CONCLUSION: Distal embolization in patients treated with primary angioplasty is visible on the coronary angiogram in 15.2% of patients. It is related to reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Additional pharmacological interventions and/ or mechanical devices should be studied to prevent and/or treat distal embolization.