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Plaque Prolapse After Stenting in Myocardial Infarction: Bad Plaque—Bad Omen?^_*

Michigan State University, Kalamazoo, Michigan.

Key Words: intravascular ultrasound • plaque prolapse • vulnerable plaque • acute myocardial infarction

These main findings fit well with our thinking about the type(s) of plaque material and the results that we might expect when placing a lattice-like metallic structure in plaques that have ruptured and have caused myocardial necrosis (2–5). "Vulnerable plaques" that rupture and cause MI are more typically bulky, lipid-laden, and associated with positive remodeling (3). As these types of plaques rupture, a thrombus may form, break up, and re-form, leaving layers of an organized thrombus that may also behave as "soft" tissue.

One of the potential limitations of the current study is that it may be difficult, using intravascular ultrasound, to distinguish between soft lipid-laden plaque and a "rubbery," organized thrombus. It is quite possible that an organized thrombus, and not plaque, could represent a significant component of the prolapsed tissue that was observed to protrude through the stent struts.

The finding that plaque prolapse was associated with a greater degree of myocardial necrosis than those cases without tissue prolapse would be consistent with increased distal plaque embolization, greater thrombus formation, transient vessel occlusion, and/or greater thrombus embolization. In any event, it is clear that soft material that protrudes through stent struts is associated with a greater extent of myocardial injury.

Although the study did not identify this tissue prolapse as a statistically significant predictor of subacute stent thrombosis (0 to 30 days), this "negative finding" must be interpreted cautiously. The study was not adequately powered to discern such a difference, and there was a worrisome trend toward greater subacute thromboses in the plaque prolapse group (2.4% vs. 0.9%; p = 0.308).

One of the other interesting findings was the association between stent design and the incidence of plaque or tissue prolapse (1). In this case, the Taxus stent (Boston Scientific Corp., Natick, Massachusetts), which is open-cell and similar in design to the old Tetra stent from Guidant (Santa Clara, California), had plaque prolapse observed in 39% of cases versus 25% of cases with the closed-cell CYPHER stent (Cordis Corp., Miami Lakes, Florida). These findings are consistent with other studies (2,6), including one of our studies comparing the open-cell Duet stent (Guidant) with the closed cell NIR stent (Boston Scientific) (Fig. 1) (6). These observations suggest that better plaque and vessel wall coverage could potentially be advantageous in the setting of stenting for acute MI, with either drug-eluting or bare-metal stents.

View larger version (52K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Plaque Prolapse Associated With Open-Cell Stent Design Panel A shows a markedly "scalloped" luminal contour in the right coronary artery after deployment of an open-cell stent (brown arrow). This is confirmed to be due to substantial plaque prolapse and invagination of plaque in the gaps between struts, by intravascular ultrasound (B, brown arrow). There is good exclusion of plaque at the site where the circumferential stent elements are present (C, yellow arrow).

	Footnotes

 
Dr. Fischell is a consultant for Cordis Corp. and Abbott, and holds license patents with Cordis Corp. and Abbott.

^_* Editorials published in JACC: Cardiovascular Imaging reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Imaging or the American College of Cardiology.

^_* Reprint requests and correspondence: Dr. Tim A. Fischell, Director, Cardiovascular Research, Borgess Heart Institute, Professor of Medicine, Michigan State University, 1521 Gull Road, Kalamazoo, Michigan 49048. (Email: tafisc{at}gmail.com).

	REFERENCES

Top REFERENCES

 

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3. Kotani J, Mintz GS, Castagna MT, et al. Intravascular ultrasound analysis of infarct-related and non-infarct-related arteries in patients who presented with an acute myocardial infarction Circulation 2003;107:2889-2893.[Abstract/Free Full Text]
4. Hong MK, Mintz GS, Lee CW, et al. Comparison of coronary plaque rupture between stable angina and acute myocardial infarction: a three-vessel intravascular ultrasound study in 235 patients Circulation 2004;110:928-933.[Abstract/Free Full Text]
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