No Reflow Phenomenon: Insight From the Catheterization Laboratory
A 74-year-old male patient with history of heavy smoking, hypertension, and hyperlipidemia presented to our emergency department with unstable angina. The patient was given sublingual nitroglycerin, aspirin, clopidogrel, and heparin drip, which resolved his chest pain. His cardiopulmonary exam was unremarkable. The electrocardiogram on presentation didn't show acute ST/T wave abnormalities. Echocardiography revealed preserved left ventricular function with no abnormal wall motion. Lexiscan stress test demonstrated ischemia involving anterior, anteroseptal, and apical ischemia. The patient was started on tirofiban infusion while undergoing coronary angiography. The left coronary system was engaged via Judkins Left 4.0 catheter, demonstrating critical mid-left anterior descending artery (LAD) lesion with a hazy lesion suggesting local thrombus burden (Figure 1). Following balloon inflation for 8 sec @ 10 atm, mid-LAD had no reflow (Figure 2). Intracoronary nitroglycerine of 200 mcg was given to exclude coronary spasm. Activated clotting time was then checked and determined to be therapeutic.
What is the best next step in management of this patient?