“Oh , it’s a well recannalised IRA and its flowing TIMI 3 as well. Now, what shall we do sir” ?, An apparently worried senior resident queried after a second look at the images from a 8 hour old STMEI .Why you sound unhappy man ? As if recanalisation is an untoward event” ! I teased my resident !
and went on to ask . . .
What we mean by recannalised IRA ? (Recan-IRA)
- It is akin to natural or pharmacological angioplasty (or combination of the two )
- It can be complete or incomplete from the IRA perspective.
- It can either result in partial or fully salvaged myocardium.
- It should be understood even a 30% recanlisation can result in TIMI 3 flow and result in near complete salvage
- Even a 90% recannalisation may not accrue the same benefit if it has happened late. So its all in timing
- Spontaneous recannalisation can some times even be superior to thrombus aspiration . However , some degree of residual thrombus would be present in most
- Residual plaque burden is also an important factor that will decide the extent of angiographic recannalisation.
- Some times the recannalisation will make the vessel near normal with only luminal irregularity
- IVUS/OCT may provide accurate assessment of Recan-IRA , it’s is not logistically acceptable in STEMI setting.
- After listening to my briefing on recannalised IRA , the fellow looked more confused than before. He bothered to ask again , what am I supposed to do once a well recannlised IRA is detected ? Should I intervene or not ?
The term recanlised IRA generally convey a hemodynamic meaning for a successful early (natural plus or minus pharmacological ) reperfusion .If every parameter is fine , and the lesion is not significantly obstructing better to pause any further procedure , as consequences of deploying stent in a well recannalised segment is not yet clear with a stro ng trend towards harm .The decision is to be taken on individual basis with reference to symptoms, stability , residual ischemia and quantum of incomplete salvage and lesion morphology .
If you believe ,a spontaneously recannalised IRA has provided a TIMI 3 flow , it is equivalent to well done job of natural thrombus aspiration by a hidden hand and catheter . Consciously respect that .Most cardiologists would have realised atleaset once , that any aggression on a God handled IRA can be counterproductive !
Is there a non academic angle to this issue ?
Undoubtedly yes , strangely inspite of a positive phenomenon for the patient , recannalised IRA leads to a difficult debate in cath lab .Suddenly , the entire collective scientific wisdom of the cardiologist is put into a stress test. There is direct fight between reality , expectations .True patient benefits , obligations to hospitals , the parasitic relations with device industry , do have a big say !
Practicing cardiology is simple , but when scientific and non scientific realities of life are in direct confrontation with patient welfare it becomes a huge struggle and only a determined few can win over this infinite fight against conscience !