Recanalization versus reperfusion for myocardial survival and preservation of ventricular geometry, ,

This article reviews the factors affecting myocardial ischemia and necrosis beyond coronary obstruction and in particular those related to the function of microcirculation and to the vulnerability of myocardial cells to deprivation as well as to restoration of blood flow. An effort has been spent to distinguish microcirculatory alterations during ischemia, after reversible ischemia, after irreversible ischemia, and in the presence of coronary atherosclerosis, independent of ischemia. Results show that the microcirculation plays a significant role in the production of ischemia and necrosis as well as in the modulation of the effect of large-vessel recanalization. The mechanisms, nature, and reversibility of microcirculatory changes cannot be generalized. They differ under different conditions and are poorly understood. The links of the chain plaque-microcirculation-myocardial cells cannot be separated; an integrated approach is needed to better understand and treat ischemic heart disease. (Am Heart J 1999;138:S89-S95.)