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Nemani L. Practical Approach to Diagnosis, Prevention, and Management of Coronary No-Reflow. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2023. [DOI: 10.25259/ijcdw_18_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Coronary no-reflow (NR) defined as inadequate myocardial perfusion despite restoration of coronary artery patency is a bane for an interventional cardiologist. It can complicate percutaneous coronary interventions especially in the setting of STEMI and dampens the potential benefits of PPCI. Broadly classified as Reperfusion NR and Interventional NR, mechanism is multifactorial. The basic underlying culprit is microvascular obstruction either secondary to distal embolization, intravascular plugging, or ischemic reperfusion injury. Coronary angiogram is an easy, readily available, and essential modality to diagnose no-reflow, but the gold standard is gadolinium-enhanced cardiovascular magnetic resonance imaging. Preventive strategies for NR should be integral part of prePCI planning especially in clinical scenario where NR is expected such as STEMI with delayed presentation and high thrombus burden, atherectomy, and SVG PCI. The cornerstone of treatment for NR is local vasodilators and antiplatelet therapy to ameliorate vasospasm and thromboembolism respectively, and different combinations of the two should be used in no specific order to achieve reversal of NR. NR phenomenon is associated with poor short-term and long-term prognosis and every attempt should be made to avoid or reverse it. Therapeutic hypothermia, hyperoxemic reperfusion therapy, targeted anti-inflammatory approach, and cellular approach appear proising but further research is mandatory.
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Affiliation(s)
- Lalita Nemani
- Department of Cardiac Sciences, Dr. Ismail Surgical Center, Dubai, United Arab Emirates,
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2
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Pantea-Roșan LR, Bungau SG, Radu AF, Pantea VA, Moisi MI, Vesa CM, Behl T, Nechifor AC, Babes EE, Stoicescu M, Gitea D, Iovanovici DC, Bustea C. A Narrative Review of the Classical and Modern Diagnostic Methods of the No-Reflow Phenomenon. Diagnostics (Basel) 2022; 12:diagnostics12040932. [PMID: 35453980 PMCID: PMC9029120 DOI: 10.3390/diagnostics12040932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 02/06/2023] Open
Abstract
The incidence of the no-reflow (NR) phenomenon varies depending on the diagnostic criteria used. If just the angiographic criteria are considered (i.e., a degree of thrombolysis in myocardial infarction ≤2), it will be found that the incidence of NR is quite low; on the other hand, when the myocardial NR is taken into account (i.e., a decrease in the quality of myocardial reperfusion expressed by the degree of myocardial blush), the real incidence is higher. Thus, the early establishment of a diagnosis of NR and the administration of specific treatment can lead to its reversibility. Otherwise, regardless of the follow-up period, patients with NR have a poor prognosis. In the present work, we offer a comprehensive perspective on diagnostic tools for NR detection, for improving the global management of patients with arterial microvasculature damage, which is a topic of major interest in the cardiology field, due to its complexity and its link with severe clinical outcomes.
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Affiliation(s)
- Larisa Renata Pantea-Roșan
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Simona Gabriela Bungau
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Andrei-Flavius Radu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Vlad Alin Pantea
- Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Mădălina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Tapan Behl
- Department of Pharmacology, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India;
| | - Aurelia Cristina Nechifor
- Analytical Chemistry and Environmental Engineering Department, Polytechnic University of Bucharest, 011061 Bucharest, Romania;
| | - Elena Emilia Babes
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Diana Carina Iovanovici
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
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3
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Dil SV, Vyshlov EV, Ryabov VV. Intracoronary epinephrine and verapamil in the refractory no-reflow phenomenon in patients with acute myocardial infarction. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-2936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Despite modern advances in performing percutaneous coronary interventions, refractory no-reflow remains a serious problem that worsens in-hospital and long-term prognosis. Low-dose adrenaline may exhibit potent beta-receptor agonist properties that mediate coronary vasodilation.Aim. To evaluate the efficacy and safety of intracoronary administration of epinephrine and verapamil, as well as their combination, compared with standard treatment in patients with ST-segment elevation myocardial infarction (STEMI) and refractory no-reflow during percutaneous coronary interventions.Material and methods. Patients with STEMI and refractory no-reflow will be randomized into 4 groups: standard therapy, intracoronary adrenaline, intracoronary verapamil, intracoronary epinephrine + verapamil. All patients will be assessed for epicardial blood flow using the Thrombolysis in Myocardial Infarction (TIMI) and Myocardial Blush Grade (MBG) scales, peak troponin levels, ST segment changes, echocardiography, magnetic roesnance imaging, and dynamic single photon emission computed tomography.Results. Based on the pharmacodynamic effects of epinephrine and verapamil, their combination is expected to have a more potent vasodilating effect.Conclusion. If the Intracoronary administration of EPInephrine and VERapamil in the refractory no-reflow phenomenon (EPIVER) study will be successful, a novel, more effective method for managing refractory no-reflow phenomenon will appear. This will ensure better preservation of left ventricular systolic function, as well as improve the prognosis and clinical course of the disease.
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Affiliation(s)
- S. V. Dil
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - E. V. Vyshlov
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - V. V. Ryabov
- Cardiology Research Institute, Tomsk National Research Medical Center
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Rasalingam R, Novak E, Rifkin RD. Improved differential diagnosis of intracardiac and extracardiac shunts using acoustic intensity mapping of saline contrast studies. Eur Heart J Cardiovasc Imaging 2019; 21:307-317. [DOI: 10.1093/ehjci/jez129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/15/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The aim of this study was to test the hypothesis that temporal patterns of saline contrast entry into, and exit from the left heart are significantly different in intra- and extra-cardiac shunts and can be used to differentiate the shunt mechanism when Valsalva manoeuvre cannot be performed, or is of uncertain quality. We propose a novel approach of mapping the temporal changes in acoustic intensity (AI) within the left and right heart to identify and define these unique patterns.
Methods and results
We screened cases of right to left shunting on resting agitated saline contrast echocardiograms with clinical criteria that identified the origin of shunting as either a patent foramen ovale or pulmonary arteriovenous malformation. Acoustic time-intensity curves were generated from the right and left heart chambers that reflected the change in saline contrast density over time. Several novel pre-specified parameters were measured from these curves, in addition to the standard heartbeat counting method, to characterize the entrance (wash-in) and exit (wash-out) patterns of saline contrast in the left heart. Statistical analysis showed that AI mapping provided superior differentiation of the two populations than did the traditional beat counting method.
Conclusion
Diagnosis of shunt mechanism from saline contrast studies can be improved over current methods through the use of AI mapping to define the rapidity that peak contrast effect develops, the speed that the contrast effect decays, and the contrast intensity late in the recording.
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Affiliation(s)
- Ravi Rasalingam
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
| | - Eric Novak
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
| | - Robert D Rifkin
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
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Min SY, Song JM, Shin Y, Sin MJ, Kim DH, Kang DH, Song JK. Quantitative segmental analysis of myocardial perfusion to differentiate stress cardiomyopathy from acute myocardial infarction: A myocardial contrast echocardiography study. Clin Cardiol 2017; 40:679-685. [PMID: 28430369 DOI: 10.1002/clc.22714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Both stress cardiomyopathy (SCMP) and acute myocardial infarction (AMI) present with similar clinical symptoms and signs, and apical akinesis. HYPOTHESIS Quantitative segmental analysis of myocardial contrast echocardiography (MCE) helps to differentiate AMI from SCMP. METHODS Real-time MCE was performed in 33 consecutive patients who presented with an acute symptom/sign and a new apical akinesis on echocardiography. In 18 left ventricular (LV) myocardial segments, a replenishment curve was obtained in each segment to measure peak plateau myocardial contrast intensity (MCI) (A) and the replenishment curve slope (β). The calibrated MCI was also measured in each segment. RESULTS Among 33 patients, 22 were diagnosed with SCMP and 11 were diagnosed with AMI according to comprehensive diagnostic criteria. A, β, Aβ, and the calibrated MCI were lower in akinetic than in normokinetic segments in both the SCMP and AMI groups. In the akinetic segments, A, β, Aβ, and the calibrated MCI in SCMP patients were each higher than those in AMI patients. In patient-based analyses, areas under the ROC curves of A, β, Aβ, and the calibrated MCI for diagnosing AMI were 0.769, 0.607, 0.822, and 0.934, respectively. The optimal cutoff values to diagnose AMI were Aβ < 3.7 dB/sec (sensitivity 82%, specificity 82%) and a calibrated MCI < -23 dB (sensitivity 91%, specificity 95%). CONCLUSIONS Although myocardial perfusion is relatively reduced in the akinetic segments of SCMP, a quantitative segmental analysis of myocardial perfusion using MCE helps to discriminate AMI from SCMP.
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Affiliation(s)
- Sun-Yang Min
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong-Min Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yewon Shin
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Min-Jung Sin
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae-Hee Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Hyun Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Guo Y, Du GQ, Xue JY, Xia R, Wang YH. A novel myocardium segmentation approach based on neutrosophic active contour model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2017; 142:109-116. [PMID: 28325439 DOI: 10.1016/j.cmpb.2017.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Automatic delineation of the myocardium in echocardiography can assist radiologists to diagnosis heart problems. However, it is still challenging to distinguish myocardium from other tissue due to a low signal-to-noise ratio, low contrast, vague boundary, and speckle noise. The purpose of this study is to automatically detect myocardium region in left ventricle myocardial contrast echocardiography (LVMCE) images to help radiologists' diagnosis and further measurement on infarction size. METHODS The LVMCE image is firstly mapped into neutrosophic similarity (NS) domain using the intensity and homogeneity features. Then, a neutrosophic active contour model (NACM) is proposed and the energy function is defined by the NS values. Finally, the ventricle is detected using the curve evolving results. The ventricle's boundary is identified as the endocardium. To speed up the evolution procedure and increase the detection accuracy, a clustering algorithm is employed to obtain the initial ventricle region. The curve evolution procedure in NACM is utilized again to obtain the epicardium, where the initial contour uses the detected endocardium and the anatomy knowledge on the thickness of the myocardium. RESULTS Echocardiographic studies are performed on 10 male Sprague-Dawley rats using a Vivid 7 system including 5 normal cases and 5 rats with myocardial infarction. The myocardium boundaries manually outlined by an experienced radiologist are used as the reference standard for the performance evaluation. Two metrics, Hdist and AvgDist, are employed to evaluate the detection results. The NACM method was compared with those from the eliminated particle swarm optimization (EPSO) and active contour model without edges (ACMWE) methods. The mean and standard deviation of the Hdist and AvgDist on endocardium are 6.83 ± 1.12mm and 0.79 ± 0.28mm using EPSO method, 7.12 ± 0.98mm and 0.82 ± 0.32mm using ACMWE method, and 4.55 ± 0.9mm and 0.58 ± 0.18mm using NACM method, respectively. The improvement on epicardium is much more significant, and two metrics are decreased from 7.45 ± 1.24mm, and 1.47 ± 0.34mm using EPSO method, and 8.21±0.43mm, and 1.73±0.47mm using ACMWE method, to 4.94 ± 0.82mm, and 0.84 ± 0.22mm using NACM method, respectively. CONCLUSIONS The proposed method can automatically detect myocardium accurately, and is helpful for clinical therapeutics to measure myocardial perfusion and infarct size.
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Affiliation(s)
- Yanhui Guo
- Department of Computer Science, University of Illinois at Springfield, Springfield, IL USA.
| | - Guo-Qing Du
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jing-Yi Xue
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rong Xia
- Oracle Corporation, Westminster, CO, USA
| | - Yu-Hang Wang
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Miyata-Fukuoka Y, Kawai H, Iseki O, Yamanaka Y, Ueda Y, Yokoyama M, Hirata KI. Myocardial blood volume reserve by intravenous contrast echocardiography predicts improvement in left ventricular function in patients with nonischemic dilated cardiomyopathy. J Echocardiogr 2016; 14:163-170. [PMID: 27394435 DOI: 10.1007/s12574-016-0302-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/20/2016] [Accepted: 06/28/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Impaired myocardial perfusion has been shown in nonischemic dilated cardiomyopathy (DCM). Intravenous myocardial contrast echocardiography (MCE) has been introduced to examine myocardial blood volume (MBV) noninvasively. This study was designed to evaluate if MBV reserve assessed by intravenous MCE with adenosine triphosphate (ATP) can predict efficacy of optimal medical therapy in patients with DCM. METHODS AND RESULTS Fifteen DCM patients and 8 control subjects underwent conventional echocardiography and intravenous MCE. We obtained the change in peak contrast integrated backscatter intensity (∆PI) by ATP on the left ventricular (LV) anteroseptal myocardium. After 3 months of optimal medical therapy in DCM patients, we reperformed conventional echocardiography. A good responder to therapy was defined as a decrease in LVDd >5 mm to final LVDd <55 mm and increase in LVEF >20 % to final LVEF >45 %. In DCM patients, ∆PI was lower compared to controls (p < 0.001). Good responders to therapy (n = 6) had higher ∆PI than poor responders (n = 9) (p < 0.05). CONCLUSIONS The present study demonstrates that the response to the medical therapy in DCM is predicted by the assessment of dilator reserve in MBV. Intravenous MCE with ATP may provide useful information to evaluate MBV reserve.
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Affiliation(s)
- Yoko Miyata-Fukuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroya Kawai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
- Department of Cardiology, Hyogo Brain and Heart Center, 520 Saisho-Ko, Himeji, Hyogo, 670-0981, Japan.
| | - Osamu Iseki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshio Yamanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshiaki Ueda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Mitsuhiro Yokoyama
- Department of Cardiology, Hyogo Brain and Heart Center, 520 Saisho-Ko, Himeji, Hyogo, 670-0981, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Yamada S, Komuro K, Taniguchi M, Uranishi A, Komatsu H, Asanuma T, Ishikura F, Onozuka H, Mikami T, Tsutsui H, Beppu S. A fundamental study for quantitative measurement of ultrasound contrast concentration by low mechanical index contrast ultrasonography. J Med Ultrason (2001) 2016; 33:77-83. [PMID: 27277725 DOI: 10.1007/s10396-006-0089-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 01/05/2006] [Indexed: 12/01/2022]
Abstract
PURPOSE In high mechanical index (MI) contrast ultrasonography it has been shown that the power of contrast signal intensity (CI) has a strong linear correlation with the concentration of the ultrasound contrast agent under conditions of constant applied acoustic pressure. However, it is unclear whether the linearity is preserved in low-MI contrast ultrasonography. Thus, we investigated the relationship between ultrasound contrast concentration and CI in vitro. METHODS Solutions of the ultrasound contrast agents Definity and Imagent were prepared at concentrations of 0.5, 2, 8, 32, and 128 μl/l. Placing a jelly block between the transducer and the solution, the solutions were transmitted using pulse subtraction imaging with an MI of 0.05, 0.1, and 0.5. CI was measured in dB in a region of interest 3 mm in height placed just below the border between the jelly and the solution. Data were plotted using double logarithm scales, where the concentration was expressed in dB as 10 × log (concentration). RESULTS CI in dB had a strong linear correlation with concentration in dB for both agents with any MI. Best fitted slopes were close to 1, indicating that the power of CI is proportional to the concentration. CONCLUSIONS In low-MI contrast ultrasonography, the power of CI is proportional to contrast concentration, and CI in dB is logarithmic to the concentration. Thus, the microbubble concentration can be quantitatively measured even in low-MI contrast ultrasonography.
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Affiliation(s)
- Satoshi Yamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita, Sapporo, 060-8638, Japan.
| | - Kaoru Komuro
- Department of Clinical Research, Hakodate National Hospital, Hakodate, Japan
| | - Mariko Taniguchi
- School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka, Japan
| | - Ayumi Uranishi
- School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka, Japan
| | - Hiroshi Komatsu
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita, Sapporo, 060-8638, Japan
| | - Toshihiko Asanuma
- School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka, Japan
| | - Fuminobu Ishikura
- School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka, Japan
| | - Hisao Onozuka
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita, Sapporo, 060-8638, Japan
| | - Taisei Mikami
- Department of Health Sciences, Hokkaido University School of Medicine, Sapporo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita, Sapporo, 060-8638, Japan
| | - Shintaro Beppu
- School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka, Japan
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Du GQ, Xue JY, Guo Y, Chen S, Du P, Wu Y, Wang YH, Zong LQ, Tian JW. Measurement of myocardial perfusion and infarction size using computer-aided diagnosis system for myocardial contrast echocardiography. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2466-2477. [PMID: 26048775 DOI: 10.1016/j.ultrasmedbio.2015.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 02/19/2015] [Accepted: 04/21/2015] [Indexed: 06/04/2023]
Abstract
Proper evaluation of myocardial microvascular perfusion and assessment of infarct size is critical for clinicians. We have developed a novel computer-aided diagnosis (CAD) approach for myocardial contrast echocardiography (MCE) to measure myocardial perfusion and infarct size. Rabbits underwent 15 min of coronary occlusion followed by reperfusion (group I, n = 15) or 60 min of coronary occlusion followed by reperfusion (group II, n = 15). Myocardial contrast echocardiography was performed before and 7 d after ischemia/reperfusion, and images were analyzed with the CAD system on the basis of eliminating particle swarm optimization clustering analysis. The myocardium was quickly and accurately detected using contrast-enhanced images, myocardial perfusion was quantitatively calibrated and a color-coded map calibrated by contrast intensity and automatically produced by the CAD system was used to outline the infarction region. Calibrated contrast intensity was significantly lower in infarct regions than in non-infarct regions, allowing differentiation of abnormal and normal myocardial perfusion. Receiver operating characteristic curve analysis documented that -54-pixel contrast intensity was an optimal cutoff point for the identification of infarcted myocardium with a sensitivity of 95.45% and specificity of 87.50%. Infarct sizes obtained using myocardial perfusion defect analysis of original contrast images and the contrast intensity-based color-coded map in computerized images were compared with infarct sizes measured using triphenyltetrazolium chloride staining. Use of the proposed CAD approach provided observers with more information. The infarct sizes obtained with myocardial perfusion defect analysis, the contrast intensity-based color-coded map and triphenyltetrazolium chloride staining were 23.72 ± 8.41%, 21.77 ± 7.8% and 18.21 ± 4.40% (% left ventricle) respectively (p > 0.05), indicating that computerized myocardial contrast echocardiography can accurately measure infarct size. On the basis of the results, we believe the CAD method can quickly and automatically measure myocardial perfusion and infarct size and will, it is hoped, be very helpful in clinical therapeutics.
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Affiliation(s)
- Guo-Qing Du
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jing-Yi Xue
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yanhui Guo
- School of Science, St. Thomas University, Miami Gardens, Florida, USA
| | - Shuang Chen
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pei Du
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yan Wu
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yu-Hang Wang
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li-Qiu Zong
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jia-Wei Tian
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China.
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Abstract
It is now possible to perform myocardial contrast echocardiography at the bedside with an intravenous injection of commercially available contrast media. Although myocardial contrast echocardiography is a sensitive method for the detection of coronary stenosis and myocardial viability, its diagnosis has relied largely on the subjective interpretation of regional perfusion by experienced clinicians. Thus, quantification of myocardial contrast echocardiography data and displaying comprehensive images have been necessary for its routine application. In this review, new methods for quantifying or displaying myocardial contrast echocardiography parameters will be introduced: firstly, parametric imaging that displays the parameters of myocardial blood volume, blood flow velocity and myocardial blood flow separately; and secondly, color-coded maps of myocardial blood volume established from one myocardial contrast echocardiography image. These quantitative techniques can provide comprehensive and easy-to-understand images, although the quality of the baseline image remains a critical factor.
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Affiliation(s)
- Hiroshi Ito
- Sakurabashi Watanabe Hospital, Division of Cardiology, Kita-ku, Osaka 530-0001, Japan.
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11
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Ito H. Etiology and Clinical Implications of Microvascular Dysfunction in Patients With Acute Myocardial Infarction. Int Heart J 2014; 55:185-9. [DOI: 10.1536/ihj.14-057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hiroshi Ito
- Department of Cardiovascular Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Field of Functional Physiology, Okayama University
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Tang MX, Mulvana H, Gauthier T, Lim AKP, Cosgrove DO, Eckersley RJ, Stride E. Quantitative contrast-enhanced ultrasound imaging: a review of sources of variability. Interface Focus 2011; 1:520-39. [PMID: 22866229 PMCID: PMC3262271 DOI: 10.1098/rsfs.2011.0026] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 04/26/2011] [Indexed: 12/14/2022] Open
Abstract
Ultrasound provides a valuable tool for medical diagnosis offering real-time imaging with excellent spatial resolution and low cost. The advent of microbubble contrast agents has provided the additional ability to obtain essential quantitative information relating to tissue vascularity, tissue perfusion and even endothelial wall function. This technique has shown great promise for diagnosis and monitoring in a wide range of clinical conditions such as cardiovascular diseases and cancer, with considerable potential benefits in terms of patient care. A key challenge of this technique, however, is the existence of significant variations in the imaging results, and the lack of understanding regarding their origin. The aim of this paper is to review the potential sources of variability in the quantification of tissue perfusion based on microbubble contrast-enhanced ultrasound images. These are divided into the following three categories: (i) factors relating to the scanner setting, which include transmission power, transmission focal depth, dynamic range, signal gain and transmission frequency, (ii) factors relating to the patient, which include body physical differences, physiological interaction of body with bubbles, propagation and attenuation through tissue, and tissue motion, and (iii) factors relating to the microbubbles, which include the type of bubbles and their stability, preparation and injection and dosage. It has been shown that the factors in all the three categories can significantly affect the imaging results and contribute to the variations observed. How these factors influence quantitative imaging is explained and possible methods for reducing such variations are discussed.
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Affiliation(s)
- M.-X. Tang
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
| | - H. Mulvana
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - T. Gauthier
- Department of Experimental Medicine and Toxicology, Hammersmith Hospital, Imperial College London, London W12 0NN, UK
| | - A. K. P. Lim
- Hammersmith Hospital, MRC Clinical Sciences Centre, Faculty of Medicine, Imperial College London, London W12 0NN, UK
| | - D. O. Cosgrove
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - R. J. Eckersley
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - E. Stride
- Department Mechanical Engineering, University College London, London WC1E 7JE, UK
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Caskey CF, Hu X, Ferrara KW. Leveraging the power of ultrasound for therapeutic design and optimization. J Control Release 2011; 156:297-306. [PMID: 21835212 DOI: 10.1016/j.jconrel.2011.07.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/21/2011] [Indexed: 12/19/2022]
Abstract
Contrast agent-enhanced ultrasound can facilitate personalized therapeutic strategies by providing the technology to measure local blood flow rate, to selectively image receptors on the vascular endothelium, and to enhance localized drug delivery. Ultrasound contrast agents are micron-diameter encapsulated bubbles that circulate within the vascular compartment and can be selectively imaged with ultrasound. Microbubble transport-based estimates of local blood flow can quantify changes resulting from anti-angiogenic therapies and facilitate differentiation of angiogenic mechanisms. Microbubbles that are conjugated with targeting ligands attach to endothelial surface receptors that are upregulated in disease, providing high signal-to-noise ratio images of pathological vasculature. In addition to imaging applications, microbubbles can be used to enhance localized gene and drug delivery, either by changing membrane and vascular permeability or by carrying and locally releasing cargo. Our goal in this review is to provide an overview of the use of contrast-enhanced ultrasound methodologies in the design and evaluation of therapeutic strategies with emphases on quantitative blood flow mapping, molecular imaging, and enhanced drug delivery.
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Affiliation(s)
- Charles F Caskey
- Department of Biomedical Engineering, University of California, Davis, One Shields Ave, Davis, CA 95616, USA
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15
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Ito H. The no-reflow phenomenon associated with percutaneous coronary intervention: its mechanisms and treatment. Cardiovasc Interv Ther 2010; 26:2-11. [DOI: 10.1007/s12928-010-0034-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Indexed: 11/28/2022]
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16
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Sboros V, Tang MX. The assessment of microvascular flow and tissue perfusion using ultrasound imaging. Proc Inst Mech Eng H 2010; 224:273-90. [PMID: 20349819 DOI: 10.1243/09544119jeim621] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Imaging microvascular flow is of diagnostic value for a wide range of diseases including cancer, inflammation, and cardiovascular disease. The introduction of microbubbles as ultrasound contrast agents offers significant signal enhancement to the otherwise weakly scattered signal from blood in the circulation. Microbubbles provide maximum impedance mismatch, but are not linear scatterers. Their complex response to ultrasound has generated research on both their behaviour and their scattered-signal processing. Nearly 20 years ago signal processing started with simple spectral filtering of harmonics showing contrast-enhanced images. More recent pulse encoding techniques have achieved good cancellation of tissue echoes. The good quality contrast-only images enabled ultrasound contrast-imaging applications to be established in microvascular measurements in the liver and the myocardium. The field promises to advance the quantification of microvascular flow kinetics.
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Affiliation(s)
- V Sboros
- Medical Physics, University of Edinburgh, Edinburgh, UK.
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17
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Tang MX, Kamiyama N, Eckersley RJ. Effects of nonlinear propagation in ultrasound contrast agent imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:459-66. [PMID: 20133035 DOI: 10.1016/j.ultrasmedbio.2009.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 11/12/2009] [Accepted: 11/24/2009] [Indexed: 05/12/2023]
Abstract
This paper investigates two types of nonlinear propagation and their effects on image intensity and contrast-to-tissue ratio (CTR) in contrast ultrasound images. Previous studies have shown that nonlinear propagation can occur when ultrasound travels through tissue and microbubble clouds, making tissue farther down the acoustic path appear brighter in pulse inversion (PI) images, thus reducing CTR. In this study, the effect of nonlinear propagation through tissue or microbubbles on PI image intensity and CTR are compared at low mechanical index. A combination of simulation and experiment with SonoVue microbubbles were performed using a microbubble dynamics model, a laboratory ultrasound system and a clinical prototype scanner. The results show that, close to the bubble resonance frequency, nonlinear propagation through a bubble cloud of a few centimeter thickness with a modest concentration (1:10000 dilution of SonoVue microbubbles) is much more significant than through tissue-mimicking material. Consequently, CTR in regions distal to the imaging probe is greatly reduced for nonlinear propagation through the bubble cloud, with as much as a 12-dB reduction compared with nonlinear propagation through tissue-mimicking material. Both types of nonlinear propagation cause only a small change in bubble PI signals at the bubble resonance frequency. When the driving frequency increases beyond bubble resonance, nonlinear propagation through bubbles is greatly reduced in absolute values. However because of a greater reduction in nonlinear scattering from bubbles at higher frequencies, the corresponding CTR is much lower than that at bubble resonance frequency.
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Affiliation(s)
- Meng-Xing Tang
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, UK.
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18
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Yamaki T, Iwai-Takano M, Yaoita H, Ogawa K, Tajima H, Takeishi Y, Maruyama Y. Participation of mast cells in angiogenesis in the border zone of myocardial infarction in rats. J Med Ultrason (2001) 2009; 36:119-27. [PMID: 27277224 DOI: 10.1007/s10396-009-0229-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 06/02/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND We hypothesized that mast cells may participate in coronary angiogenesis in acute myocardial infarction, contributing to myocardial salvage. METHODS The left coronary artery was occluded in control (n = 30) and Ws rats (n = 30), which genetically lacked c-kit, resulting in a mast cell deficiency. Four weeks later, the infarct area, i.e., infarct core and surrounding infarct areas, and the non-infarct area were assessed histopathologically. The mast cell and small vessel densities were assessed using toluidine blue and alkaline phosphatase staining. Myocardial perfusion was assessed by myocardial contrast echocardiography (MCE). RESULTS In Ws rats, the percentage infarct core area increased (p < 0.05) compared with the controls, whereas the percentage surrounding infarct area decreased (p < 0.01). Mast cell density increased most in the surrounding infarct area (p < 0.01) in control rats, whereas mast cells were absent in Ws rats. Compared with the controls, coronary microvessel density decreased in the surrounding infarct area in Ws rats (p < 0.01). MCE showed that the percentage infarct core area, i.e., perfusion defect, increased (p < 0.05) and the percentage surrounding infarct area, i.e., reduced perfusion area, decreased (p < 0.01) in Ws rats. CONCLUSION Mast cells may participate in promoting coronary angiogenesis in the infarct area surrounding the infarct core, contributing to attenuation of left ventricular dysfunction.
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Affiliation(s)
- Takayoshi Yamaki
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
| | - Masumi Iwai-Takano
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan.
| | - Hiroyuki Yaoita
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
| | - Kazuei Ogawa
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
| | - Hiroko Tajima
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
| | - Yasuchika Takeishi
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
| | - Yukio Maruyama
- Department of Cardiology and Hematology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan
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Coronary Microcirculatory Dysfunction in Aortic Stenosis: Myocardial Contrast Echocardiography Study. Ann Thorac Surg 2009; 87:715-9. [DOI: 10.1016/j.athoracsur.2008.11.078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 11/21/2008] [Accepted: 11/24/2008] [Indexed: 11/23/2022]
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Sakuma T, Motoda C, Tokuyama T, Oka T, Tamekiyo H, Okada T, Otsuka M, Okimoto T, Toyofuku M, Hirao H, Muraoka Y, Ueda H, Masaoka Y, Hayashi Y. Exogenous adenosine triphosphate disodium administration during primary percutaneous coronary intervention reduces no-reflow and preserves left ventricular function in patients with acute anterior myocardial infarction: a study using myocardial contrast echocardiography. Int J Cardiol 2008; 140:200-9. [PMID: 19081151 DOI: 10.1016/j.ijcard.2008.11.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 09/21/2008] [Accepted: 11/08/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unknown whether adenosine triphosphate disodium (ATP) administration during primary percutaneous coronary intervention (PCI) is useful in anterior acute myocardial infarction (AMI). METHODS The study was a prospective, non-randomized, open-label trial. Primary PCI was successfully performed in 204 consecutive patients with first anterior AMI. ATP at a mean dose of 117 microg/kg/min for 45 min on an average was infused intravenously during PCI in 100 patients (Group 1). In the other 104 patients, normal saline was administered (Group 2). ST-segment resolution (STR) was estimated 90 min after recanalization. The no-reflow ratio was measured 2 weeks later, using intravenous myocardial contrast echocardiography. Left ventricular ejection fraction (LVEF), LV regional wall motion (LVRWM), and LV end-diastolic volume index (LVEDVI) were measured 6 months later. RESULTS Baseline patient characteristics of the two groups were similar, including TIMI risk scores. Significant STR (> or =50% resolution compared to baseline) (66% versus 50%; Group 1 versus Group 2, p=0.02), no-reflow ratio (24% versus 34%, indicated by mean values, p=0.02), LVEF (61% versus 55%, p=0.0007), LVRWM (-1.56 versus -2.05, using the SD/chord, p=0.0001), and LVEDVI (60 ml/m(2) versus 71 ml/m(2), p=0.0007) were significantly better in Group 1, and the no-reflow ratio, LVEF, LVRWM and LVEDVI were significantly better in ATP-administered patients, regardless of antecedent angina or advanced age. ATP Administration was consistently identified as a significant determinant for STR, no-reflow ratio, LVEF, LVRWM, and LVEDVI. CONCLUSIONS Intravenous ATP administration during reperfusion is an independent determinant of STR and the no-reflow ratio, and LVEF, LVRWM, and LVEDVI at 6 months after primary PCI.
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Affiliation(s)
- Tadamichi Sakuma
- Division of Cardiology, Cardiovascular Center, Akane Foundation Tsuchiya General Hospital, Hiroshima, Japan.
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21
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Li W, Tanaka K, Morioka K, Takamori A, Handa M, Yamada N, Ihaya A. Long-term effect of gene therapy for chronic ischemic myocardium using platelet-derived endothelial cell growth factor in dogs. J Gene Med 2008; 10:412-20. [PMID: 18196499 DOI: 10.1002/jgm.1156] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND We previously reported the 2-week benefits of platelet-derived endothelial cell growth factor (PD-ECGF) gene therapy in chronically ischemic myocardium. However, the long-term effects and safety using this gene have not been reported. METHODS Chronic myocardial ischemia was created in 24 dogs by stenosing the origin of the left anterior descending coronary artery (LAD) using an ameroid constrictor. Two weeks later, the PD-ECGF gene, the LacZ gene, or saline was infused directly into the myocardium in the LAD area. The myocardial blood volume and myocardial function were examined prior to ischemia, immediately before gene injection, and for 6 months following injection, and then the organs were harvested for histological and molecular examination. RESULTS PD-ECGF gene treatment significantly attenuated endocardial infarction at 6 months. Myocardial blood volume and myocardial function decreased in all three groups after ameroid implantation, but recovered after 2 weeks in the PD-ECGF-treated group, and maintained a higher level of function during the examination period. Histological analysis demonstrated that angiogenesis and arteriogenesis occurred after PD-ECGF gene treatment. There was a decreased expression of the pro-apoptotic proteins, active caspase-3 and Bax, and the number of apoptotic myocardial cells was lower in the PD-ECGF-treated group. Histological examination demonstrated that no abnormal histological changes or neoplasms were found in any organs. CONCLUSIONS We conclude that gene targeting of ischemic myocardium using PD-ECGF generated long-term improvement in cardiac function by causing angiogenesis, arteriogenesis and inhibiting apoptosis, but did not induce neoplasms in the remote organs, and may be a promising therapy.
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Affiliation(s)
- Wei Li
- Second Department of Surgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.
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22
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Yoshifuku S, Chen S, McMahon E, Korinek J, Yoshikawa A, Ochiai I, Sengupta PP, Belohlavek M. Parametric detection and measurement of perfusion defects in attenuated contrast echocardiographic images. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:739-48. [PMID: 17526605 DOI: 10.7863/jum.2007.26.6.739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Attenuation of radio frequency (RF) signals limits the use of contrast echocardiography. The harmonic-to-fundamental ratio (HFR) of the RF signals compensates for attenuation. We tested whether HFR analysis measures the left ventricular nonperfused area under simulated experimental attenuation. METHODS Radio frequency image data from short axis systolic projections were obtained from 11 open-chest dogs with left anterior descending or left circumflex coronary artery occlusion followed by left atrial bolus injection of a perflutren microbubble contrast agent. Clinical attenuation was simulated by calibrated silicone pads interposed between the epicardial surface and the transducer to induce mild (7-dB) and severe (14-dB) reduction of the backscattered RF signals. Harmonic-to-fundamental ratio values were calculated for each image pixel for 0-, 7-, and 14-dB attenuation conditions and reproducibly showed a "perfused area" and a "nonperfused area." A reference nonperfused area was obtained by manual delineation in high-quality contrast scans. RESULTS Correlations of the HFR-detected and manually outlined perfusion defect areas were R = 0.92 for 0 dB, R = 0.94 for 7 dB, and R = 0.90 for 14 dB; the mean difference was less than 0.36 cm(2) (negligible) in all 3 attenuation settings. Conclusions. Attenuation compensation by our HFR method allows precise measurement of myocardial perfusion defect areas in contrast scans with simulated high level of attenuation.
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Affiliation(s)
- Shiro Yoshifuku
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Yoshifuku S, Chen S, McMahon EM, Yoshikawa A, Sengupta P, Korinek J, Belohlavek M. Parametric harmonic-to-fundamental ratio contrast echocardiography: a novel approach to identification and accurate measurement of left ventricular area under variable levels of ultrasound signal attenuation. ULTRASONICS 2007; 46:109-18. [PMID: 17276474 PMCID: PMC2034328 DOI: 10.1016/j.ultras.2006.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 12/08/2006] [Accepted: 12/12/2006] [Indexed: 05/13/2023]
Abstract
OBJECTIVES We introduced a harmonic-to-fundamental ratio (HFR) of the radiofrequency (RF) signals that reduces confounding effects of attenuation. We studied whether HFR analysis of RF signals received from contrast microbubbles allows accurate measurement of the left ventricular (LV) cavity area under varying levels of attenuation. BACKGROUND Attenuation is a fundamental problem in ultrasound imaging and limits the use of clinical echocardiography. METHODS RF data from short axis systolic and diastolic scans were obtained from 14 open-chest dogs following left-atrial bolus of Optison. Attenuation was induced by interposed silicone pads calibrated to induce 7dB or 14dB reductions of the backscattered RF signal. RF images were reconstructed from the RF signals, HFR values calculated for each image pixel for 0dB, 7dB and 14dB attenuation conditions, and LV area obtained by summation of "LV cavity pixels". A reference LV cavity area was obtained from endocardial border tracings in enhanced scans by experts. RESULTS Correlation of the HFR-defined and reference areas at systole was R=0.95, R=0.94, and R=0.91 for 0dB, 7dB and 14dB levels of attenuation, respectively, and at diastole was R=0.95 for 0dB, 7dB and 14dB levels of attenuation. The mean difference from both systolic and diastolic values was <1.45 cm(2) (i.e. negligible) in all attenuation settings. CONCLUSION Our novel HFR method supports precise measurement of the LV cavity area in contrast images with simulated high attenuation of ultrasound signals.
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Affiliation(s)
- Shiro Yoshifuku
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Shigao Chen
- Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Eileen M. McMahon
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Akiko Yoshikawa
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Partho Sengupta
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Josef Korinek
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Marek Belohlavek
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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Abstract
Myocardial contrast echocardiography (MCE) is a noninvasive imaging technique that relies on the ultrasound detection of microbubble contrast agents. These agents are confined to the intravascular space thereby producing signal enhancement from the blood pool. This review encompasses many of the key concepts regarding the clinical application of MCE. The first section focuses on the composition, safety, and biokinetics of ultrasound contrast agents. Then we discuss new ultrasound imaging methodology that has been developed to enhance detection of contrast agent and to assess perfusion at the tissue level. Next, the clinical applications of contrast ultrasound are reviewed. These include enhancement of the cardiac chambers for better assessment of cardiac function and masses, myocardial perfusion imaging for the detection of coronary artery disease, and the assessment of myocardial viability and microvascular reflow. Finally, we discuss some of the future applications for MCE, which include molecular imaging of disease and drug/gene delivery. The overall aim of the review is to update the clinician on state-of-the-art MCE and how it can be applied in patients with cardiovascular disease.
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Trindade MLZH, Caldas MA, Tsutsui JM, Rosario MA, Rochitte CE, Nicolau JC, Ramires JAF, Mathias W. Determination of size and transmural extent of acute myocardial infarction by real-time myocardial perfusion echocardiography: a comparison with magnetic resonance imaging. J Am Soc Echocardiogr 2007; 20:126-35. [PMID: 17275697 DOI: 10.1016/j.echo.2006.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The exact determination of acute myocardial infarction (AMI) extent is still a challenging issue. Quantitative myocardial perfusion echocardiography (MPE) with parametric imaging (PI) and gray scale (GS) has been shown to accurately measure infarcted area in animals, but not in human beings. We sought to validate MPE quantification of transmural extent and size of AMI using magnetic resonance imaging (MRI) as a gold standard. METHODS Twenty patients (12 men, 64 +/- 13 years) underwent MPE and MRI between the second and fifth day post-AMI. Infarct area and location, number of involved segments, and transmural extent in each segment were determined by PI using beta value and GS. Results were compared with late enhanced MRI. RESULTS There was 99% agreement between both methods regarding the segmental location. The correlation between infarct area by MRI and GS was 0.82 (P < .001) whereas MRI and beta PI was 0.92 (P < .001). The correlation between transmural extent by MRI and GS was 0.77 (P < .001), and between MRI and beta PI was 0.93 (P < .001). CONCLUSION There was a good correlation between MPE, in special beta PI, with MRI in measuring infarcted area and its transmural extent in patients with AMI.
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Affiliation(s)
- Maria L Z H Trindade
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Ito H, Komura N, Iwakura K, Kawano S, Okamura A, Fujii K. Combination study of myocardial perfusion and left ventricular filling provides an excellent prediction of clinical outcomes in patients with reperfused myocardial infarction. Basic Res Cardiol 2007; 101:400-7. [PMID: 16915527 DOI: 10.1007/s00395-006-0619-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The no reflow phenomenon and left ventricular (LV) diastolic dysfunction are surrogate markers of poor outcomes in patients with myocardial infarction (MI). We studied the relationship between contrast perfusion defects and restrictive filling patterns for predicting prognosis after MI. Mitral inflow velocity and myocardial contrast perfusion were studied 2 weeks after reperfusion in 226 consecutive patients with acute MI. The cohort was divided into two groups according to the number of perfusion defect segments (PD); large-PD and small-PD. Mitral inflow was classified into two categories according to deceleration time; non-restrictive and restrictive. The patients were divided into 4 groups (small-PD/non-restrictive, n = 124; small-PD/restrictive, n = 29; large-PD/non-restrictive, n = 50; large-PD/restrictive, n = 23). LV end-diastolic volume index was the greatest and cardiac event rate was the highest in large-PD/restrictive, followed by large- PD/non-restrictive, small-PD/restrictive, and by small- PD/non-restrictive (81 +/- 19 vs. 74 +/- 17 vs. 66 +/- 19 vs. 59 +/- 15 ml/m2, events: 61 % vs. 16% vs. 14% vs. 8 %). Multivariate analysis revealed the large-PD is the most powerful predictive factor related to cardiac events (odds ratio = 5.5, P = 0.004) followed by the restrictive filing pattern (4.3, P = 0.005). Co-existence of large-PD and restrictive filling is a strong predictor of adverse outcomes in the patients with MI.
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Affiliation(s)
- H Ito
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan.
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Ito H. No-reflow phenomenon and prognosis in patients with acute myocardial infarction. ACTA ACUST UNITED AC 2006; 3:499-506. [PMID: 16932767 DOI: 10.1038/ncpcardio0632] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 06/06/2006] [Indexed: 12/29/2022]
Abstract
The rapid restoration of coronary flow to the jeopardized myocardium has become an essential part of therapy after acute myocardial infarction. Despite an open infarct-related artery, breakdown of or obstruction to coronary microvasculature can markedly reduce blood flow to the infarct zone. This effect is known as the no-reflow phenomenon. Advances in imaging modalities have improved visualization of no reflow, showing its frequency to be higher than was estimated by clinical judgment alone. This phenomenon is important because it correlates with infarct size and provides useful prognostic information. No reflow is associated with reduced left ventricular ejection fraction, left ventricular remodeling, and poor clinical outcomes, placing patients with this effect in a high-risk group among reperfused patients. The focus of reperfusion therapy is shifting towards improved myocardial perfusion, which could promote functional recovery of viable muscle, reduce infarct expansion, and increase the delivery of blood-borne components, thereby accelerating the healing process. Various pharmacologic interventions and catheter-based devices to retrieve embolic materials have been proposed. Further studies to improve understanding of the pathophysiology of microvascular dysfunction will, however, help in the further development of preventive and therapeutic strategies. In this article, I discuss in depth the data available on the no-reflow phenomenon.
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Affiliation(s)
- Hiroshi Ito
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan.
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Indermühle A, Vogel R, Meier P, Wirth S, Stoop R, Mohaupt MG, Seiler C. The relative myocardial blood volume differentiates between hypertensive heart disease and athlete's heart in humans. Eur Heart J 2006; 27:1571-8. [PMID: 16717078 DOI: 10.1093/eurheartj/ehl024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The adaptation of the myocardial microcirculation in humans to pathologic and physiologic stress has not been examined in vivo so far. We sought to test whether the relative blood volume (rBV) measured by myocardial contrast echocardiography (MCE) can differentiate between left ventricular (LV) hypertrophy (LVH) in hypertensive heart disease and athlete's heart. METHODS AND RESULTS Four groups were investigated: hypertensive patients with LVH (n = 15), semi-professional triathletes with LVH (n = 15), professional football players (n = 15), and sedentary control individuals without cardiovascular disease (n = 15). MCE was performed at rest and during adenosine-induced hyperaemia. The rBV (mL mL(-1)), its exchange frequency (beta, min(-1)), and myocardial blood flow (mL min(-1) g(-1)) were derived from steady state and refill sequences of ultrasound contrast agent. Hypertensive patients had lower rBV (0.093 +/- 0.013 mL mL(-1)) than triathletes (0.141 +/- 0.012 mL mL(-1), P < 0.001), football players (0.129 +/- 0.014 mL mL(-1), P < 0.001), and sedentary individuals (0.126 +/- 0.018 mL mL(-1), P < 0.001). Conversely, the exchange frequency (beta) was significantly higher in hypertensive patients (11.3 +/- 3.8 min(-1)) than in triathletes (7.4 +/- 1.8 min(-1)), football players (7.7 +/- 2.3 min(-1)), and sedentary individuals (9.0+/-2.5 min(-1)). An rBV below 0.114 mL mL(-1) distinguished hypertensive patients and triathletes with a sensitivity of 93% and a specificity of 100%. CONCLUSION Pathologic and physiologic LVH were differentiated non-invasively and accurately by rBV, a measure of vascularisation assessed by MCE.
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Affiliation(s)
- Andreas Indermühle
- Department of Cardiology, University Hospital Bern, CH-3010 Bern, Switzerland
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Okamura A, Ito H, Iwakura K, Kawano S, Kurotobi T, Date M, Inoue K, Ogihara T, Fujii K. Effect of reactive hyperemia after coronary recanalization on myocardial tissue reperfusion by thrombolysis in myocardial infarction flow grade in acute myocardial infarction. Am J Cardiol 2006; 97:617-23. [PMID: 16490424 DOI: 10.1016/j.amjcard.2005.09.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2005] [Revised: 09/20/2005] [Accepted: 09/20/2005] [Indexed: 10/25/2022]
Abstract
Thrombolysis In Myocardial Infarction (TIMI) flow grade is widely used to evaluate myocardial tissue reperfusion in acute myocardial infarction (AMI), but the current grading system is incomplete. Therefore, we clarified the regulation of epicardial coronary flow velocity with the progression of microvascular dysfunction in AMI. We studied 36 patients with first anterior AMI. After intervention, we assessed TIMI flow grade and measured average peak velocity (APV) at baseline and after infusion of adenosine triphosphate (48 microg; baseline and hyperemic APVs, respectively) with a Doppler guidewire. We performed myocardial contrast echocardiography after 2 weeks to assess microvascular integrity (good reflow vs no reflow) and left ventriculography at admission and discharge (24 +/- 2 days) to measure regional wall motion (SD/chord). Patients were classified into 3 groups based on TIMI flow grade and microvascular integrity: TIMI grade 3 flow/good reflow (n = 16), TIMI grade 3 flow/no reflow (n = 12), and TIMI grade 2 flow (n = 8). Baseline APV was comparable in the patients with TIMI grade 3 flow but hyperemic APV was higher in patients with TIMI grade 3 flow/good reflow than in those with TIMI grade 3 flow/no reflow (hyperemic APV 59.3 +/- 25.8 vs 32.8 +/- 8.9 cm/s, p <0.01). All patients with TIMI grade 2 flow showed no reflow and the lowest values of baseline and hyperemic APVs. Regional wall motion at discharge was higher in patients with TIMI grade 3 flow/good reflow than in those with TIMI grade 3 flow/no reflow and TIMI grade 2 flow (-1.44 +/- 0.70, -2.69 +/- 0.31, and -2.88 +/- 0.48 SD/chord, respectively, p <0.01). In conclusion, compensatory reactive hyperemia preserves epicardial coronary flow velocity even in patients with microvascular damage, and with the progression of damage, this compensatory hyperemia can no longer preserve epicardial coronary flow velocity, and baseline APV is decreased in TIMI grade 2 flow.
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Affiliation(s)
- Atsunori Okamura
- Division of Cardiology, Sakurabashi Watanabe Hospital, Watanabe, Japan
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Ito H. Quantitative Myocardial Contrast Echocardiography in Coronary Artery Disease. J Echocardiogr 2006. [DOI: 10.2303/jecho.4.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Micari A, Belcik TA, Balcells EA, Powers E, Wei K, Kaul S, Lindner JR. Improvement in microvascular reflow and reduction of infarct size with adenosine in patients undergoing primary coronary stenting. Am J Cardiol 2005; 96:1410-5. [PMID: 16275189 DOI: 10.1016/j.amjcard.2005.06.090] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 06/28/2005] [Accepted: 06/28/2005] [Indexed: 01/11/2023]
Abstract
The aim of this study was to use myocardial contrast echocardiography to evaluate the effect of intravenous adenosine on microvascular reflow in patients with acute myocardial infarction who underwent primary coronary stenting (PCS). Thirty patients who underwent primary PCS for acute myocardial infarction were randomized to intravenous adenosine (50 to 70 mug/kg/min) or vehicle for 3 hours. Myocardial contrast echocardiography was performed before and sequentially after PCS to determine the risk area during coronary occlusion and infarct size. The risk area was similar in the adenosine- and placebo-treated patients. The infarct size as a ratio to the risk area was smaller in patients treated with adenosine when measured at 3 to 5 days (0.37 +/- 0.29 vs 0.68 +/- 0.25, p <0.01) and at 4 weeks (0.34 +/- 0.26 vs 0.60 +/- 0.21, p <0.01) after PCS. This effect was greatest when patency was achieved <4 hours after symptom onset (0.18 +/- 0.18 vs 0.74 +/- 0.31, p <0.05), with little effect after 4 hours. The relative microvascular blood volume in the risk area at 4 weeks was higher in patients receiving adenosine than in those receiving placebo (0.73 +/- 0.22 vs 0.57 +/- 0.20, p <0.01), and was highest when patency was achieved in <4 hours. In conclusion, the adjunctive use of intravenous adenosine after PCS reduces the infarct size relative to the risk area. This beneficial effect occurs primarily in those undergoing early intervention.
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Affiliation(s)
- Antonio Micari
- Cardiovascular Imaging Center, Cardiovascular Division, University of Virginia, Charlottesville, VA, USA
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Abstract
There is a complex relation between what can be seen using perfusion imaging techniques, and what can be measured.
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Bodí V, Sanchís J, Losada A, García D, Núñez J, Pellicer M, Millet J, Chorro FJ, Llácer À. Estudio de la perfusión coronaria postinfarto mediante análisis cuantitativo de la ecocardiografía miocárdica con inyección de contraste por vía intravenosa. Rev Esp Cardiol 2005. [DOI: 10.1157/13071887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Nishida Y, Ito H, Iwakura K, Tanaka K, Kawano S, Okamura A, Maekawa Y, Inoue K, Hori M, Fujii K. Tissue Inflammation Impairs Tissue-Level Perfusion and Promotes Left Ventricular Remodeling in Patients With Acute Myocardial Infarction. J Echocardiogr 2005. [DOI: 10.2303/jecho.3.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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35
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Demaria AN, Ben-Yehuda O, Berman D, Feld GK, Greenberg BH, Knoke JD, Knowlton KU, Lew WYW, Narula J, Sahn D, Tsimikas S. Highlights of the year in JACC2004. J Am Coll Cardiol 2005; 45:137-53. [PMID: 15629388 DOI: 10.1016/j.jacc.2004.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 11/15/2004] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony N Demaria
- Cardiology Division, University of California-San Diego, San Diego, California
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