1
|
Goswami NJ, Moody JM, Bailey SR. Percutaneous Mechanical Reperfusion During Acute Myocardial Infarction. J Intensive Care Med 2016. [DOI: 10.1177/0885066602017004002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The treatment of acute myocardial infarction has progressed from bedrest to mechanical, catheter-based reperfusion. The authors review the use of percutaneous coronary intervention (PCI) as a primary treatment for acute myocardial infarction and the use of adjunctive agents. The most recent American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for the use of PCI in ST segment elevation myocardial infarction (MI) advocate the use of PCI as primary therapy at those centers in which the procedure can be performed within accepted standards. Because a majority of hospitals (80%) do not have the capability of performing primary PCI, most patients are treated with thrombolytic therapy. PCI should be considered in those patients treated with thrombolytic therapy who have persistent or recurrent ischemia and/or cardiogenic shock. For patients with non-ST elevation MI, the use of an invasive strategy (early angiography and PCI if needed) has recently shown to be beneficial. Although revascularization is the basis of the acute therapy of MI, additional pharmacologic therapy in the acute setting is now recognized as a key to favorable long-term outcome.
Collapse
Affiliation(s)
- Nilesh J. Goswami
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Joe M. Moody
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX,
| | - Steven R. Bailey
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| |
Collapse
|
2
|
Niccoli G, Cosentino N, Crea F. Letter by Niccoli et al regarding article, "intracoronary versus intravenous administration of abciximab in patients with st-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration: the comparison of intracoronary versus intravenous abciximab administration during emergency reperfusion of st-segment elevation myocardial infarction (CICERO) trial". Circulation 2011; 124:e230; author reply e231. [PMID: 21859979 DOI: 10.1161/circulationaha.110.011262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
3
|
Funaro S, Galiuto L, Boccalini F, Cimino S, Canali E, Evangelio F, DeLuca L, Paraggio L, Mattatelli A, Gnessi L, Agati L. Determinants of microvascular damage recovery after acute myocardial infarction: results from the acute myocardial infarction contrast imaging (AMICI) multi-centre study. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:306-12. [PMID: 21367810 DOI: 10.1093/ejechocard/jer009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS Microvascular damage (MD) occurring soon after primary percutaneous coronary intervention (PPCI) may reverse or remain sustained within the first week after ST-elevation myocardial infarction (STEMI). We investigated the incidence, determinants, and long-term clinical relevance of MD reversal after PPCI. METHODS AND RESULTS Serial two-dimensional echocardiograms (2DE) and a myocardial contrast study were obtained within 24 h of PPCI (T1) and at pre-discharge (T2) in 110 successfully re-perfused STEMI patients. Six months 2DE and 2-year clinical follow-up were obtained. After PPCI myocardial re-perfusion was normal at T1 only in 40 patients (36%, 'normal reflow'), recovered at T2 in 33 (30%, 'reversible MD'), and remained abnormal in 37 (34%, 'sustained MD'). At follow-up, normal reflow and reversible MD were coupled with a significant reduction in the infarct area, decrease in cardiac volumes, and a slight non-significant improvement in systolic function. Conversely, in the sustained MD group, the infarct area did not change and cardiac volumes significantly increased with a parallel worsening in systolic function. By multivariate analysis, independent predictors of reversible MD were: absence of family history of coronary artery disease (CAD), younger age, shorter time to re-perfusion, and absence of diabetes. The 2-year combined events rate was significantly lower in reversible MD (log-rank test P= 0.03) compared with sustained MD patients. CONCLUSIONS In STEMI patients treated according to the current guidelines, MD frequently occurs soon after re-perfusion but it is reversible in ~50% of cases and it is associated with a favourable functional and clinical outcome. Family history of CAD, aging, time to re-perfusion, and diabetes are independent predictors of MD reversibility.
Collapse
Affiliation(s)
- Stefania Funaro
- Department of Cardiology, Catholic University of the Sacred Heart, Campobasso, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Abstract
Therapy for acute myocardial infarction has advanced dramatically since the early 1980s with the use of early intravenous fibrinolytic therapy. Combining low-dose fibrinolysis and platelet lysis appears to provide an additional increase in infarct-related artery (IRA) patency, but the large-scale mortality reduction trials evaluating this strategy are just getting under way. Recently, considerable attention has shifted away from the epicardial arteries to the microvasculature. Contemporary evidence suggests that epicardial patency does not necessarily translate to actual perfusion at the myocardial level. Techniques to evaluate beyond thrombolysis in myocardial infarction (TIMI) epicardial flow are now available and validated. In addition, there are promising treatments for the prevention or alleviation of certain forms of microvascular obstruction. This review attempts to clarify the confusion surrounding epicardial flow and "myocardial malperfusion" and to provide some insight into the next direction in acute myocardial infarction therapeutics.
Collapse
Affiliation(s)
- J P Gassler
- Department of Cardiology, Joseph J. Jacobs Center for Thrombosis and Vascular Biology, Cleveland Clinic Foundation, Ohio 44195, USA
| | | |
Collapse
|
5
|
Cho GY, Lee CW, Hong MK, Kang DH, Song JK, Kim JJ, Park SW, Park SJ. Rescue use of abciximab improves regional left ventricular function after early incomplete reperfusion in acute myocardial infarction. Clin Cardiol 2009; 24:197-201. [PMID: 11288964 PMCID: PMC6655055 DOI: 10.1002/clc.4960240305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Abciximab was shown to have important beneficial effects beyond the maintenance of epicardial coronary artery patency. However, it remains uncertain whether abciximab may lead to a better functional outcome in patients with acute myocardial infarction (AMI) and with incomplete reperfusion after primary angioplasty (PA). HYPOTHESIS The study aimed to evaluate whether rescue use of abciximab may lead to a better functional outcome in such patients. METHODS The study included 25 patients with first AMI who met the following criteria: (1) total occlusion of the infarct-related artery, (2) PA within 12 h of symptom onset, (3) postprocedural diameter stenosis < 30%, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2. Echocardiographic examination was performed before and on Days 7 and 30 after PA. The study population was divided into two groups: Group 1 (usual care, n = 13) and Group 2 (rescue use of abciximab, n = 12). Baseline characteristics were similar between the two groups. RESULTS Peak level of creatine kinase was higher in Group 1 than in Group 2 (5,800+/-2,700 vs. 3,800+/-2,000 U/I, p < 0.05). At 1 month follow-up, infarct zone wall motion score index (2.71+/-0.26 vs. 2.05+/-0.63, p < 0.01) and left ventricular (LV) volume indices were smaller in Group 2 than in Group 1, whereas LV ejection fraction was higher in Group 2 than in Group 1 (52.1+/-7.8 vs. 42.1+/-6.4, p < 0.01). At 1-month, abciximab was the only independent predictor of wall motion recovery index by multiple regression analysis. CONCLUSIONS Rescue use of abciximab may reduce the infarct size in patients with AMI and TIMI grade 2 flow after PA, which may improve the recovery of regional LV function.
Collapse
Affiliation(s)
- G Y Cho
- Department of Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Coser A, Franchi E, Marini M, Cemin R, Benini A, Beltrame F, Marini A, Pascotto M, Rognoni A, Ambrosio G, Marino PN. Intravenous contrast echocardiography after myocardial infarction: relationship among residual myocardial perfusion, contractile reserve and long-term remodelling. J Cardiovasc Med (Hagerstown) 2007; 8:1012-9. [DOI: 10.2459/jcm.0b013e32801da2bd] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
7
|
Temporal changes in TIMI myocardial perfusion grade in relation to epicardial flow, ST-resolution and left ventricular function after primary percutaneous coronary intervention. Coron Artery Dis 2007; 18:513-8. [DOI: 10.1097/mca.0b013e3282c1fdb6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Djaballah W, Muller MA, Angioï M, Moulin F, Codreanu A, Mandry D, Ethevenot G, Karcher G, Aliot E, Marie PY. Nitrate-enhanced gated SPECT in patients with primary angioplasty for acute myocardial infarction: evidence of a reversible and nitrate-sensitive impairment of myocardial perfusion. Eur J Nucl Med Mol Imaging 2007; 34:1981-90. [PMID: 17665196 DOI: 10.1007/s00259-007-0423-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 02/12/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Reperfusion of myocardial infarction (MI) leads to a reversible dysfunction of coronary vessels. We hypothesised that vasodilating drugs such as nitrates might improve sestamibi uptake within viable areas of recently reperfused MI, thereby enhancing prediction of subsequent improvements in perfusion and contractility. This study was aimed at assessing nitrate-enhanced sestamibi gated SPECT after MI reperfusion. METHODS Twenty-nine patients underwent rest followed by nitrate sestamibi gated SPECT at 9 +/- 3 days after primary angioplasty for acute MI and at follow-up, 4-10 months later. Four MBq/kg of (99m)Tc-sestamibi was injected at rest, and 12 MBq/kg after nitroglycerin spray. RESULTS Follow-up improvements were documented for both perfusion (P+) and contractility (C+) in 18% of the 180 initially abnormal segments, in neither perfusion (P-) nor contractility (C-) in 44%, in contractility only (C+P-) in 16% and in perfusion only (C-P+) in 22%. Perfusion improvement was related to lower sestamibi uptake on baseline rest SPECT (P+: 42 +/- 15% vs P-: 50 +/- 15%, p = 0.001) and, moreover, to a higher increase between rest and nitrate uptake (P+: +9.5 +/- 6.5% vs P-: +2.0 +/- 5.9%, p < 0.001). Contractility improvement was related to sestamibi uptake on baseline nitrate SPECT (C+: 58 +/- 15% vs C-: 38 +/- 16%, p < 0.001), a variable enhancing the prediction provided by sestamibi uptake at rest (p < 0.05). CONCLUSION The improvement in perfusion which is documented in the months following MI reperfusion is predicted by initial nitrate enhancement of sestamibi uptake, suggesting a mechanism of reversible vascular injury. In this particular setting, sestamibi uptake is a better predictor of contractility recovery when determined after nitrate administration rather than under conventional resting conditions.
Collapse
|
9
|
Evolución a medio plazo de la perfusión miocárdica y remodelado ventricular después del infarto agudo de miocardio. Rev Esp Cardiol 2007. [DOI: 10.1016/s0300-8932(07)75062-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
10
|
Galiuto L, Gabrielli FA, Lombardo A, La Torre G, Scarà A, Rebuzzi AG, Crea F. Reversible microvascular dysfunction coupled with persistent myocardial dysfunction: implications for post-infarct left ventricular remodelling. Heart 2006; 93:565-71. [PMID: 16980514 PMCID: PMC1955556 DOI: 10.1136/hrt.2006.091538] [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: 02/05/2023] Open
Abstract
BACKGROUND Recent studies have shown that microvascular dysfunction after myocardial infarction is a dynamic phenomenon. AIMS To evaluate the implications of dynamic changes in microvascular dysfunction on contractile recovery and left ventricular remodelling, and to identify the ideal timing of assessment of such microvascular dysfunction. METHODS AND RESULTS In 39 patients with a first myocardial infarction who underwent successful percutaneous coronary intervention, microvascular dysfunction was studied by myocardial contrast echocardiography (MCE) at 24 h, 1 week and 3 months after the procedure. Real-time MCE was performed by contrast pulse sequencing and intravenous Sonovue. 14 patients exhibited left ventricular remodelling at 3 months (>20% increase in left ventricular end-diastolic volume, group B), whereas 25 did not (group A). Microvascular dysfunction was similar in the two groups at 24 h and improved in group A only, being significantly better than that of group B at 1 week (p<0.05) and 3 months (p<0.005). Improvement in microvascular dysfunction was not associated with improvement in wall motion in the same segments. With multivariate analysis including all echocardiographic variables, microvascular dysfunction at 1 week was found to be the only independent predictor of left ventricular remodelling (p<0.01). With a cut-off value of 1.4, 1-week microvascular dysfunction predicts left ventricular remodelling with sensitivity and specificity of 73%. CONCLUSIONS Improvement in microvascular dysfunction occurs early after myocardial infarction, although it is not associated with a parallel improvement in wall motion but is beneficial in preventing left ventricular remodelling. Accordingly, 1-week microvascular dysfunction is a powerful and independent predictor of left ventricular remodelling.
Collapse
Affiliation(s)
- Leonarda Galiuto
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
11
|
Senior R. Diagnostic and imaging considerations: role of viability. Heart Fail Rev 2006; 11:125-34. [PMID: 16937031 DOI: 10.1007/s10741-006-9483-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Left ventricular systolic dysfunction is a recognised feature of heart failure. In developed nations, the leading cause of left ventricular systolic dysfunction is coronary artery disease. Revascularisation is a treatment strategy for patients with predominant symptoms of heart failure and significant left ventricular dysfunction. Presence or absence of myocardial viability has been shown to affect outcome after revascularisation. There are various techniques to assess myocardial viability. However, limitations of current literature, lack of completed randomised trials and high peri-procedural trials create significant uncertainty about the optimal strategy. This review focuses on the role of non-invasive testing for myocardial viability in patients with left ventricular systolic dysfunction and heart failure and also outlines the pros and cons of each technique.
Collapse
Affiliation(s)
- Roxy Senior
- Department of Cardiovascular Medicine, Northwick Park Hospital, Watford Road, Harrow Middlesex, HA1 3UJ, United Kingdom.
| |
Collapse
|
12
|
Laissy JP, Hyafil F, Huart V, Serfaty JM, Chillon S, Schouman-Claeys E, Faraggi M. Value of contrast-enhanced, balanced cine-MR sequences in the assessment of apparent infarct size after acute myocardial infarction: A prospective comparison with delayed-enhancement sequences. J Magn Reson Imaging 2005; 22:765-71. [PMID: 16270294 DOI: 10.1002/jmri.20443] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the diagnostic value of contrast-enhanced (CE) delayed cine steady-state free precession (SSFP) sequences in the assessment of apparent infarct size after acute myocardial infarction (MI). MATERIALS AND METHODS Contrast-enhanced (CE) balanced cine-SSFP sequences were compared with delayed-enhancement (DE) T1 sequences for their ability to detect segmental abnormal enhancement in 29 consecutive patients with recent successfully reperfused acute MI. RESULTS The extent of myocardial involvement revealed by postcontrast cine-SSFP sequences and DE images was closely correlated (Spearman r = 0.86, P < 0.001). There was no significant difference between the two sequences in assessing subendocardial or transmural involvement. CONCLUSION In addition to DE sequences, CE cine-SSFP sequences should play a role in assessing necrotic and jeopardized myocardium after acute MI.
Collapse
|
13
|
Song JM, Lee JH, Kim YH, Kang DH, Song JK, Hong MK, Park SW, Park SJ, Kim YH. Intravenous Versus Intracoronary Myocardial Contrast Echocardiography for Evaluation of No-Reflow After Primary Percutaneous Coronary Intervention. Echocardiography 2005; 22:818-25. [PMID: 16343164 DOI: 10.1111/j.1540-8175.2005.00125.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We sought to compare intravenous myocardial contrast echocardiography (IV-MCE) with intracoronary myocardial contrast echocardiography (IC-MCE) in detecting no-reflow and predicting the short-term outcome of left ventricular function after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). METHODS IC-MCE and IV-MCE were performed immediately after PCI (D1) of 28 patients with anterior wall AMI. IV-MCE was repeated at the next day of PCI (D2), and left ventricular systolic function was evaluated at D2 and 30 days later (D30). RESULTS There was good agreement between IC-MCE and IV-MCE at D1 in determining no-reflow (kappa= 0.78, P < 0.001) as well as between IV-MCE at D1 and D2 (kappa= 0.93, P < 0.001). The patients with no-reflow on IC-MCE (n = 13) and those on IV-MCE at D2 (n = 11) showed no improvement in left ventricular ejection fraction (LVEF) after 1 month (49 +/- 9% to 48 +/- 7%, P = 0.55, and 51 +/- 6% to 49 +/- 7%, P = 0.20). However, the patients with reflow on IC-MCE (n = 15) and those on IV-MCE at D2 (n = 17) demonstrated significant improvement in LVEF (55 +/- 6% to 62 +/- 5%, P < 0.005, and 53 +/- 7% to 60 +/- 8%, P < 0.005). In predicting segmental functional recovery after 1 month, sensitivity and specificity of IC-MCE were 85% and 67%, respectively, and those of IV-MCE at D2 were 95% and 40%, respectively. CONCLUSION IV-MCE at D2 might be substituted for IC-MCE performed immediately after PCI for the evaluation of no-reflow and prediction of left ventricular systolic function after 1 month in patients with anterior wall AMI.
Collapse
Affiliation(s)
- Jong-Min Song
- Division of Cardiology, Department of Internal Medicine, Asan [corrected] Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Aggeli C, Bonou M, Stefanadis C. Potential clinical applications of myocardial contrast echocardiography in evaluating myocardial perfusion in coronary artery disease. Int J Cardiol 2005; 104:1-9. [PMID: 16137502 DOI: 10.1016/j.ijcard.2004.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Revised: 10/28/2004] [Accepted: 11/07/2004] [Indexed: 11/30/2022]
Abstract
Myocardial contrast echocardiography (MCE) is a relatively new technique that uses microbubbles to produce myocardial opacification. Recent advances in echocardiography have resulted in improved detection of microbubbles within the myocardium allowing combined acquisition of function and perfusion data, thus making MCE suitable for bedside use. Regardless of the imaging modality chosen or the type of stress used, MCE detects changes developing in the coronary microcirculation, providing important information for the evaluation of severity of coronary artery disease and for the detection of viable myocardial tissue in acute or chronic coronary artery disease.
Collapse
Affiliation(s)
- Constadina Aggeli
- First Department of Cardiology, University of Athens, Hippokration Hospital, Athens, Greece.
| | | | | |
Collapse
|
15
|
Korosoglou G, Labadze N, Giannitsis E, Bekeredjian R, Hansen A, Hardt SE, Selter C, Kranzhoefer R, Katus H, Kuecherer H. Usefulness of real-time myocardial perfusion imaging to evaluate tissue level reperfusion in patients with non-ST-elevation myocardial infarction. Am J Cardiol 2005; 95:1033-8. [PMID: 15842966 DOI: 10.1016/j.amjcard.2004.12.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Revised: 12/16/2004] [Accepted: 12/16/2004] [Indexed: 12/25/2022]
Abstract
Microvascular integrity is a prequisite for functional recovery in patients who have myocardial infarction after recanalization of the infarct-related coronary artery. In this study, we investigated whether impaired myocardial perfusion is present in patients who have non-ST-elevation myocardial infarction and whether the extent and time course of myocardial tissue reperfusion as assessed by myocardial contrast echocardiography (MCE) are related to functional recovery. Consecutive patients (n = 32) who presented with a first non-ST-elevation myocardial infarction were included in our study. MCE was performed on admission, 1 to 4 hours after angioplasty, and at 24 hours, 4 days, and 4 weeks of follow-up. Contrast images were analyzed visually and quantitatively. Myocardial blood flow was estimated by calculating the product of peak signal intensity and the slope of signal intensity increase. Improvement of wall motion on follow-up echocardiograms after 4 weeks served as a reference for functional recovery of impaired left ventricular function. Of 496 segments available for analysis, 128 (26%) were initially dysfunctional and 96 (75%) recovered at 4 weeks of follow-up. Myocardial tissue reperfusion occurred gradually, expanding over the first 24 hours after percutaneous coronary intervention (myocardial blood flow of 0.4 +/- 0.3 initially, 0.6 +/- 0.4 at 24 hours, and 1.6 +/- 0.7 dB/s at 4 weeks of follow-up, p <0.001). Extent of tissue reperfusion was closely related to grade of improvement of global ejection fraction (r2 = 0.76, p <0.001). MCE predicted functional recovery with a sensitivity of 81%, a specificity of 88%, and accuracy of 83% on a segmental level. Thus, impaired microvascular integrity is suggested by MCE in patients who present with non-ST-elevation myocardial infarction. Improvement of regional tissue perfusion after revascularization is closely related to functional recovery. This information may aid risk stratification and allow monitoring of the effectiveness of reperfusion therapy in these patients.
Collapse
|
16
|
Abstract
MCE is a reliable, bedside technique for assessment of a patient with acute coronary syndrome. It can be used to estimate the myocardial risk-area and infarct size and to establish peri-infarct viability. This information is critical in both management decision-making and in assigning prognosis in the setting of acute coronary syndromes.
Collapse
Affiliation(s)
- Roxy Senior
- Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ, UK.
| | | | | |
Collapse
|
17
|
Pizzuto F, Voci P, Romeo F. Value of echocardiography in predicting future cardiac events after acute myocardial infarction. Curr Opin Cardiol 2003; 18:378-84. [PMID: 12960471 DOI: 10.1097/00001573-200309000-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Short- and long-term survival after acute myocardial infarction mainly depends on three factors: the amount of myocardium that had become necrotic, the area of myocardium at further risk of becoming necrotic, and the patency of the infarct-related artery. Echocardiography is a low-cost, safe, bedside, repeatable tool, particularly useful for prognostic stratification after myocardial injury. Two-dimensional echocardiography analyzes left ventricular function, the most powerful predictor of survival immediately after acute myocardial infarction. Myocardial contrast echocardiography measures the infarct size and detects viable myocardium. Stress echocardiography stratifies patients with viable myocardium and/or multivessel coronary artery disease who need further diagnostic and therapeutic interventions. Transthoracic coronary Doppler ultrasonography assesses effective recanalization and coronary flow reserve of the left anterior descending coronary artery. Further technologic advances are needed to allow direct noninvasive measurement of flow by transthoracic Doppler ultrasonography in other coronary arteries.
Collapse
Affiliation(s)
- Francesco Pizzuto
- Section of Cardiology I, School of Medicine I, La Sapienza University, Rome, Italy.
| | | | | |
Collapse
|
18
|
Galiuto L, Lombardo A, Maseri A, Santoro L, Porto I, Cianflone D, Rebuzzi AG, Crea F. Temporal evolution and functional outcome of no reflow: sustained and spontaneously reversible patterns following successful coronary recanalisation. Heart 2003; 89:731-7. [PMID: 12807843 PMCID: PMC1767736 DOI: 10.1136/heart.89.7.731] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To identify in humans the temporal patterns of no reflow and their functional implications. METHODS 24 patients with first acute myocardial infarction and successful coronary recanalisation by recombinant tissue-type plasminogen activator (n = 15) or primary percutaneous transluminal coronary angioplasty (n = 9) were studied by myocardial contrast echocardiography within 24 hours of recanalisation and at one month's follow up. Myocardial contrast echocardiography was performed by intermittent harmonic power Doppler and intravenous Levovist. The regional contrast score index (CSI) was calculated within dysfunctioning myocardium. Videointensity was measured (dB) within risk and control areas and their ratio was calculated. RESULTS In 8 patients reflow was observed at 24 hours and persisted at one month. Conversely in 16 patients areas of no reflow were detectable at 24 hours. At one month, no reflow was spontaneously reversible in 9 patients (mean (SD) CSI and videointensity ratio improved from 2.5 (0.5) to 1.4 (0.6) and from 0.6 (0.1) to 0.7 (0.1), respectively; p < 0.05) and was sustained in the remaining 7 patients (CSI and videointensity ratio remained unchanged from 2.6 (0.6) to 2.6 (0.5) and from 0.5 (0.2) to 0.5 (0.2), respectively; NS). Left ventricular function improved significantly in patients with reflow and reversible no reflow. Volumes were enlarged only in patients with sustained no reflow. CONCLUSIONS No reflow detected at 24 hours may be sustained or spontaneously reversible at one month. Such reversibility of the phenomenon is associated with preserved left ventricular volumes and function. Clarification of the mechanisms of delayed reversibility may lead to tailored treatment of no reflow even in the subacute phase of myocardial infarction.
Collapse
Affiliation(s)
- L Galiuto
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy. Institute of Cardiology, Vita e Salute University, S. Raffaele Hospital, Milan, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Garot P, Pascal O, Simon M, Monin JL, Teiger E, Garot J, Guéret P, Dubois-Randé JL. Impact of microvascular integrity and local viability on left ventricular remodelling after reperfused acute myocardial infarction. Heart 2003; 89:393-7. [PMID: 12639866 PMCID: PMC1769279 DOI: 10.1136/heart.89.4.393] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess left ventricular remodelling in patients with reperfused acute myocardial infarction and to study its relation to microvascular damage. PATIENTS 25 patients successfully treated by primary percutaneous coronary angioplasty for acute myocardial infarction. SETTING University hospital METHODS Indexed end diastolic (EDVi) and end systolic (ESVi) volumes were assessed on admission and repeated at days 1 and 8. Coronary flow reserve (CFR) was assessed in the infarct related artery on day 1. Myocardial blood volume was assessed on admission and at day 8 by myocardial contrast echocardiography. In patients who manifested persistent myocardial dysfunction at hospital discharge (n = 21), local inotropic reserve was assessed by dobutamine echocardiography at day 7. RESULTS On admission, patients with and without local viability had similar EDVi and ESVi (EDVi 67 (9) and 73 (14) ml/m(2), respectively; ESVi 34 (8) and 40 (11) ml/m(2), respectively; NS). EDVi increased to 97 (22) ml/m(2) in patients without local viability (p < 0.01 v admission) but remained unchanged at 70 (11) ml/m(2) in patients with viable myocardium (NS v admission). For pooled patient data, the percentage change in EDVi correlated with CFR (r = 0.76, p < 0.0001) and myocardial blood volume in the infarct territory (r = 0.80, p < 0.0001). CONCLUSION Left ventricular dilatation may preferably occur in patients without local viability and is correlated with early CFR and extent of myocardial blood volume in the infarct territory.
Collapse
Affiliation(s)
- P Garot
- Fédération de Cardiologie, Hôpital Henri Mondor, Créteil, France.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Badano LP, Werren M, Di Chiara A, Fioretti PM. Contrast echocardiographic evaluation of early changes in myocardial perfusion after recanalization therapy in anterior wall acute myocardial infarction and their relation with early contractile recovery. Am J Cardiol 2003; 91:532-7. [PMID: 12615255 DOI: 10.1016/s0002-9149(02)03300-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Temporal changes in myocardial perfusion after recanalization and their relation with functional recovery in patients with acute myocardial infarction (AMI) using intravenous myocardial contrast echocardiography (MCE) have not yet been clarified. To address this issue, 19 patients with first, uncomplicated anterior wall AMI were studied using intravenous MCE within 24 hours of recanalization and before discharge. MCE was performed using harmonic power Doppler. Each asynergic left ventricular (LV) myocardial segment was scored for myocardial perfusion (1 = complete, 0.7 = patchy but >50%, 0.3 = patchy <50%, and 0 = absent) and a regional perfusion index was calculated within the dysfunctioning myocardium. During the day-1 study (11 +/- 2 hours from recanalization), the regional perfusion index was 0.4 +/- 0.3 and the LV wall motion score index was 1.9 +/- 0.2. During the study before discharge (7 +/- 4 days from admission), all but 2 patients showed an improvement of either perfusion index (0.6 +/- 0.3, p <0.0001) or wall motion score index (1.7 +/- 0.4, p <0.0001). Changes in perfusion score from 24-hours to before discharge showed a significant correlation with LV segment contractile recovery at 2-month of follow-up (R(2) = 0.42, 95% confidence interval 0.33 to 0.50, p <0.0001). Thus, our data show that after recanalized AMI, there is a significant amount of microvascular obstruction that recovers in the days after, and the extent of this perfusion improvement appears to be related with early myocardial contractile recovery. Our data provide clinical evidence for a transient microvascular dysfunction after successfully recanalized AMI.
Collapse
Affiliation(s)
- Luigi Paolo Badano
- Cardiovascular Science Department, Cardiology Unit, A.O. S Maria della Misericordia, Udine, Italy.
| | | | | | | |
Collapse
|
21
|
Palagi C, Mengozzi G, Rovai D, Volterrani D, Dell'Anna R, Giorgi D, Petronio AS, Di Bello V, Mariani M. Assessment of myocardial perfusion with intravenous contrast echocardiography: comparison with (99) Tc-tetrofosmin single photon emission computed tomography and dobutamine echocardiography. Echocardiography 2003; 20:37-45. [PMID: 12848696 DOI: 10.1046/j.1540-8175.2003.00005.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the study was to evaluate the accuracy of intermittent, harmonic power Doppler (HPD) during intravenous Levovist infusion in identifying myocardial perfusion abnormalities in patients with recent infarction. Fifty-five patients with first acute myocardial infarction, successfully treated by primary PTCA, were studied after 1 month by myocardial contrast echocardiography (MCE), 99mTc tetrofosmin single photon emission computed tomography (SPECT), and low dose dobutamine echocardiography (DE). Scoring myocardial perfusion as normal, moderately, or severely reduced; MCE and SPECT were in agreement in 71% of segments(k = 0.414). Discordance was mainly due to ventricular walls with normal enhancement by MCE and moderate perfusion abnormalities by SPECT. Scoring perfusion as present or absent, the agreement significantly improved up to 86% (k = 0.59). Sensitivity and specificity of HPD for identifying SPECT perfusion defects were 63% and 93%, respectively. The agreement between MCE and SPECT was higher(85%, k = 0.627)in patients with anterior infarction. An improvement in regional contractile function was noted after dobutamine in 79 dysfunctional segments. A normal perfusion or a moderate perfusion defect by MCE were detected in 71 of 79 of these segments, while a severe perfusion defect was observed in 59 of 85 ventricular segments without dobutamine-induced wall-motion improvement. Sensitivity and specificity by HPD in detecting segments with contractile reserve were 90% and 69%, respectively. Thus, intermittent HPD during Levovist infusion allows myocardial perfusion abnormalities to be detected in patients with recent infarction. This method has a limited sensitivity but a high specificity in detecting SPECT perfusion defects, and a good sensitivity but a limited specificity in detecting contractile reserve.
Collapse
|
22
|
Jesús Jiménez Borreguero L, Ruiz-Salmerón R. Valoración de la viabilidad miocárdica en pacientes prerrevascularización. Rev Esp Cardiol (Engl Ed) 2003. [DOI: 10.1016/s0300-8932(03)76943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
23
|
Shimada K, Sakanoue Y, Kobayashi Y, Ehara S, Hirose M, Nakamura Y, Fukuda D, Yamagishi H, Yoshiyama M, Takeuchi K, Yoshikawa J. Assessment of myocardial viability using coronary zero flow pressure after successful angioplasty in patients with acute anterior myocardial infarction. Heart 2003; 89:71-6. [PMID: 12482796 PMCID: PMC1767508 DOI: 10.1136/heart.89.1.71] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the relation between coronary flow reserve (CFR), coronary zero flow pressure (Pzf), and residual myocardial viability in patients with acute myocardial infarction. DESIGNS Prospective study. SETTING Primary care hospital. PATIENTS 27 consecutive patients with acute anterior myocardial infarction. MAIN OUTCOME MEASURES F-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 27 patients who underwent successful intervention within 12 hours of onset of a first acute anterior myocardial infarction. Within three days before discharge they had < 25% stenosis in the culprit lesion as determined by angiography 24 (3) days after acute myocardial infarction. Pzf and the slope index of the flow-pressure relation (SIFP) were calculated from the simultaneously recorded aortic pressure and coronary flow velocity signals at peak hyperaemia.%FDG was quantified by comparing FDG uptake in the infarct myocardium with FDG uptake in the normal myocardium. RESULTS There was a correlation between %FDG and CFR, where y = -1.477x + 62.517, r = -0.072 (NS). There was also a correlation between %FDG and SIFP, where y = -0.975x + 60.542, r = -0.045 (NS), and a significant correlation between %FDG and Pzf, where y = -0.98x + 85.108, r = -0.696 (p < 0.001). CONCLUSIONS CFR does not correlate with FDG-PET at the time of postreperfusion evaluation of residual myocardial viability. The parameter that correlates best with residual myocardial viability is Pzf and this may be a useful index for predicting patient prognosis.
Collapse
Affiliation(s)
- K Shimada
- Department of Internal Medicine and Cardiology Graduate School of Medicine, Osaka City University Medical School, Osaka, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Garot P, Pascal O, Simon M, El Amine S, Benacerraf S, Champagne S, Benaiem N, Mazoit JX, Hittinger L, Garot J, Dubois-Rande JL, Gueret P, Teiger E. Usefulness of combined quantitative assessment of myocardial perfusion and velocities by myocardial contrast and doppler tissue echocardiography during coronary blood flow reduction. J Am Soc Echocardiogr 2003; 16:1-8. [PMID: 12514628 DOI: 10.1067/mje.2003.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to characterize regional myocardial perfusion and contraction in a closed-chest swine model during and after coronary blood flow reduction using myocardial contrast and Doppler tissue echocardiography. METHODS AND RESULTS Regional myocardial perfusion was assessed by myocardial contrast echocardiography using the corrected contrast peak intensity (baseline-subtracted contrast peak intensity), the peak intensity ratio (contrast peak intensity in ischemic/control wall), and a transmural video-intensity gradient. Regional peak systolic velocities and strain rate were measured using M-mode color Doppler tissue echocardiography. In 12 pigs, coronary blood flow reduction resulted in a significant decrease in peak intensity ratio and in peak systolic velocities in the subendocardium. At baseline and during ischemia, corrected contrast peak intensity and peak systolic velocities in the subendocardium, video-intensity gradient, and strain rate were closely related (r = 0.88 and 0.93, respectively). After reperfusion, in contrast to peak systolic strain rate that remained altered, the peak intensity ratio and video-intensity gradient recovered nearly baseline values. CONCLUSION The combination of myocardial contrast and Doppler tissue echocardiography may distinguish between ischemic and postischemic myocardial wall dysfunction during severe coronary blood flow reduction.
Collapse
Affiliation(s)
- Philippe Garot
- Fédération de Cardiologie, INSERM U400, Hôpital Henri Mondor, AP-HP, Créteil, France.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
Identification of viable myocardium after acute myocardial infarction (MI) or in the setting of severe chronic ischemic heart disease has important clinical implications. Myocardial contrast echocardiography (MCE) has been used for the evaluation of myocardial viability by assessing myocardial perfusion and microvascular integrity. In acute MI, MCE can identify the no-reflow phenomenon after revascularization, which has significant implications regarding recovery of function and clinical outcomes. Serial changes in myocardial perfusion can also be evaluated for the prediction of ultimate recovery of function. In the setting of chronic ischemic left ventricular dysfunction, early studies have shown that MCE is helpful in the identification of myocardial hibernation and in the prediction of recovery of function after revascularization, with accuracy similar to radionuclide techniques. Preliminary studies using the new quantitative MCE parameters of myocardial blood flow and velocity derived from intravenous contrast administration appear to enhance the diagnostic accuracy of MCE in the evaluation of myocardial viability.
Collapse
Affiliation(s)
- William A Zoghbi
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas 77030, USA.
| |
Collapse
|
26
|
Garot P, Pascal O, Simon M, Monin JL, Dupouy P, Elbaz N, Teiger E, Garot J, Guéret P, Dubois-Randé JL. Time course and relation to local viability of microvascular function and volume after reperfused acute myocardial infarction. Am J Cardiol 2002; 89:1341-6. [PMID: 12062725 DOI: 10.1016/s0002-9149(02)02344-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We assessed the time course of the alterations of microvascular function and myocardial perfusion, as well their relation to local inotropic reserve (IR), in 21 patients who underwent successful primary coronary angioplasty for acute myocardial infarction and in whom local myocardial dysfunction persisted at hospital discharge. Coronary flow reserve (CFR) and myocardial perfusion were assessed immediately after angioplasty, and on day 1 and day 8 by intracoronary Doppler and myocardial contrast echocardiography, respectively. Dobutamine echocardiography was performed on day 7 for assessment of local IR. After angioplasty, CFR was severely altered in patients with (n = 14) and without (n = 7) IR (1.44 +/- 0.26 and 1.36 +/- 0.21, respectively; p = NS). Among patients with IR, CFR increased significantly at day 1 (2.26 +/- 0.62, p <0.005 vs acute stage) compared with those without IR (p = NS vs acute). In contrast, the extent of microvascular obstruction as defined by contrast echocardiography remained unchanged in all patients at day 1 compared with acute measurements. Microvascular obstruction decreased at day 8 in the sole subset of patients with local IR (p <0.05 vs acute stage). In patients treated by immediate coronary angioplasty for acute myocardial infarction, subsequent improvement of myocardial perfusion is associated with preexistent recruitable microvascular function in the infarct-related artery. The presence of reversible microvascular dysfunction at the early stage after acute myocardial infarction is associated with local tissue viability in humans.
Collapse
Affiliation(s)
- Philippe Garot
- Fédération de Cardiologie, Hôpital Henri Mondor, INSERM U400, Créteil, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Andrássy P, Zielinska M, Busch R, Schömig A, Firschke C. Myocardial blood volume and the amount of viable myocardium early after mechanical reperfusion of acute myocardial infarction: prospective study using venous contrast echocardiography. Heart 2002; 87:350-5. [PMID: 11907010 PMCID: PMC1767076 DOI: 10.1136/heart.87.4.350] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Myocardial capillary perfusion is a prerequisite of myocellular viability after reperfusion of acute myocardial infarction. It was hypothesised that the magnitude of myocardial capillary perfusion, assessed by transmural signal intensity in venous contrast echocardiography as a corollary of the blood volume of myocardial capillaries, and the amount of viable myocardium, represented by differential levels of contractile function two weeks after reperfusion, are correlated. OBJECTIVES To evaluate the role of venous contrast echocardiography for the identification of viable myocardium in patients with acute myocardial infarction early after successful mechanical reperfusion. METHODS 60 patients with a first acute myocardial infarction underwent venous contrast echocardiography several hours after successful mechanical reperfusion (median time interval 190 min.). The relative transmural videointensity (median (25th, 75th percentiles)) of akinetic segments was determined. After two weeks, contractile function was re-evaluated at rest and during dobutamine infusion if segments without functional recovery were present. RESULTS Relative videointensity early after reperfusion differed significantly between functional groups after two weeks: normokinesia (88% (77%, 100%)), hypokinesia (74% (54%, 99%)), and akinesia with (61% (48%, 76%)) and without contractile reserve (31% (22%, 46%)). Relative videointensity and contractile function were significantly correlated (r = -0.67). The diagnostic accuracy of relative videointensity > 50% for prediction of contractility of initially akinetic segments at rest or during dobutamine was 82% (chi2 = 76.2, p < 0.001). CONCLUSIONS Early after successful mechanical reperfusion of acute myocardial infarction, the magnitude of capillary perfusion in the perfusion territory of an infarct related artery is correlated with the amount of viable myocardium. Quantitative venous contrast echocardiography can be used for accurate identification of viable myocardium.
Collapse
Affiliation(s)
- P Andrássy
- Deutsches Herzzentrum München, Lazarettstrasse 36, D-80636 Munich, Germany
| | | | | | | | | |
Collapse
|
28
|
Affiliation(s)
- S R Dixon
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | | |
Collapse
|
29
|
Swinburn JM, Lahiri A, Senior R. Intravenous myocardial contrast echocardiography predicts recovery of dysynergic myocardium early after acute myocardial infarction. J Am Coll Cardiol 2001; 38:19-25. [PMID: 11451273 DOI: 10.1016/s0735-1097(01)01317-1] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We aimed to ascertain whether triggered intravenous myocardial contrast echocardiography (MCE) can predict functional recovery in patients with acute myocardial infarction (AMI) and to determine the optimal triggering interval in this setting. BACKGROUND Detection of myocardial viability early after AMI has both therapeutic and prognostic implications. Myocardial contrast echocardiography using intracoronary injections of contrast can detect viable myocardium, but there is little data on the use of recently developed intravenous MCE techniques for this purpose. METHODS Ninety-six patients with recent AMI (4.8 +/- 1.7 days) underwent echocardiography at baseline and six months later or three months after revascularization to determine regional function (score 1 = normal to 3 = akinetic). Myocardial contrast echocardiography was performed at baseline using intravenous injections of Optison. Triggering intervals of 1:1 (early) and 1:10 (delayed) cardiac cycles were used. Segments were deemed viable if they demonstrated homogeneous contrast opacification. RESULTS Of 400 akinetic segments at baseline, 109 (27%) improved during the follow-up period, and 375 (94%) were adequately visualized with MCE, of which 59 (16%) were homogeneously opacified by early and 125 (33%) by delayed MCE (negative predictive value for recovery of contractile function 74% and 84%, positive predictive value 29% and 47%, respectively). Independent predictors of functional recovery were delayed MCE (odds ratio [OR]: 4.0, p < 0.001), revascularization (OR: 6.0, p < 0.001), and log creatine kinase (OR: 0.5, p = 0.03). However, the presence or absence of >90% stenosis of the infarct-related artery did not influence the ability of triggered MCE to predict functional recovery. CONCLUSIONS Intravenous delayed triggered MCE can independently detect myocardial viability early after AMI.
Collapse
Affiliation(s)
- J M Swinburn
- Department of Cardiac Research, Northwick Park Hospital, Harrow, United Kingdom
| | | | | |
Collapse
|
30
|
Ugolini P, Delouche A, Herment A, Diebold B. In vitro quantification of flow using continuous infusion of Levovist and pairs of harmonic power Doppler images. ULTRASOUND IN MEDICINE & BIOLOGY 2001; 27:637-642. [PMID: 11397528 DOI: 10.1016/s0301-5629(01)00358-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
To evaluate the potential of harmonic power Doppler to quantify perfusion using a continuous infusion of contrast, two dialysis cartridges were perfused with different flow rates adjusted between 0 to 300 mL/min, corresponding to flow ratios comprised between 300:0 and 150:150. The contrast agent (Levovist, Schering) was injected at constant rates (0.6 to 5 g/h). Sequential pairs of images showing simultaneously the cross-sections of the two filters were acquired with a HDI 5000 (ATL) and the Doppler data were processed with HDI lab software (ATL). The absolute values of the signal in the different regions-of-interest (ROI) were not closely related to flow rate. At the opposite, the rapid signal decrease between the first and the second image of each pair was inversely proportional to the flow rate. An index of perfusion [PerI = image 1/(image 1 -- image 2)] was defined. It correlated closely with the absolute and relative flow rates. For the latter, the slopes of regression were found to be independent of the infusion rate of Levovist. Thus, the use of pairs of images combined with a continuous infusion of Levovist provide a quantification of perfusion.
Collapse
Affiliation(s)
- P Ugolini
- INSERM U494 and Department of Cardiology, Hopital Européen Georges Pompidou, Paris, France
| | | | | | | |
Collapse
|
31
|
Rovai D, Morales MA, Amyot R, L'Abbate A. Clinical experience with SonoVue in myocardial perfusion imaging. Echocardiography 2000; 17:S17-23. [PMID: 11058235 DOI: 10.1111/j.1540-8175.2000.tb01190.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Ultrasound-enhancing agents have the potential to evaluate myocardial perfusion, adding a new dimension to echocardiography. This article summarizes the clinical studies involving SonoVue, a new intravenous ultrasound contrast agent, in assessing myocardial perfusion. Safe and well tolerated, SonoVue coupled with echocardiography has the capability to identify perfusion abnormalities, as confirmed by scintigraphic imaging. While the optimal modalities for ultrasound perfusion assessment are not yet determined, numerous technical advances have been introduced: continuous infusion or slow intravenous administration of the agent, harmonic intermittent imaging, pulse inversion, background subtraction, color coding, and others. SonoVue is a promising new agent in the booming field of myocardial contrast echocardiography.
Collapse
Affiliation(s)
- D Rovai
- CNR, Clinical Physiology Institute, Via Savi, 8, 56126 Pisa, Italy.
| | | | | | | |
Collapse
|
32
|
Lepper W, Hoffmann R, Kamp O, Franke A, de Cock CC, Kühl HP, Sieswerda GT, Dahl JV, Janssens U, Voci P, Visser CA, Hanrath P. Assessment of myocardial reperfusion by intravenous myocardial contrast echocardiography and coronary flow reserve after primary percutaneous transluminal coronary angioplasty [correction of angiography] in patients with acute myocardial infarction. Circulation 2000; 101:2368-74. [PMID: 10821812 DOI: 10.1161/01.cir.101.20.2368] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery. METHODS AND RESULTS Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the "no-reflow" region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR >/=1.6; n=17) and a nonrecovery group (CFR <1.6; n=8). Baseline CFR did not differ between groups. MCE ratio to the risk region was smaller in the recovery group compared with the nonrecovery group (34+/-49% vs 81+/-46%, P=0.009). A ratio to the risk region of </=50% defined an MCE reperfusion group. It was associated with improvement of CFR from 1.67+/-0.47 at baseline to 2. 15+/-0.53 at 24 hours (P<0.001) and of regional wall motion score index from 2.6+/-0.5 to 1.9+/-0.5 at 4 weeks (P<0.001). CONCLUSIONS Intravenous MCE can be used to define perfusion defects after AMI. Assessment of microcirculation by MCE corresponds to evaluation by CFR. Serial intravenous MCE has the potential to identify patients likely to have improved left ventricular function after AMI.
Collapse
Affiliation(s)
- W Lepper
- Medical Clinic I, University RWTH, Aachen, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
Treatment for ST-elevation myocardial infarction (MI) has advanced rapidly in the last few years with improvements in early fibrinolytic therapy, primary percutaneous revascularization, and use of potent platelet glycoprotein IIb/IIIa inhibitors. It is now obvious that establishing epicardial patency after myocardial infarction is not synonymous with tissue-level perfusion. Techniques and therapies are now available that measure true tissue-level perfusion and that may improve tissue-level perfusion after myocardial infarction.
Collapse
Affiliation(s)
- D Mukherjee
- Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | |
Collapse
|