Predictive value of ischemic mitral regurgitation during the acute phase of ST elevation myocardial infarction treated with primary coronary intervention for left ventricular remodeling in long-term follow-up

Left ventricular reverse remodeling in patients with anterior wall ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention

Introduction

The study aimed to evaluate the prevalence and predictors of left ventricular (LV) reverse remodeling and its impact on long-term prognosis in patients with anterior ST-segment elevation myocardial infarction (STEMI).

Aim

To assess the percentage of reverse remodeling and its prognostic factors in anterior STEMI patients.

Material and methods

This observational study included 40 patients with first ever STEMI of the anterior wall. LV reverse remodeling was defined as the reduction of left ventricular end-systolic volume (ΔLVESV) by ≥ 10% in 3D transthoracic echocardiography (3D-TTE) at 3-month follow-up. 3D-TTE and speckle tracking imaging were performed during index hospitalization, while 3D-TTE and cardiac magnetic resonance (CMR) were performed at 3 months following the procedure. Patients were followed up for a median time of 3.4 years in order to evaluate major adverse cardiovascular events.

Results

Left ventricular reverse remodeling at 3-month follow-up was confirmed in 15 (37.5%) patients. The presence of reverse remodeling was predicted by lower troponin levels (unit OR = 0.86, p = 0.02), lower sum of ST-segment elevations before (unit OR = 0.87, p = 0.03) and after PCI (unit OR = 0.40, p = 0.03), lower maximal ST-segment elevation after PCI (unit OR = 0.01, p = 0.03), lower wall motion score index (unit OR 0.40, p = 0.03) and more negative anterior wall global longitudinal strain (unit OR = 0.88, p = 0.045). Nine MACE were reported in the without reverse remodeling group only. Non-significantly better event-free survival in the reverse remodeling group was demonstrated (log-rank p = 0.07).

Conclusions

Development of reverse modeling in patients with optimal revascularization and tailored pharmacotherapy is relatively high. Further studies are warranted in order to adjudicate its prognostic role for the prediction of adverse events.

Prognostic Significance of Ischemic Mitral Regurgitation on Outcomes in Acute ST-Elevation Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention

Ischemic mitral regurgitation (IMR) has been associated with worse outcome myocardial infarction. However, severity of mitral regurgitation (MR) and its impact on patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) remains unknown. We sought to determine impact of increasing severity of IMR on outcomes in patients with STEMI undergoing primary PCI. All patients presenting with STEMI who underwent primary PCI within 12 hours of symptoms from 1994 to 2014 were included. IMR was graded from 0 to 4+ within 3 days of index myocardial infarction by echocardiography. Overall, 4,005 patients with STEMI were included. None, 1+, 2+, 3+, and 4+ MR were present in 3,200 (79.9%), 427 (10.7%), 260 (6.5%), 91 (2.3%), and 27 (0.7%) patients, respectively. On multivariate logistic regression analysis, more severe MR was associated with older age, female gender, lower body mass index, anemia, inferior STEMI, and longer door-to-balloon time. The 30-day mortality rates were 6.8%, 7.3%, 8.8%, 19.8%, and 26.1%, respectively, with increasing grade of MR. The 1-year mortality rates were 10.8%, 12.4%, 20.8%, 37.4%, and 37.1%, whereas 5-year mortality rates were 16.2%, 23.1%, 36.5%, 53.8%, and 63%, respectively (p <0.001 all), for none to 4+ MR. After adjusting for age, gender, co-morbidities, ejection fraction, and shock by multivariate analysis, severity of IMR was associated with incremental effect on long-term mortality (hazard ratios of 1.42, 1.83, 2.41, and 2.95 for 1+ to 4+ MR respectively, p <0.01 for all). In conclusion, higher grades of MR in patients with STEMI undergoing primary PCI are associated with worse short- and long-term outcomes.

Outcomes of ischaemic mitral regurgitation in anterior versus inferior ST elevation myocardial infarction

Background

Ischaemic mitral regurgitation (IMR) is a detrimental complication of ST elevation myocardial infarction (STEMI).

Objective

We sought to determine patient characteristics and outcomes of patients with IMR with focus on anterior or inferior location of STEMI.

Methods

All patients presenting with STEMI complicated by IMR to our centre who underwent primary percutaneous coronary intervention within the first 12 hours of presentation from 1995 to 2014 were included. IMR was graded from 1+ to 4+ within 3 days of index myocardial infarction by echocardiography, divided into 2 groups based on infarct location and outcomes were compared.

Results

Overall, 805 patients were included. There were 302 (17.8%) patients with mitral regurgitation (MR) out of the 1700 patients with anterior STEMI while 503 (21.8%) had MR out of the 2305 patients with inferior STEMI. There was no significant difference between both groups in comorbidities, clinical presentation or door-to-balloon time (DBT; median 104 vs 106 min, p=0.5). 30-day and 1-year mortality were higher in anterior STEMI compared with inferior STEMI (14.9% vs 6.8% and 26.4% vs 14.3%, respectively, p<0.001 both), as well as 5-year mortality (39.7% vs 24.8%, p<0.01). When analysis was performed for each grade of IMR, anterior was associated with worse outcomes in every grade. On multivariate cox survival analysis, after adjustment for age, gender, comorbidities, grade of IMR, ejection fraction and DBT, anterior STEMI was still associated with worse outcomes (HR 1.62 (95% CI 1.23 to 2.12), p<0.001).

Conclusions

Although IMR occurs more frequently with inferior infarction, outcomes are worse following anterior infarction.

Prognostic importance of mitral regurgitation complicated by acute myocardial infarction during a 5-year follow-up period in the drug-eluting stent era

BACKGROUND

Mitral regurgitation (MR) is a frequent complication of left-ventricular dysfunction, with an incidence ranging from 13 to 59% after acute myocardial infarction (AMI), which is associated with poor clinical outcome. The aim of this study was to assess the clinical and angiographic characteristics associated with MR, the incidence and predictors of MR, and the outcomes of MR after AMI in those who were successfully treated with primary percutaneous coronary intervention (PCI) using a drug-eluting stent.

METHODS

We analyzed a multicenter all-comer AMI registry and identified 4748 patients between January 2004 and December 2009. Of these, 1894 patients were treated with PCI using a drug-eluting stent and had MR. The association between MR and the composite of major adverse cardiac and cerebrovascular events (MACCE; all-cause death, recurrent nonfatal myocardial infarction, stroke, and any revascularization) was examined.

RESULTS

Patients with MR after the index PCI showed significantly higher cumulative incidence of MACCE compared with no-MR patients over the 5-year survival period (P=0.002). When the MR groups were compared on the basis of the severity of MR, ranging from mild to severe grades, a higher grade of MR was found to be associated with a higher incidence of MACCE (P<0.001). Multivariate Cox proportional hazard analysis revealed that no reflow, left-ventricular ejection fraction less than 50%, and anemia, in addition to MR, were consistently associated with increased all-cause death during the 5-year period (adjusted hazard ratio 1.408, 95% confidence interval 1.052-1.884, P=0.021).

CONCLUSION

MR after AMI in patients successfully treated with primary PCI was associated with poor long-term outcome regardless of ST-segment elevation at diagnosis during the drug-eluting stent era.

Two-dimensional speckle-tracking echocardiography assessment of left ventricular remodeling in patients after myocardial infarction and primary reperfusion

INTRODUCTION

Left ventricular remodeling (LVR) is the most prognostically important consequence of acute myocardial infarction (AMI). The aim of the study was to assess the value of speckle tracking echocardiography in the prediction of left ventricular remodeling in patients after AMI and primary coronary angioplasty (PCI).

MATERIAL AND METHODS

Eighty-eight patients (F/M = 31/57 patients; 63.6 ±11 years old) with coronary artery disease (CAD) and successful PCI were enrolled and divided into group I with ST-elevation myocardial infarction or non-ST elevation myocardial infarction and group II with stable angina pectoris. Conventional and speckle tracking echocardiography was performed 3 days (baseline), 30 days and 90 days after PCI. Patients were divided into 2 groups based on the presence of LVR (increase of LV end-diastolic and/or end-systolic volume > 20%) at 3 months follow-up.

RESULTS

At initial presentation, 2-chamber longitudinal strain (9.4 ±3.5% vs. -11.6 ±3.6%, p < 0.04) and 4-chamber transverse strain (10.4 ±8.2% vs. 15.6 ±8%, p < 0.003) were lower in the LVR+ group compared to the LVR- group. LV wall motion score index did not differ between the two groups. After 30 days, circumferential apical and basal strain (-15.58 ±8.9% vs. -25.53 ±8.8%, p < 0.001; -15.02 ±5.6 vs. -19.78 ±6.3, p < 0.008), radial apical strain (9.96 ±8.4% vs. 14.15 ±5.5%, p < 0.03), 4-chamber longitudinal strain (-8.7 ±5.8% vs. -13.47 ±3.9%, p < 0.005), 4-chamber transverse strain (10.5 ±8.1% vs. 16.7 ±8.3%, p < 0.03), apical rotation (3.84 ±2.5° vs, 5.66 ±3.2°, p < 0.04) and torsion (6.15 ±4.1° vs. 8.98 ±4.6°, p < 0.03) were significantly decreased in the LVR+ group compared to the LVR- group. According to ROC analysis, circumferential apical strain > -15.92% (sensitivity 93%, specificity 59%, positive predictive value 90%) was the most powerful predictor of remodeling after primary PCI in AMI.

CONCLUSIONS

Our results suggest that impaired indices of LV deformation detected 3 days and 30 days after AMI may provide important predictive value in LV remodeling and patients' follow-up.

Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation

Background

Studies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).

Methods

Using our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1–3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments.

Results

From January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 – 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 – 6.89]; p = 0.004). At a median follow-up of 366 days [34–582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 – 5.53]; p = 0.04).

Conclusions

After primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.