1
|
Mir A, Rahman MF, Ragab KM, Fathallah AH, Daloub S, Alwifati N, Hagrass AI, Nourelden AZ, Elsayed SM, Kamal I, Elhady MM, Khan R. Efficacy and Safety of Therapeutic Hypothermia as an Adjuvant Therapy for Percutaneous Coronary Intervention in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2023. [PMID: 37792341 DOI: 10.1089/ther.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
The study aims to compare the use of hypothermia in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) with control. We systematically searched four electronic databases until March 2022. The inclusion criteria were any study design that compared hypothermia in patients with MI undergoing PCI with control. The risk of bias assessment of the included randomized controlled trials was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The meta-analysis was performed on RevMan. A total of 19 studies were entered. Regarding the mortality, there were nonsignificant differences between hypothermia and control (odds ratio [OR] = 1.06, 95% confidence interval [CI] 0.75 to 1.50, p = 0.73). There was also no significant difference between the control and hypothermia in recurrent MI (OR = 1.21, 95% CI 0.64 to 2.30, p = 0.56). On the other hand, the analysis showed a significant favor for hypothermia over the control infarct size (mean difference = -1.76, 95% CI -3.04 to -0.47, p = 0.007), but a significant favor for the control over hypothermia in the overall bleeding complications (OR = 1.88, 95% CI 1.11 to 3.18, p = 0.02). Compared with the control, hypothermia reduced the infarct size of the heart, but this finding was not consistent across studies. However, the control had lower rates of bleeding problems. The other outcomes, such as death and the incidence of recurrent MI, were similar between the two groups.
Collapse
Affiliation(s)
- Ali Mir
- Department of Internal Medicine, University at Buffalo, Buffalo, New York, USA
| | | | | | | | - Shaden Daloub
- Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Nader Alwifati
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | | | | | | | - Ibrahim Kamal
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Raheel Khan
- Department of Internal Medicine, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
2
|
Hypothermia as an Adjunctive Therapy to Percutaneous Intervention in ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Control Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:8-15. [PMID: 36115819 DOI: 10.1016/j.carrev.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In the setting of acute ST-elevation myocardial infarction (STEMI), several randomized control trials (RCTs) suggested a potential benefit with the use of therapeutic hypothermia (TH). However, results from previous studies are contradictory. METHOD We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared to the standard percutaneous coronary intervention (PCI) in awake patients with STEMI. The primary outcomes were the infarct size (IS) and microvascular obstruction (MVO) assessed by cardiac imaging at the end of follow-up. The secondary outcomes were major adverse cardiovascular events (MACE), procedure-related complications, and door-to-balloon time. Relative risk (RR) or the mean difference (MD) and corresponding 95 % confidence intervals (CIs) were calculated using the random-effects model. RESULTS A total of 10 RCTs, including 706 patients were included. As compared to standard PCI, TH was not associated with a statistically significant improvement in the IS (MD: -0.87 %, 95%CI: -2.97, 1.23; P = 0.42) or in the MVO (MD: 0.11 %, 95%CI: -0.06, 0.27; P = 0.21). MACE and its components were comparable between the two groups. However, the TH approach was associated with an increased risk of infection and prolonged door-to-balloon time. Furthermore, there was a trend in the TH group toward an increased incidence of stent thrombosis and paroxysmal atrial fibrillation. CONCLUSIONS According to our meta-analysis of published RCTs, TH is not beneficial in awake patients with STEMI and has a marginal safety profile with potential for care delays. Larger-scale RCTs are needed to further clarify our results.
Collapse
|
3
|
Romeo FJ, Mazurek R, Sakata T, Mavropoulos SA, Ishikawa K. Device-Based Approaches Targeting Cardioprotection in Myocardial Infarction: The Expanding Armamentarium of Innovative Strategies. J Am Heart Assoc 2022; 11:e026474. [PMID: 36382949 PMCID: PMC9851452 DOI: 10.1161/jaha.122.026474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Coronary reperfusion therapy has played a pivotal role for reducing mortality and heart failure after acute myocardial infarction. Although several adjunctive approaches have been studied for reducing infarct size further, both ischemia-reperfusion injury and microvascular obstruction are still major contributors to both early and late clinical events after acute myocardial infarction. The progress in the field of cardioprotection has found several promising proof-of-concept preclinical studies. However, translation from bench to bedside has not been very successful. This comprehensive review discusses the importance of infarct size as a driver of clinical outcomes post-acute myocardial infarction and summarizes recent novel device-based approaches for infarct size reduction. Device-based interventions including mechanical cardiac unloading, myocardial cooling, coronary sinus interventions, supersaturated oxygen therapy, and vagal stimulation are discussed. Many of these approaches can modify ischemic myocardial biology before reperfusion and offer unique opportunities to target ischemia-reperfusion injury.
Collapse
Affiliation(s)
- Francisco José Romeo
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Renata Mazurek
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Tomoki Sakata
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | | | - Kiyotake Ishikawa
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| |
Collapse
|
4
|
Larsen AI, Grejs AM, Vistisen ST, Strand K, Skadberg Ø, Jeppesen AN, Duez CHV, Kirkegaard H, Søreide E. Kinetics of 2 different high-sensitive troponins during targeted temperature management in out-of-hospital cardiac arrest patients with acute myocardial infarction: a post hoc sub-study of a randomised clinical trial. BMC Cardiovasc Disord 2022; 22:342. [PMID: 35907787 PMCID: PMC9339199 DOI: 10.1186/s12872-022-02778-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Short term hypothermia has been suggested to have cardio protective properties in acute myocardial infarction (AMI) by reducing infarct size as assessed by troponins. There are limited data on the kinetics of these biomarkers in comatose out-of-hospital cardiac arrest (OHCA) patients, with and without AMI, undergoing targeted temperature management (TTM) in the ICU.
Purpose The aim of this post hoc analyses was to evaluate and compare the kinetics of two high-sensitivity cardiac troponins in OHCA survivors, with and without acute myocardial infarction (AMI), during TTM of different durations [24 h (standard) vs. 48 h (prolonged)]. Methods In a sub-cohort (n = 114) of the international, multicentre, randomized controlled study “TTH48” we measured high-sensitive troponin T (hs-cTnT), high-sensitive troponin I (hs-cTnI) and CK-MB at the following time points: Arrival, 24 h, 48 h and 72 h from reaching the target temperature range of 33 ± 1 °C. All patients diagnosed with an AMI at the immediate coronary angiogram (CAG)—18 in the 24-h group and 25 in the 48-h group—underwent PCI with stent implantation. There were no stent thromboses.
Results Both the hs-cTnT and hs-cTnI changes over time were highly influenced by the cause of OHCA (AMI vs. non-AMI). In contrast to non-AMI patients, both troponins remained elevated at 72 h in AMI patients. There was no difference between the two time-differentiated TTM groups in the kinetics for the two troponins.
Conclusion In comatose OHCA survivors with an aetiology of AMI levels of both hs-cTnI and hs-cTnT remained elevated for 72 h, which is in contrast to the well-described kinetic profile of troponins in normotherm AMI patients. There was no difference in kinetic profile between the two high sensitive assays. Different duration of TTM did not influence the kinetics of the troponins. Trial registration: Clinicaltrials.gov Identifier: NCT01689077, 20/09/2012.
Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02778-4.
Collapse
Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Sciences, University of Bergen, Bergen, Norway.
| | - Anders Morten Grejs
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Tilma Vistisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Anni Nørgaard Jeppesen
- Division for Heart- Lung- and Vascular Surgery, Anaesthesiology section, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Eldar Søreide
- Department of Clinical Sciences, University of Bergen, Bergen, Norway.,Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
| |
Collapse
|
5
|
Zhang A, Rastogi R, Marsh KM, Yang B, Wu D, Kron IL, Yang Z. Topical Neck Cooling Without Systemic Hypothermia Attenuates Myocardial Ischemic Injury and Post-ischemic Reperfusion Injury. Front Cardiovasc Med 2022; 9:893837. [PMID: 35837603 PMCID: PMC9274088 DOI: 10.3389/fcvm.2022.893837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Following acute myocardial infarction (MI), irreversible damage to the myocardium can only be reduced by shortening the duration between symptom onset and revascularization. While systemic hypothermia has shown promising results in slowing pre-revascularization myocardial damage, it is resource intensive and not conducive to prehospital initiation. We hypothesized that topical neck cooling (NC), an easily implemented therapy for en route transfer to definitive therapy, could similarly attenuate myocardial ischemia-reperfusion injury (IRI). Methods Using an in vivo mouse model of myocardial IRI, moderate systemic hypothermia or NC was applied following left coronary artery (LCA) occlusion and subsequent reperfusion, at early, late, and post-reperfusion intervals. Vagotomy was performed after late NC in an additional group. Hearts were harvested to measure infarct size. Results Both hypothermia treatments equally attenuated myocardial infarct size by 60% compared to control. The infarct-sparing effect of NC was temperature-dependent and timing-dependent. Vagotomy at the gastroesophageal junction abolished the infarct-sparing effect of late NC. Cardiac perfusate isolated following ischemia had significantly reduced cardiac troponin T, HMGB1, cell-free DNA, and interferon α and β levels after NC. Conclusions Topical neck cooling attenuates myocardial IRI in a vagus nerve-dependent manner, with an effect comparable to that of systemic hypothermia. NC attenuated infarct size when applied during ischemia, with earlier initiation resulting in superior infarct sparing. This novel therapy exerts a cardioprotective effect without requiring significant change in core temperature and may be a promising practical strategy to attenuate myocardial damage while patients await definitive revascularization.
Collapse
|
6
|
El Farissi M, Keulards DCJ, Zelis JM, van 't Veer M, Zimmermann FM, Pijls NHJ, Otterspoor LC. Hypothermia for Reduction of Myocardial Reperfusion Injury in Acute Myocardial Infarction: Closing the Translational Gap. Circ Cardiovasc Interv 2021; 14:e010326. [PMID: 34266310 DOI: 10.1161/circinterventions.120.010326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Myocardial reperfusion injury-triggered by an inevitable inflammatory response after reperfusion-may undo a considerable part of the myocardial salvage achieved through timely percutaneous coronary intervention in patients with acute myocardial infarction. Because infarct size is strongly correlated to mortality and risk of heart failure, the importance of endeavors for cardioprotective therapies to attenuate myocardial reperfusion injury and decrease infarct size remains undisputed. Myocardial reperfusion injury is the result of several complex nonlinear phenomena, and for a therapy to be effective, it should act on multiple targets involved in this injury. In this regard, hypothermia remains a promising treatment despite a number of negative randomized controlled trials in humans with acute myocardial infarction so far. To turn the tide for hypothermia in patients with acute myocardial infarction, sophisticated solutions for important limitations of systemic hypothermia should continue to be developed. In this review, we provide a comprehensive overview of the pathophysiology and clinical expression of myocardial reperfusion injury and discuss the current status and possible future of hypothermia for cardioprotection in patients with acute myocardial infarction.
Collapse
Affiliation(s)
- Mohamed El Farissi
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jo M Zelis
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Marcel van 't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Luuk C Otterspoor
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| |
Collapse
|
7
|
Yamada KP, Kariya T, Aikawa T, Ishikawa K. Effects of Therapeutic Hypothermia on Normal and Ischemic Heart. Front Cardiovasc Med 2021; 8:642843. [PMID: 33659283 PMCID: PMC7919696 DOI: 10.3389/fcvm.2021.642843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/21/2021] [Indexed: 12/24/2022] Open
Abstract
Therapeutic hypothermia has been used for treating brain injury after out-of-hospital cardiac arrest. Its potential benefit on minimizing myocardial ischemic injury has been explored, but clinical evidence has yet to confirm positive results in preclinical studies. Importantly, therapeutic hypothermia for myocardial infarction is unique in that it can be initiated prior to reperfusion, in contrast to its application for brain injury in resuscitated cardiac arrest patients. Recent advance in cooling technology allows more rapid cooling of the heart than ever and new clinical trials are designed to examine the efficacy of rapid therapeutic hypothermia for myocardial infarction. In this review, we summarize current knowledge regarding the effect of hypothermia on normal and ischemic hearts and discuss issues to be solved in order to realize its clinical application for treating acute myocardial infarction.
Collapse
Affiliation(s)
- Kelly P Yamada
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Taro Kariya
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Tadao Aikawa
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kiyotake Ishikawa
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
8
|
Basalay MV, Yellon DM, Davidson SM. Targeting myocardial ischaemic injury in the absence of reperfusion. Basic Res Cardiol 2020; 115:63. [PMID: 33057804 PMCID: PMC7560937 DOI: 10.1007/s00395-020-00825-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
Sudden myocardial ischaemia causes an acute coronary syndrome. In the case of ST-elevation myocardial infarction (STEMI), this is usually caused by the acute rupture of atherosclerotic plaque and obstruction of a coronary artery. Timely restoration of blood flow can reduce infarct size, but ischaemic regions of myocardium remain in up to two-thirds of patients due to microvascular obstruction (MVO). Experimentally, cardioprotective strategies can limit infarct size, but these are primarily intended to target reperfusion injury. Here, we address the question of whether it is possible to specifically prevent ischaemic injury, for example in models of chronic coronary artery occlusion. Two main types of intervention are identified: those that preserve ATP levels by reducing myocardial oxygen consumption, (e.g. hypothermia; cardiac unloading; a reduction in heart rate or contractility; or ischaemic preconditioning), and those that increase myocardial oxygen/blood supply (e.g. collateral vessel dilation). An important consideration in these studies is the method used to assess infarct size, which is not straightforward in the absence of reperfusion. After several hours, most of the ischaemic area is likely to become infarcted, unless it is supplied by pre-formed collateral vessels. Therefore, therapies that stimulate the formation of new collaterals can potentially limit injury during subsequent exposure to ischaemia. After a prolonged period of ischaemia, the heart undergoes a remodelling process. Interventions, such as those targeting inflammation, may prevent adverse remodelling. Finally, harnessing of the endogenous process of myocardial regeneration has the potential to restore cardiomyocytes lost during infarction.
Collapse
Affiliation(s)
- M V Basalay
- The Hatter Cardiovascular Institute, 67 Chenies Mews, London, WC1E 6HX, UK
| | - D M Yellon
- The Hatter Cardiovascular Institute, 67 Chenies Mews, London, WC1E 6HX, UK
| | - S M Davidson
- The Hatter Cardiovascular Institute, 67 Chenies Mews, London, WC1E 6HX, UK.
| |
Collapse
|
9
|
Bashtawi Y, Almuwaqqat Z. Therapeutic Hypothermia in STEMI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 29:77-84. [PMID: 32807668 DOI: 10.1016/j.carrev.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/16/2020] [Accepted: 08/04/2020] [Indexed: 11/26/2022]
Abstract
In this review article we tried to find an answer to the question, should local coronary hypothermia be a part of the early reperfusion strategy in patients with STEMI to prevent reperfusion injury, no-reflow phenomenon, and to reduce the infarct size and mortality. Hypothermia can save cardiomyocytes if achieved in a timely fashion before reperfusion. Intracoronary hypothermia can be adjunct to PCI by lessening ischemia/reperfusion injury on cardiomyocytes and reduction in infarct size. Reperfusion induced Calcium overload, generation of ROS and subsequent activation of Mitochondrial permeability transition pore (MPT) are major contributors to reperfusion injury. Hypothermia reduces calcium loading of the cell and maintains cellular energy and tissue level glucose which can scavenger ROS. Hypothermia reduces MPT activation and thus reduces infarct size. Systemic cooling trials failed to reduce infarct size, perhaps because the target temperature was not reached fast enough, and it was associated with systemic side effects. The need for rapid induction of hypothermia to <35 °C with the ethical concern of delaying reperfusion while cooling the patient and the inconsistency of endovascular cooling results lead to a belief that endovascular cooling may exceed the acceptable level of invasiveness in the context of other novels cardioprotective, regenerative and reperfusion therapies. Clinical trials showed the safety and feasibility of novel intracoronary hypothermia with rapid induction and maintenance of hypothermia using routine PCI equipment ahead of reperfusion. Two phases of cooling were applied without significant delay in the door to balloon time. Cooling of the coronary artery leads to cooling of its dependant myocardium without affecting adjacent myocardium. Heat transfer occurred by heat conduction during the occlusion phase and heat convention during the reperfusion phase. Fine-tuning of saline temperature and infusion rate helped to improve the protocol. The best duration of hypothermia before and after reperfusion is not known and needs further investigation. A balance between the undoubted cardioprotective effects of hypothermia with iatrogenic prolongation of ischemia time needs to be established. A reduction in infarct size was observed but needs to be validated with large randomized trials. Furthermore, it might be possible to augment the cardioprotective effects of intracoronary hypothermia by combination with other cardioprotective approaches such as antioxidant drugs and afterload reducing agents.
Collapse
Affiliation(s)
- Yazan Bashtawi
- Department of Medicine, King Hussein Cancer Center, Amman, Jordan.
| | - Zakaria Almuwaqqat
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, United States of America
| |
Collapse
|
10
|
Affiliation(s)
- Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
11
|
Huber C, Huber M, Ding Y. Evidence and opportunities of hypothermia in acute ischemic stroke: Clinical trials of systemic versus selective hypothermia. Brain Circ 2019; 5:195-202. [PMID: 31950095 PMCID: PMC6950508 DOI: 10.4103/bc.bc_25_19] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022] Open
Abstract
Stroke is the second leading cause of death globally and the third leading cause disability. Acute ischemic stroke (AIS), resulting from occlusion of major vessels in the brain, accounts for approximately 87% of strokes. Despite this large majority, current treatment options for AIS are severely limited and available to only a small percentage of patients. Therapeutic hypothermia (TH) has been widely used for neuroprotection in the setting of global ischemia postcardiac arrest, and recent evidence suggests that hypothermia may be the neuroprotective agent that stroke patients desperately need. Several clinical trials using systemic or selective cooling for TH have been published, reporting the safety and feasibility of these methods. Here, we summarize the major clinical trials of TH for AIS and provide recommendations for future studies.
Collapse
Affiliation(s)
- Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
12
|
Merrill TL, Mitchell JE, Merrill DR, Gorman JH, Gorman RC, Gillespie MJ. Myocardial tissue salvage is correlated with ischemic border region temperature at reperfusion. Catheter Cardiovasc Interv 2019; 96:E593-E601. [PMID: 31478608 DOI: 10.1002/ccd.28480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Our pilot study investigated the association between region-specific myocardial tissue temperature and tissue salvage using a novel tri-lumen cooling catheter to provide rapid localized cooling directly to the heart in an open-chest porcine model of ischemia-reperfusion. BACKGROUND Therapeutic hypothermia remains a promising strategy to limit reperfusion injury following myocardial ischemia. METHODS Large swine underwent 60 min of coronary occlusion followed by 3 hr of reperfusion. Prior to inducing ischemia, six temperature probes were placed directly on the heart, monitoring myocardial temperatures in different locations. Hemodynamic parameters and core temperature were also collected. Approximately 15 min prior to reperfusion, the cooling catheter was inserted via femoral artery and the distal tip advanced proximal to the occluded coronary vessel under fluoroscopic guidance. Autologous blood was pulled from the animal via femoral sheath and delivered through the central lumen of the cooling catheter, delivering at 50 ml/min, 27°C at the distal tip. Cooling was continued for an additional 25 min after reperfusion followed by a 5-min controlled rewarming. Hearts were excised and assessed for infarct size per area at risk. RESULTS Although cooling catheter performance was consistent throughout the study (38 W), the resulting tissue cooling was not. Our results show a correlation between myocardial tissue salvage and ischemic border region (IBR) temperature at the time of reperfusion (R2 = 0.59, p = 0.027). IBR tissue is the tissue located at the boundary between healthy and ischemic tissues. CONCLUSIONS Our findings suggest that localized, rapid, short-term myocardial tissue cooling has the potential to limit reperfusion injury in humans.
Collapse
Affiliation(s)
- Thomas L Merrill
- Department of Mechanical Engineering and Biomedical Engineering, Rowan University, Glassboro, New Jersey.,Catheter Development, Focal Cool, LLC, Mullica Hill, New Jersey
| | | | | | - Joseph H Gorman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew J Gillespie
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Myocardial hypothermia induced after reperfusion does not prevent adverse left ventricular remodeling nor improve cardiac function. Life Sci 2019; 229:98-103. [PMID: 30991060 DOI: 10.1016/j.lfs.2019.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/21/2022]
Abstract
AIMS The purpose of the study was to determine whether late therapeutic hypothermia (LTH), administered after reperfusion, could prevent adverse left ventricular (LV) remodeling and improve cardiac function in the rat myocardial ischemia/reperfusion model. MAIN METHODS Rats were randomized to normothermia (n = 10) or LTH (initiated at 1 min after coronary artery reperfusion, n = 10) and subjected to 30 min of coronary occlusion followed by 6 weeks of reperfusion. Hypothermia was induced by pumping cold saline over the anterior surface of the LV until the temperature cooled to <32 °C. In the normothermic group, the heart was bathed in saline at 38 °C. KEY FINDINGS After 6 weeks of recovery, fractional shortening of the LV was comparable in the LTH (20.2 ± 0.6%) and normothermic group (20.0 ± 2.1%; p = 0.918). Postmortem LV volume (0.47 ± 0.04 ml in LTH and 0.44 ± 0.05 ml in normothermic group) and lung wet/dry weight ratio were similar in both groups. There were no significant differences in scar size, scar thickness, infarct expansion index, LV cavity or transmurality (%) between groups. This data contrasts with our previous study showing that hypothermia administered during the ischemic phase significantly reduced the scar size; decreased LV cavity, infarct expansion index and transmurality (%), and improved the scar thickness. SIGNIFICANCE LTH did not prevent adverse LV remodeling nor improve cardiac function in the rat myocardial ischemia/reperfusion model. To have a long term benefit on remodeling, hypothermia must be administered during the ischemic phase and not just the reperfusion phase.
Collapse
|
14
|
Koutsoukis A, Kanakakis I. Challenges and unanswered questions in STEMI management. Hellenic J Cardiol 2019; 60:211-215. [DOI: 10.1016/j.hjc.2019.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/23/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023] Open
|
15
|
Kurz MC, Lyden P, Dae M, Noc M. Studies Targeting Stroke and Acute Myocardial Infarction. Ther Hypothermia Temp Manag 2019; 9:8-12. [PMID: 30614768 DOI: 10.1089/ther.2018.29054.mck] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Michael C Kurz
- 1 Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick Lyden
- 2 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Dae
- 3 Department of Radiology, Biomedical Imaging and Medicine, University of California San Francisco, San Francisco, California
| | - Marko Noc
- 4 Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| |
Collapse
|
16
|
Noc M, Friberg H, Huang CH, Empey PE. Therapeutic Hypothermia in Cardiac Arrest. Ther Hypothermia Temp Manag 2018; 8:195-198. [PMID: 30412452 DOI: 10.1089/ther.2018.29051.mjn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Marko Noc
- 1 Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Hans Friberg
- 2 Department of Emergency Medicine, Skane University Hospital, Lund University, Lund, Sweden
| | - Chien-Hua Huang
- 3 Department of Emergency Medicine, National Taiwan University, Medical College and Hospital, Taipei, Taiwan
| | - Philip E Empey
- 4 Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
17
|
Dae M, O'Neill W, Grines C, Dixon S, Erlinge D, Noc M, Holzer M, Dee A. Effects of endovascular cooling on infarct size in ST-segment elevation myocardial infarction: A patient-level pooled analysis from randomized trials. J Interv Cardiol 2018; 31:269-276. [PMID: 29243292 PMCID: PMC6001463 DOI: 10.1111/joic.12485] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES This study sought to examine the relationship between temperature at reperfusion and infarct size. BACKGROUND Hypothermia consistently reduces infarct size when administered prior to reperfusion in animal studies, however, clinical results have been inconsistent. METHODS We performed a patient-level pooled analysis from six randomized control trials of endovascular cooling during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in 629 patients in which infarct size was assessed within 1 month after randomization by either single-photon emission computed tomography (SPECT) or cardiac magnetic resonance imaging (cMR). RESULTS In anterior infarct patients, after controlling for variability between studies, mean infarct size in controls was 21.3 (95%CI 17.4-25.3) and in patients with hypothermia <35°C it was 14.8 (95%CI 10.1-19.6), which was a statistically significant absolute reduction of 6.5%, or a 30% relative reduction in infarct size (P = 0.03). There was no significant difference in infarct size in anterior ≥35°C, or inferior infarct patients. There was no difference in the incidence of death, ventricular arrhythmias, or re-infarction due to stent thrombosis between hypothermia and control patients. CONCLUSIONS The present study, drawn from a patient-level pooled analysis of six randomized trials of endovascular cooling during primary PCI in STEMI, showed a significant reduction in infarct size in patients with anterior STEMI who were cooled to <35°C at the time of reperfusion. The results support the need for trials in patients with anterior STEMI using more powerful cooling devices to optimize the delivery of hypothermia prior to reperfusion.
Collapse
Affiliation(s)
- Michael Dae
- Department of Radiology and Biomedical ImagingUniversity of California San FranciscoSan FranciscoCalifornia
| | - William O'Neill
- Division of CardiologyHenry Ford Hospital/Wayne State UniversityDetroitMichigan
| | - Cindy Grines
- Division of CardiologyNorthwell HealthManhassetNew York
| | - Simon Dixon
- Department of Cardiovascular MedicineBeaumont HealthRoyal OakMichigan
| | - David Erlinge
- Department of CardiologyLund UniversityClinical SciencesSkane University HospitalLundSweden
| | - Marko Noc
- Center for Intensive Internal MedicineUniversity Medical Center LjubljanaSlovenia
| | - Michael Holzer
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Anne Dee
- Clinical Affairs and BiostatisticsZOLL CirculationSan JoseCalifornia
| |
Collapse
|