Gadomer-enhanced MR Imaging in the Detection of Microvascular Obstruction: Alleviation with Nicorandil Therapy

Reperfusion injury in acute ischemic stroke: Tackling the irony of revascularization

Reperfusion injury is an unfortunate consequence of restoring blood flow to tissue after a period of ischemia. This phenomenon can occur in any organ, although it has been best studied in cardiac cells. Based on cardiovascular studies, neuroprotective strategies have been developed. The molecular biology of reperfusion injury remains to be fully elucidated involving several mechanisms, however these mechanisms all converge on a similar final common pathway: blood brain barrier disruption. This results in an inflammatory cascade that ultimately leads to a loss of cerebral autoregulation and clinical worsening. In this article, the authors present an overview of these mechanisms and the current strategies being employed to minimize injury after restoration of blood flow to compromised cerebral territories.

Nicorandil prior to primary percutaneous coronary intervention improves clinical outcomes in patients with acute myocardial infarction: a meta-analysis of randomized controlled trials

Background: Nicorandil prior to reperfusion by primary percutaneous coronary intervention (PCI) in patients with ST-segment elevated myocardial infarction (STEMI) has been suggested to be beneficial. However, results of previous randomized controlled trials (RCTs) were not consistent. We aimed to perform a meta-analysis to systematically evaluate the effect of periprocedural nicorandil in these patients. Methods: Related studies were obtained by searching PubMed, Embase and Cochrane's Library. Effects of perioperative nicorandil on the incidence of no-reflow phenomenon (NRP), corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC), wall motion score (WMS), left ventricular ejection fraction (LVEF), heart failure (HF) exacerbation of rehospitalization and incidence of major cardiovascular adverse events (MACE) were analyzed. Results: Eighteen RCTs with 2,055 patients were included. Treatment of nicorandil prior to PCI significantly reduced the incidence of NRP (risk ratio [RR]: 0.47, P<0.001), and reduced CTFC (weighed mean difference [WMD]: -4.54, P<0.001) immediately after PCI. Moreover, although nicorandil did not significantly affect WMS (WMD: 0.04, P=0.91), treatment of nicorandil significantly increased LVEF in STEMI patients undergoing primary PCI (WMD: 1.89%, P<0.001). In addition, nicorandil significantly reduced the risk of HF exacerbation or rehospitalization (RR: 0.44, P=0.001) and the incidence of MACE (RR: 0.68, P<0.001). Further analyses showed that effects of nicorandil on LVEF, HF exacerbation and MACE were consistent within one month after PCI and during follow-up. Conclusions: Periprocedural nicorandil improves coronary blood flow, cardiac systolic function and prognosis in STEMI patients receiving primary PCI.

Reperfusing the myocardium - a damocles Sword

Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown that 50% of muscle die of ischemia and another 50% die because of reperfusion. It is characterized by myocardial, vascular, or electrophysiological dysfunction that is induced by the restoration of blood flow to previously ischemic tissue. This phenomenon reduces the efficiency of the present modalities used to combat the ischemic myocardium. Moreover, despite an improved understanding of the pathophysiology of this process and encouraging preclinical trials of multiple agents, most of the clinical trials to prevent RI have been disappointing and leaves us at ground zero to explore newer approaches.

Contrast agents for cardiovascular magnetic resonance imaging: an overview

Contrast agents for Cardiovascular Magnetic Resonance (CMR) play a major role in research and clinical cardiology.

Functional Analysis of Vascularized Collagen/Fibrin Templates by MRI In Vivo

Functional monitoring of the fate of implanted templates, which restore the function of lost tissues, is still a challenge. Whereas histology can give excellent insight into material and tissue remodeling, longitudinal studies are hampered by the invasive character. Noninvasive imaging techniques, which allow longitudinal studies in the same individual and provide functional information, might be beneficial. In this study, magnetic resonance imaging (MRI) was applied as a noninvasive tool to monitor the progress of vasculogenesis and inosculation in in vitro prevascularized collagen/fibrin templates implanted in mice during a period of 4 weeks. MRI results were compared with histological findings to evaluate whether the two technologies were complementary and to evaluate the added value of MRI. When in vitro prevascularized templates were implanted in mice, histological analysis showed the presence of mouse blood cells in the engineered vessels 2 weeks after implantation. The MR images showed that template perfusion, a measure of vascularity, became significant at 3 weeks. For tissue engineering purposes, contrast-enhanced MRI appears to be an attractive tool to evaluate the vascular outcome longitudinally without the need to sacrifice animals and the functional information can be superimposed on the static histological information.

Macromolecular Imaging Agents Containing Lanthanides: Can Conceptual Promise Lead to Clinical Potential?

Macromolecular magnetic resonance imaging (MRI) contrast agents are increasingly being used to improve the resolution of this noninvasive diagnostic technique. All clinically-approved T₁ contrast agents are small molecule chelates of gadolinium [Gd(III)] that affect bound water proton relaxivity. Both the small size and monomeric nature of these agents ultimately limits the image resolution enhancement that can be achieved for both contrast enhancement and pharmacokinetic/biodistribution reasons. The multimeric nature of macromolecules, such as polymers, dendrimers, and noncovalent complexes of small molecule agents with proteins, have been shown to significantly increase the image contrast and resolution due to their large size and ability to incorporate multiple Gd(III) chlelation sites. Also, macromolecular agents are advantageous as they have the ability to be designed to be nontoxic, hydrophilic, easily purified, aggregation-resistant, and have controllable three-dimensional macromolecular structure housing the multiple lanthanide chelation sites. For these reasons, large molecule diagnostics have the ability to significantly increase the relaxivity of water protons within the targeted tissues and thus the image resolution for many diagnostic applications. The FDA approval of a contrast agent that consists of a reversible, non-covalent coupling of a small Gd(III) chelate with serum albumin for blood pool imaging (marketed under the trade names of Vasovist and Ablivar) proved to be one of the first diagnostic agent to capitalize on these benefits from macromolecular association in humans. However, much research and development is necessary to optimize the safety of these unique agents for in vivo use and potential clinical development. To this end, recent work in the field of polymer, dendrimer, and noncovalent complex-based imaging agents are reviewed herein and the future outlook of this field is discussed.

Effects of chronic treatment with a low dose of nicorandil on the function of the rat aorta during ageing

1. It is known that ATP-sensitive potassium (K(ATP)) channels regulate the membrane potential of smooth muscle cells and vascular tone. Because their activity is altered during ageing, many pharmacological treatments aimed at improving K(ATP) channel and cardiovascular functions have been evaluated. Nicorandil, a K(ATP) channel opener, nitric oxide (NO) donor and anti-oxidant, induces vasodilation, decreases blood pressure and exhibits cardioprotection in ageing, as well as after ischaemia-reperfusion. 2. In the present study, using tension myography and biochemical and histological techniques, we investigated the effects of chronic (2 months) low-dose nicorandil (0.1 mg/kg per day) treatment on the function of rat aorta during ageing (in 4-, 12- and 24-month old rats). 3. The results showed that chronic nicorandil treatment significantly improves mechanical relaxation and noradrenaline-induced vasoconstriction in aged rats. At all ages, the nicorandil-induced vasodilation was primarily mediated by its NO donor group. Nicorandil treatment resulted in an additional 0.5-1 elastic lamella in the aorta and decreased total protein, collagen and elastin content in the aortic wall at all ages. However, in 4-month-old rats, nicorandil significantly increased the elastin : total protein ratio by 19%. 4. In contrast with results of previous studies that used high doses of nicorandil (i.e. 60 mg/kg per day), low-dose nicorandil treatment in the present study did not lead to a progressive desensitization to nicorandil and may be beneficial in improving arterial function in ageing or cardiovascular diseases.

Myocardial microinfarction after coronary microembolization in swine: MR imaging characterization

PURPOSE

To use first-pass perfusion and delayed-enhanced (DE) magnetic resonance (MR) imaging for the detection of the early effects of coronary microembolization on myocardial perfusion and viability.

MATERIALS AND METHODS

Approval was obtained from the institutional committee on animal research. A hybrid x-ray and MR imaging system was used to guide the endovascular catheter and quantify the left anterior descending coronary artery (LAD) perfusion territory before microembolization and ischemic myocardium and microinfarction after microembolization. The embolic agent was selectively delivered in the LAD in six pigs. First-pass perfusion MR imaging was performed 1 hour and 1 week after microembolization. Microinfarction was measured on DE MR images in beating and nonbeating hearts (high-spatial-resolution sequence) by using extracellular and blood pool MR contrast media and after death. The Wilcoxon signed rank test and correlation analysis were used.

RESULTS

The LAD perfusion territory was 35% of left ventricular (LV) mass +/- 2 (standard error of the mean). Microembolization caused perfusion deficit in 15.7% of LV mass +/- 2.6 compared with that of LAD territory (P = .03). At 1 week, perfusion parameters improved and the extent of hypoperfused territory declined (4.6% of LV mass +/- 1.4, P = .03). Microinfarction size expanded from 1.4% of LV mass +/- 0.2 at 1 hour to 7.5% of LV mass +/- 1.2 at 1 week. In nonbeating hearts and at triphenyltetrazolium chloride staining at 1 week, microinfarction size was 7.6% of LV mass +/- 1.4 and 7.2% of LV mass +/- 1.5, respectively. There was no correlation between the ejection fraction and the extents of microinfarction or hypoperfused territory. Histopathologic findings confirmed the presence of patchy microinfarction.

CONCLUSION

Coronary microembolization caused persistent decline in myocardial perfusion at first-pass perfusion imaging. DE MR imaging has the potential to help reliably quantify subacute microinfarction. The magnitude of LV dysfunction is not related to the extents of microinfarction or hypoperfused territory.

Nicorandil protects ATP-sensitive potassium channels against oxidation-induced dysfunction in cardiomyocytes of aging rats

ATP-sensitive potassium channels (K(ATP) channels) regulate vascular tone and cardiac contraction through their action on the membrane potential of smooth muscle cells and cardiomyocytes. Because aging and diseases alter K(ATP) channel activity, many pharmacological treatments aimed at improving their function, therefore cardiovascular function, have been evaluated. Nicorandil, a K(ATP) channel opener, nitric oxide donor and antioxidant, is used as a treatment of angina pectoris and induces vasodilation, blood pressure decrease and cardioprotection in aging as well as after ischemia-reperfusion. Here, using the patch-clamp technique, we have studied the effect a chronic low dose of nicorandil (0.1 mg/kg per day for 2 months), on the activity of cardiomyocyte K(ATP) channels as a function of age, in newborn, 4-, 12- and 24-month old rats. Nicorandil exerted an anti-oxidant and protective action on cardiomyocyte K(ATP) channels, especially in aged animals, leading to restoration of a normal channel activity. These findings could justify further therapeutical applications.

MRI evaluation of microvascular obstruction in experimental reperfused acute myocardial infarction using a T1 and T2 preparation pulse sequence

PURPOSE

To investigate a T1 and T2 preparation pulse sequence to evaluate microvascular obstruction (MO) in a porcine model of reperfused acute myocardial infarction (AMI).

MATERIALS AND METHODS

A total of 14 pigs with reperfused AMI underwent MRI examinations at baseline and three to four hours after reperfusion. MRI scans included a left ventricular functional study, T1 and T2 measurement on a 1.5T MRI system. At reperfusion, first-pass myocardial perfusion (FPMP) images were obtained after bolus injection of gadopentetate dimeglumine followed by an intravenous drip. Delayed contrast-enhanced MRI (DE-MRI) and T1 measurements were performed 30 and 45 minutes, respectively, after the bolus, during a constant infusion of gadopentetate dimeglumine.

RESULTS

In 11 pigs MO was hypoenhanced in FPMP and DE-MRI. In later T1 preparation difference images postcontrast, MO was hyperenhanced while delayed hyperenhanced (DHE) regions appeared dark. MO areas on DE-MRI and T1 images were comparable. T1 reduction (%) postcontrast in MO was small compared to measurements from DHE regions (P < 0.0001) and similar to those from control segments (P = 0.66). Precontrast T1 and T2 values at reperfusion from MO and DHE regions were larger than in control regions.

CONCLUSION

Using T1 preparation under a constant gadopentetate dimeglumine (Gd-DTPA) infusion, delayed imaging at 30 to 45 minutes demonstrates MO as a positive contrast with larger T1 values. Elevated T1 and T2 values in MO precontrast may also help to differentiate them from both control and DHE regions.

Characterization of myocardial viability using MR and CT imaging

Cardiovascular magnetic resonance (MR) imaging is of proven clinical value for the noninvasive characterization of myocardial viability. Computed tomography (CT) is also being exploited for this indication. Examples of each of these imaging strategies for the assessment of myocardial viability will be provided in this review. Key MRI concepts and practical considerations such as customized MR imaging techniques and tailored imaging protocols dedicated to viability assessment are outlined with the primary focus on recent developments. Clinical applications of MR-based viability assessment are reviewed, ranging from rapid functional cine imaging to tissue characterization using T2-weighted imaging and T1-weighted late-contrast-enhanced imaging. Next, the merits and limitations of state-of-the-art CT imaging are surveyed, and their implications for viability assessment are considered. The final emphasis is on current trends and future directions in noninvasive viability assessment using MRI and CT.