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Welt FGP, Batchelor W, Spears JR, Penna C, Pagliaro P, Ibanez B, Drakos SG, Dangas G, Kapur NK. Reperfusion Injury in Patients With Acute Myocardial Infarction: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:2196-2213. [PMID: 38811097 DOI: 10.1016/j.jacc.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/15/2024] [Accepted: 02/26/2024] [Indexed: 05/31/2024]
Abstract
Despite impressive improvements in the care of patients with ST-segment elevation myocardial infarction, mortality remains high. Reperfusion is necessary for myocardial salvage, but the abrupt return of flow sets off a cascade of injurious processes that can lead to further necrosis. This has been termed myocardial ischemia-reperfusion injury and is the subject of this review. The pathologic and molecular bases for myocardial ischemia-reperfusion injury are increasingly understood and include injury from reactive oxygen species, inflammation, calcium overload, endothelial dysfunction, and impaired microvascular flow. A variety of pharmacologic strategies have been developed that have worked well in preclinical models and some have shown promise in the clinical setting. In addition, there are newer mechanical approaches including mechanical unloading of the heart prior to reperfusion that are in current clinical trials.
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Affiliation(s)
- Frederick G P Welt
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah, USA.
| | | | - J Richard Spears
- Department of Cardiovascular Medicine, Beaumont Systems, Royal Oak, Michigan, USA
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; Department of Cardiology, Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Stavros G Drakos
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Health System, New York, New York, USA
| | - Navin K Kapur
- The CardioVascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, USA
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Benenati S, Crimi G, Macchione A, Giachero C, Pescetelli F, Balbi M, Porto I, Vercellino M. Mechanical Unloading of the Left Ventricle before Coronary Reperfusion in Preclinical Models of Myocardial Infarction without Cardiogenic Shock: A Meta-Analysis. J Clin Med 2022; 11:jcm11164913. [PMID: 36013152 PMCID: PMC9409839 DOI: 10.3390/jcm11164913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 12/09/2022] Open
Abstract
Aim: to compare a conventional primary reperfusion strategy with a primary unloading approach before reperfusion in preclinical studies. Methods: we performed a meta-analysis of preclinical studies. The primary endpoint was infarct size (IS). Secondary endpoints were left ventricle end-diastolic pressure (LVEDP), mean arterial pressure (MAP), heart rate (HR), cardiac output (CO). We calculated mean differences (MDs) and associated 95% confidence intervals (CIs). Sensitivity and subgroup analyses on the primary and secondary endpoints, as well as a meta-regression on the primary endpoint using the year of publication as a covariate, were also conducted. Results: 11 studies (n = 142) were selected and entered in the meta-analysis. Primary unloading reduced IS (MD −28.82, 95% CI −35.78 to −21.86, I2 96%, p < 0.01) and LVEDP (MD −3.88, 95% CI −5.33 to −2.44, I2 56%, p = 0.02) and increased MAP (MD 7.26, 95% CI 1.40 to 13.12, I2 43%, p < 0.01) and HR (MD 5.26, 95% CI 1.97 to 8.55, I2 1%, p < 0.01), while being neutral on CO (MD −0.11, 95% CI −0.95 to 0.72, I2 88%, p = 0.79). Sensitivity and subgroup analyses showed, overall, consistent results. The meta-regression on the primary endpoint demonstrated a significant influence of the year of publication on effect estimate. Conclusions: in animal models of myocardial infarction, a primary unloading significantly reduces IS and exerts beneficial hemodynamic effects compared to a primary reperfusion.
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Affiliation(s)
- Stefano Benenati
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, 16132 Genoa, Italy
| | - Gabriele Crimi
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
| | - Andrea Macchione
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
| | - Corinna Giachero
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
| | - Fabio Pescetelli
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
| | - Manrico Balbi
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
| | - Italo Porto
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, 16132 Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
- Correspondence: ; Tel.: +39-0105555830
| | - Matteo Vercellino
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
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Miyashita S, Kariya T, Yamada KP, Bikou O, Tharakan S, Kapur NK, Ishikawa K. Left Ventricular Assist Devices for Acute Myocardial Infarct Size Reduction: Meta-analysis. J Cardiovasc Transl Res 2021; 14:467-475. [PMID: 32860130 PMCID: PMC7914262 DOI: 10.1007/s12265-020-10068-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/10/2020] [Indexed: 01/11/2023]
Abstract
We conducted a meta-analysis of preclinical studies that tested left ventricular assist device (LVAD) therapy for reducing myocardial infarct size in experimental acute myocardial infarction (AMI). Twenty-six articles were included with a total of 488 experimental animal subjects. The meta-analysis showed that infarct size was significantly decreased by LVAD support compared to control animals (SDM, - 2.19; 95% CI, - 2.70 to - 1.69; P < 0.001). The meta-regression analysis demonstrated a high degree of heterogeneity associated with time from coronary artery occlusion to LVAD support, which correlated positively with infarct size. Subgroup analysis suggested smaller infarct size in LVAD therapies that withdrew blood from left heart than those from right heart. The proportion of left ventricular support relative to total cardiac output was positively correlated with infarct size reduction in Impella studies. Thus, early initiation of LVAD after ischemia and effective left ventricular venting may be important factors to reduce infarct size in AMI.
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Affiliation(s)
- Satoshi Miyashita
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Taro Kariya
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Kelly P Yamada
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Olympia Bikou
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Serena Tharakan
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA
| | - Navin K Kapur
- CardioVascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Kiyotake Ishikawa
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA.
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Hansen ESS, Madsen TL, Wood G, Granfeldt A, Bøgh N, Tofig BJ, Agger P, Lindhardt JL, Poulsen CB, Bøtker HE, Kim WY. Veno-occlusive unloading of the heart reduces infarct size in experimental ischemia-reperfusion. Sci Rep 2021; 11:4483. [PMID: 33627745 PMCID: PMC7904802 DOI: 10.1038/s41598-021-84025-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/05/2021] [Indexed: 11/09/2022] Open
Abstract
Mechanical unloading of the left ventricle reduces infarct size after acute myocardial infarction by reducing cardiac work. Left ventricular veno-occlusive unloading reduces cardiac work and may reduce ischemia and reperfusion injury. In a porcine model of myocardial ischemia-reperfusion injury we randomized 18 pigs to either control or veno-occlusive unloading using a balloon engaged from the femoral vein into the inferior caval vein and inflated at onset of ischemia. Evans blue and 2,3,5-triphenyltetrazolium chloride were used to determine the myocardial area at risk and infarct size, respectively. Pressure-volume loops were recorded to calculate cardiac work, left ventricular (LV) volumes and ejection fraction. Veno-occlusive unloading reduced infarct size compared with controls (Unloading 13.9 ± 8.2% versus Control 22.4 ± 6.6%; p = 0.04). Unloading increased myocardial salvage (54.8 ± 23.4% vs 28.5 ± 14.0%; p = 0.02), while the area at risk was similar (28.4 ± 6.7% vs 27.4 ± 5.8%; p = 0.74). LV ejection fraction was preserved in the unloaded group, while the control group showed a reduced LV ejection fraction. Veno-occlusive unloading reduced myocardial infarct size and preserved LV ejection fraction in an experimental acute ischemia-reperfusion model. This proof-of-concept study demonstrated the potential of veno-occlusive unloading as an adjunctive cardioprotective therapy in patients undergoing revascularization for acute myocardial infarction.
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Affiliation(s)
- Esben Søvsø Szocska Hansen
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
| | - Tobias Lynge Madsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Gregory Wood
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Asger Granfeldt
- Department of Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
| | - Nikolaj Bøgh
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
| | - Bawer Jalal Tofig
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Peter Agger
- Department of Clinical Medicine, Comparative Medicine Lab, Aarhus University, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
| | - Jakob Lykke Lindhardt
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Christian Bo Poulsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, MR Research Centre, Aarhus University, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark.
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Parikh MJ, Schuleri KH, Chakrabarti AK, O'Neill WW, Kapur NK, Wohns DH. Door-to-unload: left ventricular unloading before reperfusion in ST-elevation myocardial infarction. Future Cardiol 2021; 17:549-559. [PMID: 33599135 DOI: 10.2217/fca-2021-0006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
ST-elevation myocardial infarction treatment in the modern era has focused on minimizing time of ischemia by reducing door-to-balloon time to limit infarct size and improve survival. Although there have been significant improvements in minimizing time to coronary reperfusion, the incidence of heart failure following a myocardial infarction has remained high. Preclinical studies have shown that unloading the left ventricle for 30 min prior to coronary reperfusion can reduce infarct size and promote myocardial recovery. The DTU-STEMI randomized prospective trial will test the hypothesis that left ventricular unloading for at least 30 min prior to coronary reperfusion will improve infarct size and heart failure-related events as compared with the current standard of care.
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Affiliation(s)
- Malav J Parikh
- Spectrum Health, Frederik Meijer Heart & Vascular Institute, 100 Michigan Street NE, Grand Rapids, MI 49503, USA
| | | | | | - William W O'Neill
- Henry Ford Health Systems, 2799 W Grand Blvd, K14 Detroit, MI 4820, USA
| | - Navin K Kapur
- Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - David Hw Wohns
- Spectrum Health, Frederik Meijer Heart & Vascular Institute, 100 Michigan Street NE, Grand Rapids, MI 49503, USA
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Silva KAS, Emter CA. Large Animal Models of Heart Failure: A Translational Bridge to Clinical Success. JACC Basic Transl Sci 2020; 5:840-856. [PMID: 32875172 PMCID: PMC7452204 DOI: 10.1016/j.jacbts.2020.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Preclinical large animal models play a critical and expanding role in translating basic science findings to the development and clinical approval of novel cardiovascular therapeutics. This state-of-the-art review outlines existing methodologies and physiological phenotypes of several HF models developed in large animals. A comprehensive list of porcine, ovine, and canine models of disease are presented, and the translational importance of these studies to clinical success is highlighted through a brief overview of recent devices approved by the FDA alongside associated clinical trials and preclinical animal reports. Increasing the use of large animal models of HF holds significant potential for identifying new mechanisms underlying this disease and providing valuable information regarding the safety and efficacy of new therapies, thus, improving physiological and economical translation of animal research to the successful treatment of human HF.
Preclinical large animal models of heart failure (HF) play a critical and expanding role in translating basic science findings to the development and clinical approval of novel therapeutics and devices. The complex combination of cardiovascular events and risk factors leading to HF has proved challenging for the development of new treatments for these patients. This state-of-the-art review presents historical and recent studies in porcine, ovine, and canine models of HF and outlines existing methodologies and physiological phenotypes. The translational importance of large animal studies to clinical success is also highlighted with an overview of recent devices approved by the Food and Drug Administration, together with preclinical HF animal studies used to aid both development and safety and/or efficacy testing. Increasing the use of large animal models of HF holds significant potential for identifying the novel mechanisms underlying the clinical condition and to improving physiological and economical translation of animal research to successfully treat human HF.
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Key Words
- AF, atrial fibrillation
- ECM, extracellular matrix
- EDP, end-diastolic pressure
- EF, ejection fraction
- FDA, Food and Drug Administration
- HF, heart failure
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- HFrEF
- HFrEF, heart failure with reduced ejection fraction
- I/R, ischemia/reperfusion
- IABP, intra-aortic balloon pump
- LAD, left anterior descending
- LCx, left circumflex
- LV, left ventricular
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- RV, right ventricular
- heart failure
- large animal model
- preclinical
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Affiliation(s)
| | - Craig A Emter
- Department of Biomedical Sciences, University of Missouri-Columbia, Columbia, Missouri
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