1
|
El Kadi S, van de Veerdonk MC, Spoormans EM, Verouden NJW, Li S, Xie F, Azevedo LF, Mathias W, van Rossum AC, Porter TR, Kamp O. Sonothrombolysis in Patients With ST-Elevation Myocardial Infarction With Electrocardiographic No-Reflow After Percutaneous Coronary Intervention: A Randomized Controlled Trial. J Am Soc Echocardiogr 2024:S0894-7317(24)00346-8. [PMID: 38972613 DOI: 10.1016/j.echo.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 06/21/2024] [Accepted: 06/23/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND AND AIMS Approximately 50% of patients with ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) experience microvascular no-reflow. Pre- and post-PCI sonothrombolysis has been shown to decrease infarct size and improve left ventricular (LV) systolic function in STEMI patients receiving urgent PCI. The aim of this study was to investigate whether post-PCI sonothrombolysis alone in STEMI patients with persistent ST elevation could reduce no-reflow and infarct size. METHODS Patients with STEMI with symptoms <12 hours who had persistent ST elevation (≤70% ST resolution) after primary PCI were randomized to sonothrombolysis or control. The primary end point was summed (Σ) ST elevation 60 minutes after study intervention. Secondary end points included infarct size, myocardial perfusion score, LV ejection fraction on cardiovascular magnetic resonance imaging at 2 months follow-up, and clinical outcome at 6-month follow-up. RESULTS Sixty-seven STEMI patients with persistent ST elevation after PCI were randomized (49 left anterior descending, 18 right coronary/left circumflex artery). No difference was observed in Σ ST elevation 60 minutes after study intervention (mean difference, 0.6 mm; 95% CI, -1.1 to 2.2, P = .50). Complete ST resolution occurred in 14 (40%) of patients treated with sonothrombolysis compared to 6 (19%) of controls (P = .16). Myocardial perfusion score index (1.5 ± 0.3 vs 1.5 ± 0.3, P = .93), infarct size (18.0% ± 10% vs 16.8% ± 11%; P = .29) and LV ejection fraction on cardiovascular magnetic resonance (46% ± 8% vs 47% ± 11% in the control group; P = .86) were comparable. Incidence of all-cause death, acute coronary syndrome, and hospital admission for heart failure at 6-month follow-up was similar between the groups (sonothrombolysis, 2; control, 5). CONCLUSIONS In STEMI patients with persistent ST elevation after PCI, post-PCI sonothrombolysis did not result in more ST resolution or smaller infarct size compared to control subjects. The incidence of the combined clinical end points was remarkably low in this high-risk patient population.
Collapse
Affiliation(s)
- Soufiane El Kadi
- Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | | | - Eva M Spoormans
- Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels J W Verouden
- Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Shouqiang Li
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Feng Xie
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Wilson Mathias
- Heart Institute (InCor), University of São Paulo, Medical School, São Paulo, Brazil
| | - Albert C van Rossum
- Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Thomas R Porter
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Otto Kamp
- Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Huang D, Yang X, Ruan H, Zhuo Y, Yuan K, Ruan B, Li F. Enhancing Prediction of Myocardial Recovery After Coronary Revascularization: Integrating Radiomics from Myocardial Contrast Echocardiography with Machine Learning. Int J Gen Med 2024; 17:2539-2555. [PMID: 38841127 PMCID: PMC11151281 DOI: 10.2147/ijgm.s465023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/23/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Chronic coronary artery disease (CAD) management often relies on myocardial contrast echocardiography (MCE), yet its effectiveness is limited by subjective interpretations and difficulty in distinguishing hibernating from necrotic myocardium. This study explores the integration of machine learning (ML) with radiomics to predict functional recovery in dyskinetic myocardial segments in CAD patients undergoing revascularization, aiming to overcome these limitations. Methods This prospective study enrolled 55 chronic CAD patients, dividing into training (39 patients, 205 segments) and testing sets (16 patients, 68 segments). Dysfunctional myocardial segments were identified by initial wall motion scores (WMS) of ≥2 (hypokinesis or higher). Functional recovery was defined as a decrease of ≥1 grade in WMS during follow-up echocardiography. Radiomics features were extracted from dyssynergic segments in end-systolic phase MCE images across five cardiac cycles post- "flash" impulse and processed through a five-step feature selection. Four ML classifiers were trained and compared using these features and MCE parameters, to identify the optimal model for myocardial recovery prediction. Results Functional improvement was noted in 139 out of 273 dyskinetic segments (50.9%) following revascularization. Receiver Operating Characteristic (ROC) analysis determined that myocardial blood flow (MBF) was the most precise clinical predictor of recovery, with an area under the curve (AUC) of 0.770. Approximately 1.34 million radiomics features were extracted, with nine features identified as key predictors of myocardial recovery. The random forest (RF) model, integrating MBF values and radiomics features, demonstrated superior predictive accuracy over other ML classifiers. Validation of the RF model on the testing dataset demonstrated its effectiveness, evidenced by an AUC of 0.821, along with consistent calibration and clinical utility. Conclusion The integration of ML with radiomics from MCE effectively predicts myocardial recovery in CAD. The RF model, combining radiomics and MBF values, presents a non-invasive, precise approach, significantly enhancing CAD management.
Collapse
Affiliation(s)
- Deyi Huang
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Xingan Yang
- Department of Ultrasound, Taizhou Hospital of Zhejiang Province, Linhai City, Zhejiang Province, People’s Republic of China
| | - Hongbiao Ruan
- Department of Cardiology, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Yushui Zhuo
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Kai Yuan
- Department of Clinical Laboratory, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Bowen Ruan
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Fang Li
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| |
Collapse
|
3
|
Becher H, Alhumaid W, Windram J, Choy J. Contrast Echocardiography in Heart Failure: Update 2023. Curr Heart Fail Rep 2024; 21:63-72. [PMID: 38305851 DOI: 10.1007/s11897-024-00647-z] [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] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018. RECENT FINDINGS The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.
Collapse
Affiliation(s)
- Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada.
| | - Waleed Alhumaid
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan Windram
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan Choy
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
| |
Collapse
|
4
|
Kumar A, Connelly K, Vora K, Bainey KR, Howarth A, Leipsic J, Betteridge-LeBlanc S, Prato FS, Leong-Poi H, Main A, Atoui R, Saw J, Larose E, Graham MM, Ruel M, Dharmakumar R. The Canadian Cardiovascular Society Classification of Acute Atherothrombotic Myocardial Infarction Based on Stages of Tissue Injury Severity: An Expert Consensus Statement. Can J Cardiol 2024; 40:1-14. [PMID: 37906238 DOI: 10.1016/j.cjca.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 11/02/2023] Open
Abstract
Myocardial infarction (MI) remains a leading cause of morbidity and mortality. In atherothrombotic MI (ST-elevation MI and type 1 non-ST-elevation MI), coronary artery occlusion leads to ischemia. Subsequent cardiomyocyte necrosis evolves over time as a wavefront within the territory at risk. The spectrum of ischemia and reperfusion injury is wide: it can be minimal in aborted MI or myocardial necrosis can be large and complicated by microvascular obstruction and reperfusion hemorrhage. Established risk scores and infarct classifications help with patient management but do not consider tissue injury characteristics. This document outlines the Canadian Cardiovascular Society classification of acute MI. It is an expert consensus formed on the basis of decades of data on atherothrombotic MI with reperfusion therapy. Four stages of progressively worsening myocardial tissue injury are identified: (1) aborted MI (no/minimal myocardial necrosis); (2) MI with significant cardiomyocyte necrosis, but without microvascular injury; (3) cardiomyocyte necrosis and microvascular dysfunction leading to microvascular obstruction (ie, "no-reflow"); and (4) cardiomyocyte and microvascular necrosis leading to reperfusion hemorrhage. Each stage reflects progression of tissue pathology of myocardial ischemia and reperfusion injury from the previous stage. Clinical studies have shown worse remodeling and increase in adverse clinical outcomes with progressive injury. Notably, microvascular injury is of particular importance, with the most severe form (hemorrhagic MI) leading to infarct expansion and risk of mechanical complications. This classification has the potential to stratify risk in MI patients and lay the groundwork for development of new, injury stage-specific and tissue pathology-based therapies for MI.
Collapse
Affiliation(s)
- Andreas Kumar
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada.
| | - Kim Connelly
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, St Michael's Hospital, University of Toronto, and Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Keyur Vora
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kevin R Bainey
- University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Andrew Howarth
- Cardiac Sciences, Faculty of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Jonathon Leipsic
- Departments of Radiology and Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Suzanne Betteridge-LeBlanc
- Health Sciences North, Sudbury, Ontario, Canada; Northern Ontario School of Medicine University, and Health Sciences North, Sudbury, Ontario, Canada
| | - Frank S Prato
- Lawson Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Howard Leong-Poi
- The Division of Cardiology, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Main
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada
| | - Rony Atoui
- Northern Ontario School of Medicine University, and Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Larose
- Department of Medicine, University of Laval, Quebec City, Quebec, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine/IU Health Cardiovascular Institute, Indianapolis, Indiana, USA
| |
Collapse
|
5
|
Li M, Zeng D, Fei H, Song H, Chen J, Cao S, Hu B, Zhou Y, Guo Y, Xu X, Huang K, Zhang J, Zhou Q. Automatic Myocardial Contrast Echocardiography Image Quality Assessment Using Deep Learning: Impact on Myocardial Perfusion Evaluation. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2247-2255. [PMID: 37495498 DOI: 10.1016/j.ultrasmedbio.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/12/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE The image quality of myocardial contrast echocardiography (MCE) is critical for precise myocardial perfusion evaluation but challenging for echocardiographers. Differences in quality may lead to diagnostic heterogeneity. This study was aimed at achieving automatic MCE image quality assessment using a deep neural network (DNN) and investigating its impact on myocardial perfusion evaluation. METHODS The Resnet-18 model was used for training and testing on internal and external data sets. Quality assessment involved three aspects: left ventricular opacification (LVO), shadowing, and flash adequacy; the quality score was calculated based on image quality. This study explored the impact of the DNN-based quality score on perfusion evaluation (normal, delay or obstruction) by echocardiographers (two seniors, one junior and one novice). Additionally, the effect of the score difference between re-scans on perfusion evaluation was investigated. RESULTS The time cost for DNN prediction was 0.045 s/frame. In internal validation and external testing, the DNN achieved F1 and macro F1 scores >90% for quality assessment and had high intraclass correlation coefficients (0.954 and 0.892, respectively) in sequence quality scores. The proportion of segments deemed uninterpretable increased as the DNN-based quality score decreased. The agreement of perfusion assessment between one senior and others decreased as the quality score decreased. And the greater the score difference between the re-scans, the lower was the agreement on perfusion assessment by the same echocardiographer. CONCLUSION This study determined the effectiveness of DNN for real-time automatic MCE quality assessment. It has the potential to reduce the variability in perfusion evaluation among echocardiographers.
Collapse
Affiliation(s)
- Mingqi Li
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Dewen Zeng
- Department of Computer Science and Engineering, University of Notre Dame, South Bend, IN, USA
| | - Hongwen Fei
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Hongning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jinling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Sheng Cao
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bo Hu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yanxiang Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuxin Guo
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaowei Xu
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Kui Huang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ji Zhang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China.
| |
Collapse
|
6
|
Sun S, Chen N, Sun Q, Wei H, Fu T, Shang Z, Sun Y, Cong T, Xia Y, Xie F, Porter TR. Association Between Segmental Noninvasive Myocardial Work and Microvascular Perfusion in ST-Segment Elevation Myocardial Infarction: Implications for Left Ventricular Functional Recovery and Clinical Outcomes. J Am Soc Echocardiogr 2023; 36:1055-1063. [PMID: 37225007 DOI: 10.1016/j.echo.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Predicting left ventricular recovery (LVR) after acute ST-segment elevation myocardial infarction (STEMI) is of prognostic importance. This study aims to explore the prognostic implications of segmental noninvasive myocardial work (MW) and microvascular perfusion (MVP) after STEMI. METHODS In this retrospective study, 112 patients with STEMI who underwent primary percutaneous coronary intervention and transthoracic echocardiography after percutaneous coronary intervention were enrolled. Microvascular perfusion was analyzed by myocardial contrast echocardiography, and segmental MW was analyzed by noninvasive pressure-strain loops. A total of 671 segments with abnormal function at baseline were analyzed. The degrees of MVP were observed following intermittent high-mechanical index impulses: replenishment within 4 seconds (normal MVP), replenishment >4 seconds and within 10 seconds (delayed MVP), and persistent defect (microvascular obstruction). The correlation between MW and MVP was analyzed. The correlation of the MW and MVP with LVR (normalization of wall thickening, >25%) was assessed. The prognostic value of segmental MW and MVP for cardiac events (cardiac death, admission for congestive heart failure, or recurrent myocardial infarction) was evaluated. RESULTS Normal MVP was seen in 70 segments, delayed MVP in 236, and microvascular obstruction in 365. The segmental MW indices were independently correlated with MVP; 244 (36.4%) segments had segmental LVR at 3-month follow-up. Segmental MW efficiency and MVP were independently associated with segmental LVR (P < .05). The χ2 of combination of segmental MW efficiency and MVP was higher than either index alone for identifying segmental LVR (P < .001). At a median follow-up of 42.0 months, cardiac events occurred in 13 patients; all regional MW parameters, high sensitivity troponin I, regional longitudinal strain, and so on were associated with cardiac events. CONCLUSIONS Segmental MW indices are associated with MVP within the infarct zone following reperfused STEMI. Both are independently associated with segmental LVR, and regional MW is associated with cardiac events, providing prognostic value in STEMI patients.
Collapse
Affiliation(s)
- Siyao Sun
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Na Chen
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Qiaobing Sun
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Hong Wei
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Tingting Fu
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Zhijuan Shang
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Yinghui Sun
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Tao Cong
- Department of Cardiac Ultrasound, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China.
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Da Lian Medical University, Da Lian City, Liao Ning Province, People's Republic of China
| | - Feng Xie
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Thomas R Porter
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| |
Collapse
|
7
|
Sehatbakhsh S, Mignatti A, Murthy S, Latib A. A novel therapy in microvascular obstruction in ST-elevation myocardial infarction: pressure-controlled intermittent coronary sinus occlusion therapy. Future Cardiol 2023; 19:615-623. [PMID: 37933690 DOI: 10.2217/fca-2023-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Percutaneous coronary intervention has transformed the management of ST-elevation myocardial infarction (STEMI) due to a reduction in early mortality and need for repeat revascularization. However, the conventional revascularization strategy, combined with state-of-the-art anti-thrombotic and antiplatelet therapies, can still be associated with poor clinical outcome in some patients, because of reperfusion injury and microvascular obstruction contributing to the infarct size. To address this important therapeutic need, a broad-range of device-based treatments have been introduced. This is an overview of the pressure-controlled intermittent coronary sinus occlusion (PiCSO) device (Miracor Medical SA) which has been proposed for STEMI patients. PiCSO therapy could lead to an improved perfusion, decrease microvascular dysfunction, and thus potentially reduce infarct size.
Collapse
Affiliation(s)
| | - Andrea Mignatti
- Division of Cardiology, Montefiore Medical Center, New York, 10467 NY, USA
| | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, New York, 10467 NY, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, 10467 NY, USA
| |
Collapse
|
8
|
Liu D, Lin R, Tao B, Hu J, Cheng L, Lou X, Li M, Li S, Zhu Y, Li N, Fang Y, Wang Y, Wang Y, Cao F. Translational large animal model of coronary microvascular embolism: characterization by serial cardiac magnetic resonance and histopathology. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1741-1752. [PMID: 37316646 DOI: 10.1007/s10554-023-02860-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 06/16/2023]
Abstract
This study aimed to construct a large animal model of coronary microvascular embolism, and investigate whether it could mimic the clinical imaging phenotypes of myocardial hypoperfusion in patients with ST-segment elevation myocardial infarction (STEMI). Nine minipigs underwent percutaneous coronary embolization with microspheres, followed by cardiac magnetic resonance (CMR) on week 1, 2 and 4 post operation. Microvascular obstruction (MVO) was defined as the isolated hypointense core within the enhanced area on late gadolinium enhancement images, which evolved during a 4-week follow-up. Fibrotic fraction of the segments was measured by Masson trichrome staining using a panoramic analysis software. Iron deposit and macrophage infiltration were quantified based on Perl's blue and anti-CD163 staining, respectively. Seven out of 9 (77.8%) minipigs survived and completed all of the imaging follow-ups. Four out of 7 (57.1%) minipigs were identified as transmural infarct with MVO. The systolic wall thickening (SWT) of MVO zone was similar to that of infarct zone (P = 0.762). Histopathology revealed transmural deposition of collagen, with microvessels obstructed by microspheres. The fibrotic fraction of infarct with MVO segments was similar to that of infarct without MVO segments (P = 0.954). The fraction of iron deposit in infarct with MVO segments was higher than that of infarct without MVO segments (P < 0.05), but the fraction of macrophage infiltration between these two segments did not show statistical difference (P = 0.723). Large animal model of coronary microvascular embolism could mimic most clinical imaging phenotypes of myocardial hypoperfusion in patients with STEMI, demonstrated by serial CMR and histopathology.
Collapse
Affiliation(s)
- Dongyue Liu
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Rui Lin
- Beijing Anzhen Hospital, Key Laboratory of Remodelling-Related Cardiovascular Diseases, Collaborative Innovation Centre for Cardiovascular Disorders, Capital Medical University, Ministry of Education, Beijing, 100029, China
| | - Bo Tao
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
- Department of Cardiology, Hainan Hospital of Chinese PLA General Hospital, Sanya, Hainan, 572013, China
| | - Jianxing Hu
- Department of Radiology, First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, China
| | - Liuquan Cheng
- Department of Radiology, Sixth Medical Centre of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xin Lou
- Department of Radiology, First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, China
| | - Menglu Li
- Department of Radiology, Sixth Medical Centre of Chinese PLA General Hospital, Beijing, 100039, China
| | - Sulei Li
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Yan Zhu
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Na Li
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Yan Fang
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Yabin Wang
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China
| | - Yuan Wang
- Beijing Anzhen Hospital, Key Laboratory of Remodelling-Related Cardiovascular Diseases, Collaborative Innovation Centre for Cardiovascular Disorders, Capital Medical University, Ministry of Education, Beijing, 100029, China.
| | - Feng Cao
- Department of Cardiology, National Research Centre for Geriatric Diseases & Second Medical Centre of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, 100853, China.
| |
Collapse
|
9
|
Li M, Zeng D, Zhou Y, Chen J, Cao S, Song H, Hu B, Yuan W, Chen J, Yang Y, Wang H, Fei H, Shi Y, Zhou Q. A novel risk stratification model for STEMI after primary PCI: global longitudinal strain and deep neural network assisted myocardial contrast echocardiography quantitative analysis. Front Cardiovasc Med 2023; 10:1140025. [PMID: 37180792 PMCID: PMC10172492 DOI: 10.3389/fcvm.2023.1140025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/14/2023] [Indexed: 05/16/2023] Open
Abstract
Background In ST-segment elevation myocardial infarction (STEMI) with the restoration of TIMI 3 flow by percutaneous coronary intervention (PCI), visually defined microvascular obstruction (MVO) was shown to be the predictor of poor prognosis, but not an ideal risk stratification method. We intend to introduce deep neural network (DNN) assisted myocardial contrast echocardiography (MCE) quantitative analysis and propose a better risk stratification model. Methods 194 STEMI patients with successful primary PCI with at least 6 months follow-up were included. MCE was performed within 48 h after PCI. The major adverse cardiovascular events (MACE) were defined as cardiac death, congestive heart failure, reinfarction, stroke, and recurrent angina. The perfusion parameters were derived from a DNN-based myocardial segmentation framework. Three patterns of visual microvascular perfusion (MVP) qualitative analysis: normal, delay, and MVO. Clinical markers and imaging features, including global longitudinal strain (GLS) were analyzed. A calculator for risk was constructed and validated with bootstrap resampling. Results The time-cost for processing 7,403 MCE frames is 773 s. The correlation coefficients of microvascular blood flow (MBF) were 0.99 to 0.97 for intra-observer and inter-observer variability. 38 patients met MACE in 6-month follow-up. We proposed A risk prediction model based on MBF [HR: 0.93 (0.91-0.95)] in culprit lesion areas and GLS [HR: 0.80 (0.73-0.88)]. At the best risk threshold of 40%, the AUC was 0.95 (sensitivity: 0.84, specificity: 0.94), better than visual MVP method (AUC: 0.70, Sensitivity: 0.89, Specificity: 0.40, IDI: -0.49). The Kaplan-Meier curves showed that the proposed risk prediction model allowed for better risk stratification. Conclusion The MBF + GLS model allowed more accurate risk stratification of STEMI after PCI than visual qualitative analysis. The DNN-assisted MCE quantitative analysis is an objective, efficient and reproducible method to evaluate microvascular perfusion.
Collapse
Affiliation(s)
- Mingqi Li
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Dewen Zeng
- Department of Computer Science and Engineering, University of Notre Dame, South Bend, IN, United States
| | - Yanxiang Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jinling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Sheng Cao
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bo Hu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenyue Yuan
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jing Chen
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuanting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hao Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongwen Fei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yiyu Shi
- Department of Computer Science and Engineering, University of Notre Dame, South Bend, IN, United States
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
- Correspondence: Qing Zhou
| |
Collapse
|
10
|
Wang L, Ma Y, Jin W, Zhu T, Wang J, Yu C, Zhang F, Jiang B. Coronary microcirculation dysfunction evaluated by myocardial contrast echocardiography predicts poor prognosis in patients with ST-segment elevation myocardial infarction after percutaneous coronary intervention. BMC Cardiovasc Disord 2022; 22:572. [PMID: 36577944 PMCID: PMC9795674 DOI: 10.1186/s12872-022-02947-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The mortality rate of acute ST-segment elevation myocardial infarction (STEMI) remains substantial, despite advances in treatment strategies. Coronary microcirculation dysfunction (CMD) persists after percutaneous coronary intervention (PCI) in a substantial proportion of STEMI patients. The association between CMD assessed using myocardial contrast echocardiography (MCE) and prognosis requires further elucidation. This study aimed to evaluate the impact of CMD after successful PCI on the prognosis of patients with STEMI. METHODS We enrolled 167 patients with STEMI after PCI who underwent MCE during hospitalization between January 2018 and March 2022. Patients were classified into the CMD and non-CMD groups according to the results of MCE. The clinical data and MCE results of both groups were analyzed. Follow-up was conducted for major adverse cardiac events. RESULTS MCE detected CMD in 105 patients (62.9%). The CMD group contained fewer hypertensive patients (55.2% versus 74.2%, P = 0.015). Patients with CMD exhibited significantly higher levels of plasma troponin I (TnI) [73.2 (23.0-124.0) versus 28.9 (12.7-80.2) ng/mL, P = 0.004], higher levels of plasma B-type natriuretic peptide [255 (99-641) versus 193 (59-389) pg/mL, P = 0.004], poorer Killip classification (P = 0.038), and different culprit vessels (P < 0.001) compared to the non-CMD group. Patients with CMD exhibited lower left ventricular ejection fraction [50 (43-58) versus 61 (54-67) %, P < 0.001], poorer wall motion score index values (1.68 ± 0.4 versus 1.31 ± 0.26, P < 0.001) and poorer left ventricular global longitudinal strain [-11.2 (-8.7 to -14.1) versus -13.9 (-11.0 to -17.2) %, P < 0.001] compared to the non-CMD group. Patients underwent follow-up for 13 (7-20) months. After adjusting for hypertension, peak TnI level, culprit vessel, and Killip classification, CMD was an independent predictor of total major adverse cardiac events at 13 months' follow-up [adjusted odds ratio (OR), 2.457; 95% confidence interval (CI), 1.042-5.790; P = 0.040], and patients with CMD had a higher risk of hospitalization for heart failure (adjusted OR, 5.184; 95% CI, 1.044-25.747; P = 0.044) and repeat myocardial infarction (adjusted OR, 2.896; 95% CI, 1.109-7.565; P = 0.030). CONCLUSIONS MCE is a safe and effective method for detecting CMD in patients with STEMI. CMD detected by MCE after successful PCI in patients with STEMI is a common occurrence, which is associated with a significantly worse prognosis, especially hospitalization for heart failure and repeat myocardial infarction.
Collapse
Affiliation(s)
- Lan Wang
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Yuliang Ma
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Wenying Jin
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Tiangang Zhu
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Jing Wang
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Chao Yu
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China
| | - Feng Zhang
- grid.411634.50000 0004 0632 4559Department of Cardiology, Peking University People’s Hospital, Beijing, China ,Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Beijing, China ,grid.411634.50000 0004 0632 4559Center for Cardiovascular Translational Research, Beijing, China
| | - Bailin Jiang
- grid.411634.50000 0004 0632 4559Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| |
Collapse
|
11
|
Gibson CM, Ajmi I, von Koenig CL, Turco MA, Stone GW. Pressure-Controlled Intermittent Coronary Sinus Occlusion: A Novel Approach to Improve Microvascular Flow and Reduce Infarct Size in STEMI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 45:9-14. [PMID: 35918254 DOI: 10.1016/j.carrev.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/21/2022] [Accepted: 07/19/2022] [Indexed: 01/04/2023]
Abstract
Despite successful primary percutaneous coronary intervention (PCI) for treatment of ST-segment elevation myocardial infarction (STEMI), myocardial salvage is frequently suboptimal resulting in large infarctions with increased rates of heart failure and death. Microvascular dysfunction after the procedure is frequently present and contributes directly to poor outcomes in STEMI. Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) is a novel technology designed to mitigate microvascular dysfunction in STEMI. Non-randomized studies have suggested that PiCSO use during primary PCI in STEMI is safe, improves microvascular perfusion and reduces infarct size. Randomized trials are ongoing to investigate the safety and effectiveness of PiCSO in high-risk patients with anterior STEMI undergoing primary PCI.
Collapse
Affiliation(s)
- C Michael Gibson
- Beth Israel Lahey, USA; Baim Institute for Clinical Research (FKA Harvard Clinical Research Institute), USA; Harvard Medical School, USA
| | - Issameddine Ajmi
- Helios Frankenwaldklinik Kronach, Freisener Strasse 41, 96317 Kronach, Germany
| | - Cajetan L von Koenig
- Miracor Medical SA, E40 Business Park, Rue de Bruxelles, 174, 4340 Awans, Belgium.
| | | | - Gregg W Stone
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
| |
Collapse
|
12
|
Ma Y, Wang L, Jin W, Zhu T, Liu J, Zhao H, Wang J, Lu M, Cao C, Jiang B. Left ventricular function and coronary microcirculation in patients with mild reduced ejection fraction after STEMI. BMC Cardiovasc Disord 2022; 22:423. [PMID: 36154928 PMCID: PMC9511738 DOI: 10.1186/s12872-022-02846-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The characteristics of heart failure (HF) with mildly reduced ejection fraction (EF) (HFmrEF) overlap with those of HF with reduced EF (HFrEF) and HF with preserved EF (HFpEF) and need to be further explored. This study aimed to evaluate left ventricular (LV) function and coronary microcirculation in patients with mildly reduced ejection fraction after acute ST-segment elevation myocardial infarction (STEMI). METHODS We enrolled 119 patients with STEMI who had undergone speckle tracking imaging and myocardial contrast echocardiography during hospitalization from June 2016 to June 2021. They were classified into normal, HFmrEF, and HFrEF groups according to their left ventricular EF (LVEF): ≥ 50%, 40-50%, and ≤ 40%, respectively. The data of the HFmrEF group were analyzed and compared with those of the normal and HFrEF groups. RESULTS HFmrEF was observed in 32 patients (26.9%), HFrEF in 17 (14.3%), and normal LVEF in 70 patients (58.8%). The mean global longitudinal strain (GLS) of all patients was - 11.9 ± 3.8%. The GLS of HFmrEF patients was not significantly different from that of the HFrEF group (- 9.9 ± 2.5% and - 8.0 ± 2.3%, respectively, P = 0.052), but they were both lower than that of the normal group (- 13.8% ± 3.5%, P < 0.001). The HFmrEF group exhibited significantly poorer myocardial perfusion index (1.24 ± 0.33) than the normal group (1.08 ± 0.14, P = 0.005) but displayed no significant difference from the HFrEF group (1.18 ± 0.19, P = 0.486). Moreover, a significant difference in the incidence of regional wall motion (WM) abnormalities in the three groups was observed (P = 0.009), and the WM score index of patients with HFmrEF was 1.76 ± 0.30, similar to that of patients with HFrEF (1.81 ± 0.43, P = 0.618), but poorer than that in the normal group (1.33 ± 0.25, P < 0.001). CONCLUSIONS GLS is a more sensitive tool than LVEF for detecting LV systolic dysfunction. The LV systolic function, coronary microcirculation, and WM in patients with HFmrEF was poorer than that of patients with normal LVEF, but comparable to that in patients with HFrEF. Patients with HFmrEF after STEMI require more attention and appropriate management.
Collapse
Affiliation(s)
- Yuliang Ma
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Lan Wang
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Wenying Jin
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Tiangang Zhu
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China.
| | - Jian Liu
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Hong Zhao
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Jing Wang
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Mingyu Lu
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Chengfu Cao
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction; Center for Cardiovascular Translational Research, Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Bailin Jiang
- Department of Anesthesiology and Pain Medicine, Peking University People's Hospital, Beijing, China
| |
Collapse
|
13
|
Novel therapeutic strategies to reduce reperfusion injury after acute myocardial infarction. Curr Probl Cardiol 2022; 47:101398. [PMID: 36108813 DOI: 10.1016/j.cpcardiol.2022.101398] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
For almost 30 years, urgent revascularization termed primary percutaneous coronary intervention (pPCI) has been a cornerstone of modern care for acute myocardial infarction (AMI). It lowers mortality and improved cardiovascular outcome compared to conservative therapy including thrombolysis. Reperfusion injury, which occurs after successful re-opening of the formerly occluded coronary artery, had been exploited as a potential therapeutic target. When revascularisation became faster and pPCI was successfully performed within 60-90 minutes of symptom onset, the interest in a potential additive effect of targeting reperfusion injury vanished. More recently, several meta-analyses indicated that limiting reperfusion injury prevents microvascular obstruction and reduces final infarct size, thereby lowering the probability of heart failure events and improving quality of life in AMI survivors. Here, we describe the current strategies to limit reperfusion injury and to improve post-AMI outcomes such as systemic or intracoronary hypothermia, left-ventricular unloading, intracoronary infusion of super-saturated oxygen, intermittent coronary sinus occlusion, and C-reactive protein apharesis.
Collapse
|
14
|
Zhou YX, Hu YG, Cao S, Xiong Y, Lei JR, Yuan WY, Chen JL, Zhou Q. Prognostic value of myocardial contrast echocardiography in acute anterior wall ST-segment elevation myocardial infarction with successful epicardial recanalization. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1487-1497. [PMID: 35284974 DOI: 10.1007/s10554-022-02545-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
Abstract
Although myocardial contrast echocardiography (MCE) can evaluate microvascular perfusion abnormalities, its prognostic value is uncertain in acute anterior wall ST-Segment elevation myocardial infarction (STEMI) with successful epicardial recanalization. Therefore, the study aims to investigate the prognostic role of qualitative and quantitative MCE in acute anterior wall STEMI with successful epicardial recanalization. 153 STEMI patients were assessed by MCE within 7 days after successful epicardial recanalization. Qualitative perfusion parameters (microvascular perfusion score index, MPSI) and quantitative perfusion parameters (A, β, and Aβ) were acquired using a 17-segment model. And corrected A and Aβ were calculated. Patients were all followed for major adverse cardiovascular events (MACEs). During median follow-up of 27 (4) months, 39 (25.49%) patients experienced MACEs, while 114 (74.51%) were free from MACEs. Patients with MACEs had higher MPSI (1.65 ± 0.13 vs. No-MACEs 1.35 ± 0.20, P < 0.001), lower β (1.09 ± 0.19 s-1 vs. No-MACEs 1.34 ± 0.30 s-1, P < 0.001), corrected A (0.17 ± 0.03 dB vs. No-MACEs 0.19 ± 0.04 dB, P = 0.039) and lower corrected Aβ (0.19 ± 0.06 dB/s vs. No-MACEs 0.25 ± 0.08 dB/s, P < 0.001). MPSI of 1.44 provided an area under the curve (AUC) of 0.872, while β of 1.18 s-1 and corrected Aβ of 0.22 dB/s provided AUCs of 0.759 and 0.724, respectively. The combination of MPSI, β and corrected Aβ provided an increased AUC of 0.964 (all P < 0.05). Time-dependent ROC analysis showed that the AUCs of the MPSI, β, corrected Aβ and the combination at 1, 1.5 and 2 years indicated a strong predictive power for MACEs (AUC = 0.900/0.894/0.881 for MPSI, 0.648/0.704/0.732 for β, 0.674/0.686/0.722 for corrected Aβ, and 0.947/0.962/0.967 for the combination, respectively). Patients with MPSI < 1.44, β > 1.18 s-1, or corrected Aβ > 0.22 dB/s had lower event rate (all Log Rank P ≤ 0.001). MPSI, β, corrected Aβ, GLS and WBC were independent predictors of MACEs with adjusted hazard ratio of 34.41 (8.18-144.87), P < 0.001 for MPSI; 39.29 (27.46-65.44), P < 0.001 for β; 8.93 (1.46-54.55), P = 0.018 for corrected Aβ; 10.88 (2.83-41.86), P = 0.001 for GLS; and 1.43 (1.16-1.75), P = 0.001 for WBC. Qualitative and quantitative MCE can accurately predict MACEs in acute anterior wall STEMI with successful epicardial recanalization, and their combined predictive value is higher.
Collapse
Affiliation(s)
- Yan-Xiang Zhou
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Yu-Gang Hu
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Sheng Cao
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Ye Xiong
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Jia-Rui Lei
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Wen-Yue Yuan
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China
| | - Jin-Ling Chen
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China.
| | - Qing Zhou
- Department of Ultrasonography, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, 430060, Hubei, People's Republic of China.
| |
Collapse
|
15
|
Jin W, Wang L, Zhu T, Ma Y, Yu C, Zhang F. Usefulness of echocardiographic myocardial work in evaluating the microvascular perfusion in STEMI patients after revascularization. BMC Cardiovasc Disord 2022; 22:218. [PMID: 35562649 PMCID: PMC9107134 DOI: 10.1186/s12872-022-02648-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/22/2022] [Indexed: 11/14/2022] Open
Abstract
Background Left ventricular myocardial work (MW) assessed by echocardiography has recently been introduced as a new index of global and regional myocardial performance. The presence of microvascular obstruction after revascularization in ST-segment elevation myocardial infarction (STEMI) patients predicts poor clinical outcomes. This study aimed to explore the usefulness of MW in identifying impaired microvascular perfusion (MVP) in the patients with STEMI after revascularization. Methods One hundred and sixty STEMI patients who underwent myocardial contrast echocardiography (MCE) within 48 h after percutaneous coronary intervention (PCI) were included. Patients were divided into normal MVP and impaired MVP groups according to the myocardial perfusion score. The clinical data, coronary angiography results and echocardiographic data including Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were collected. Results Impaired MVP was found in 60% of patients. Compared with the normal MVP group, GWI (909.2 ± 287.6 mmHg% vs. 1191.2 ± 378.2 mmHg%), GCW (1198.3 ± 339.6 mmHg% vs. 1525.9 ± 420.5 mmHg%), GWE (82.7 ± 7.8% vs. 86.8 ± 5.6%) and GLS (− 11.0 ± 3.4% vs. − 14.4 ± 3.8%) were significantly reduced in the impaired MVP group. Whereas there was no statistically significant difference in left ventricular ejection fraction (LVEF) and GWW, multivariate logistic regression analysis showed that peak troponin I (OR 1.017, 95% CI 1.006–1.029; P = 0.004), final TIMI flow ≤ 2 (OR 16.366, 95% CI 1.998–134.06; P = 0.009), left ventricular end-diastolic volume index (LVEDVi) (OR 1.139 95% CI 1.048–1.239; P = 0.002), and GWI (OR 0.997 95% CI 0.994–1.000; P = 0.029) were independently associated with impaired MVP. GWI showed a good sensitivity (86.8%) but low specificity (53.7%) in identifying impaired MVP (AUC 0.712, 95% CI 0.620–0.804; P < 0.001). Combination with GWI can improve the diagnostic value of TNI or LVEVi for impaired MVP. Conclusion Impaired MVP is relatively common in STEMI patients after revascularization and independently associated with left ventricular GWI assessed by echocardiography. GWI confer incremental value to MVP assessment in STEMI patients.
Collapse
Affiliation(s)
- Wenying Jin
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Lan Wang
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Tiangang Zhu
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China.
| | - Yuliang Ma
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Chao Yu
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Feng Zhang
- Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| |
Collapse
|
16
|
Contrast Ultrasound, Sonothrombolysis and Sonoperfusion in Cardiovascular Disease: Shifting to Theragnostic Clinical Trials. JACC Cardiovasc Imaging 2022; 15:345-360. [PMID: 34656483 PMCID: PMC8837667 DOI: 10.1016/j.jcmg.2021.07.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 02/03/2023]
Abstract
Contrast ultrasound has a variety of applications in cardiovascular medicine, both in diagnosing cardiovascular disease as well as providing prognostic information. Visualization of intravascular contrast microbubbles is based on acoustic cavitation, the characteristic oscillation that results in changes in the reflected ultrasound waves. At high power, this acoustic response generates sufficient shear that is capable of enhancing endothelium-dependent perfusion in atherothrombotic cardiovascular disease (sonoperfusion). The oscillation and collapse of microbubbles in response to ultrasound also induces microstreaming and jetting that can fragment thrombus (sonothrombolysis). Several preclinical studies have focused on identifying optimal diagnostic ultrasound settings and treatment regimens. Clinical trials have been performed in acute myocardial infarction, stroke, and peripheral arterial disease often with improved outcome. In the coming years, results of ongoing clinical trials along with innovation and improvements in sonothrombolysis and sonoperfusion will determine whether this theragnostic technique will become a valuable addition to reperfusion therapy.
Collapse
|
17
|
Zhu Q, Zhang Y, Tang J, Tang N, He Y, Chen X, Gao S, Xu Y, Liu Z. Ultrasound-Targeted Microbubble Destruction Accelerates Angiogenesis and Ameliorates Left Ventricular Dysfunction after Myocardial Infarction in Mice. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2692-2701. [PMID: 34130882 DOI: 10.1016/j.ultrasmedbio.2021.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/25/2021] [Accepted: 04/25/2021] [Indexed: 06/12/2023]
Abstract
Failure of coronary recanalization within 12 h or no flow in the myocardium after percutaneous coronary intervention is associated with high mortality from myocardial infarction, and insufficient angiogenesis in the border zone results in the expansion of infarct area. In this study, we examined the effects of ultrasound-targeted microbubble destruction (UTMD) on angiogenesis and left ventricular dysfunction in a mouse model of myocardial infarction. Fifty-four mice with MI were treated with no UTMD, ultrasound (US) alone or UTMD four times (days 1, 3, 5 and 7), and another 18 mice underwent sham operation and therapy. Therapeutic US was generated with a linear transducer connected to a commercial diagnostic US system (VINNO70). UTMD was performed with the VINNO70 at a peak negative pressure of 0.8 MPa and lipid microbubbles. Transthoracic echocardiography was performed on the first and seventh days. The results indicated that UTMD decreased the infarct size ratio from 78.1 ± 5.3% (untreated) to 43.3 ± 6.4%, accelerated angiogenesis and ameliorated left ventricular dysfunction. The ejection fraction increased from 25.05 ± 8.52% (untreated) to 42.83 ± 9.44% (UTMD). Compared with that in other groups, expression of vascular endothelial growth factor and endothelial nitric oxide synthase and release of nitric oxide were significantly upregulated after UTMD treatment, indicating angiogenesis. Therefore, UTMD is a potential physical approach in the treatment of myocardial infarction.
Collapse
Affiliation(s)
- Qiong Zhu
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yi Zhang
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jiawei Tang
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Najiao Tang
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ying He
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xiaoqin Chen
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shunji Gao
- Department of Ultrasound, General Hospital of Central Theater Command, Wuhan, China
| | - Yali Xu
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Zheng Liu
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, China.
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW High mechanical index impulses from a diagnostic transducer are utilized in myocardial perfusion imaging, but can also be utilized therapeutically in three cardiovascular applications: (a) thrombus dissolution (sonothrombolysis), (b) improving microvascular flow in ischemic territories (sonoperfusion), and (c) targeted drug and nucleic acid delivery. The targeted therapeutic effect appears to be based on acoustic cavitation of the intravascular microbubbles which results in endothelial shear and pore formation, as well as mechanical destruction of thrombi. RECENT FINDINGS Within the last 5 years, clinical trials have been performed in acute myocardial infarction demonstrating successful reductions in myocardial infarct size with sonothrombolysis added to current guideline-based treatment. In patients with severe peripheral arterial disease, brief improvements in calf microvascular blood flow have been observed for 1 h after 10 min of sonoperfusion therapy. Targeted ultrasound therapies are developing for prevention of microvascular obstruction in acute coronary syndromes and peripheral vascular disease.
Collapse
|
19
|
Affiliation(s)
- Jonathan R Lindner
- Knight Cardiovascular Institute, the Oregon National Primate Research Center, Oregon Health and Science University, Portland
| |
Collapse
|