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Abu Arab T, Sedhom R, Gomaa Y, El Etriby A. Intracoronary adenosine compared with adrenaline and verapamil in the treatment of no-reflow phenomenon following primary PCI in STEMI patients. Int J Cardiol 2024; 410:132228. [PMID: 38844092 DOI: 10.1016/j.ijcard.2024.132228] [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: 03/01/2024] [Revised: 05/12/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND no-reflow can complicate up to 25% of pPCI and is associated with significant morbidity and mortality. We aimed to compare the outcomes of intracoronary epinephrine and verapamil with intracoronary adenosine in the treatment of no-reflow after primary percutaneous coronary intervention (pPCI). METHODS 108 STEMI patients had no-reflow during pPCI were assigned into four groups. Group 1, in which epinephrine and verapamil were injected through a well-cannulated guiding catheter. Group 2, in which same drugs were injected in the distal coronary bed through a microcatheter or perfusion catheter. Group 3, in which adenosine was injected through a guiding catheter. Group 4, in which adenosine was injected in distal coronary bed. Primary end point was the achievement of TIMI III flow and MBG II or III. Secondary end point was major adverse cardiovascular and cerebrovascular events (MACCEs) during hospital stay. RESULTS The study groups did not differ in their baseline characteristics. Primary end point was achieved in 15 (27.8%) patients in the guide-delivery arm compared with 34 (63%) patients in the local-delivery arm, p < 0.01. However, the primary end point did not differ between the epinephrine/verapamil group and the adenosine group (27 (50%) vs 22 (40.7%), p = 0.334). The secondary end points were similar between the study groups. CONCLUSION Local delivery of epinephrine, verapamil and adenosine in the distal coronary bed is more effective in achieving TIMI III flow with MBG II or III compared with their guide-delivery in patients who suffered no-reflow during pPCI. There was no difference between epinephrine/verapamil Vs. adenosine.
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Affiliation(s)
- Tamer Abu Arab
- Department of Cardiology, Ain Shams University Hospital, Cairo, Egypt.
| | - Ramy Sedhom
- Department of Cardiology, Ain Shams University Hospital, Cairo, Egypt
| | - Yasser Gomaa
- Department of Cardiology, Ain Shams University Hospital, Cairo, Egypt
| | - Adel El Etriby
- Department of Cardiology, Ain Shams University Hospital, Cairo, Egypt.
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2
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Contemporary Management of Severely Calcified Coronary Lesions. J Pers Med 2022; 12:jpm12101638. [PMID: 36294777 PMCID: PMC9605395 DOI: 10.3390/jpm12101638] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality’s relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.
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3
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De Maria GL, Scarsini R, Banning AP. Management of Calcific Coronary Artery Lesions: Is it Time to Change Our Interventional Therapeutic Approach? JACC Cardiovasc Interv 2020; 12:1465-1478. [PMID: 31395217 DOI: 10.1016/j.jcin.2019.03.038] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/07/2023]
Abstract
Patients with obstructive coronary lesions with a high calcium content (LHCC) have an exaggerated clinical risk, because the presence of calcification is associated with more extensive coronary atheroma and higher burden of comorbidities. Treatment of LHCC using percutaneous techniques is complex because of an increased risk of incomplete lesion preparation with suboptimal stent deployment and higher rates of acute and chronic stent failure. Rotational atherectomy has been the predominant technology for treatment of high-grade LHCC, but novel devices/technologies have entered clinical practice. It seems likely that combining enhanced intravascular imaging, which allows definition of the patterns of calcification with these new technologies, will herald a change in procedural algorithms for treatment of LHCC. This review provides an overview about LHCC with special focus on existing and emergent technologies. We also provide a proposed procedural algorithm to facilitate optimal use of technology according to specific features of LHCC and coronary anatomy.
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Affiliation(s)
| | - Roberto Scarsini
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom.
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4
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Chen BH, An DA, He J, Xu JR, Wu LM, Pu J. Myocardial Extracellular Volume Fraction Allows Differentiation of Reversible Versus Irreversible Myocardial Damage and Prediction of Adverse Left Ventricular Remodeling of ST-Elevation Myocardial Infarction. J Magn Reson Imaging 2020; 52:476-487. [PMID: 31943526 DOI: 10.1002/jmri.27047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The relationship between dynamic changes of myocardial injury in ST-elevation myocardial infarction (STEMI) patients and long-term prognosis is still unclear. PURPOSE To evaluate the extracellular volume fraction (ECV) in the differentiation of reversible from irreversible myocardial injury and the prediction value of left ventricular adverse remodeling in patients with STEMI after reperfusion. STUDY TYPE Prospective. POPULATION Twenty-four STEMI patients after reperfusion were included FIELD STRENGTH/SEQUENCE: 3.0 T, T1 mapping, ECV, T2 -STIR, and late gadolinium enhancement (LGE). ASSESSMENT All the patients underwent cardiac MRI at four timepoints (days 1, 3, and 7, and at 6 months). The regions of interest (ROIs) were selected at the infarcted myocardium (with/without intramyocardial hemorrhage [IMH] and microvascular obstruction [MVO]). STATISTICAL TESTS One-way analysis of variance and the Kruskal-Wallis test were used for the statistical analysis. RESULTS Native T1 of MI (without MVO/IMH) gradually decreased after reperfusion (P < 0.05). The ECV of MI increased during the first 3 days and then slowly declined. Native T1 of MI with MVO/IMH was the lowest (1184 msec; 1108.5-1266), while ECV (78%; 65.5-87%) was the highest, P < 0.001. Native T1 and ECV of salvageable myocardium were higher than those of the remote myocardium but lower than those of the MI without MVO or IMH (P < 0.001). ROC analysis revealed an area under the curve (AUC) of ECV (0.85, P < 0.001) for differentiating infarcted and salvageable myocardium was higher than that of native T1 mapping (AUC: 0.63, P < 0.001) in the first week after STEMI (P < 0.0001). T1 and ECV differed significantly between patients with and without left ventricle adverse remodeling (P < 0.05). DATA CONCLUSION Dynamic temporal changes in reversibly and irreversibly damaged myocardia were differentiated via native T1 and ECV mapping after primary percutaneous coronary intervention in STEMI patients. ECV may better reflect microvascular injury severity and myocardial viability. MI with higher native T1 and ECV or with severe microvascular injury (MVO and IMH) was correlated with adverse LV remodeling. LEVEL OF EVIDENCE 2 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020. J. Magn. Reson. Imaging 2020;52:476-487.
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Affiliation(s)
- Bing-Hua Chen
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dong-Aolei An
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie He
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian-Rong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lian-Ming Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Pu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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5
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Shahin M, Candreva A, Siegrist PT. Rotational Atherectomy in Acute STEMI with Heavily Calcified Culprit Lesion is a Rule Breaking Solution. Curr Cardiol Rev 2018; 14:213-216. [PMID: 29788894 PMCID: PMC6131400 DOI: 10.2174/1573403x14666180523084846] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Calcified coronary lesions represent technical challenges during percutaneous coronary intervention and are associated with a high frequency of restenosis and target lesion revascularization. Rotational atherectomy has been shown to increase procedural success in severely calcified lesions, facilitate stent delivery in undilatable lesions and ensure complete stent expansion. However, rotational atherectomy in ST-elevation Myocardial Infarction (STEMI) is traditionally avoided given the concern for slow or no reflow and considered a contraindication in lesions with a visible thrombus by its manufacturer (Rotablator, Boston Scientific). CONCLUSION This case demonstrates the successful use of rotational atherectomy to facilitate dilation and revascularization of a heavily calcified culprit lesions in a patient with acute anterior STEMI with ongoing chest pain.
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Affiliation(s)
- Mohammady Shahin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alessandro Candreva
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Patrick T Siegrist
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
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6
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Prognostic Association of Circulating Neutrophil Count with No-Reflow in Patients with ST-Segment Elevation Myocardial Infarction following Successful Primary Percutaneous Intervention. DISEASE MARKERS 2017; 2017:8458492. [PMID: 29379223 PMCID: PMC5742887 DOI: 10.1155/2017/8458492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/30/2017] [Accepted: 10/31/2017] [Indexed: 01/04/2023]
Abstract
Objective The aim of the present study was to investigate the predictive value of neutrophil count for no-reflow in patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful primary percutaneous intervention (PCI). Methods We conducted a retrospective study of 361 patients diagnosed with acute STEMI between 2011 and 2015. All patients underwent successful PCI within 12 h from the onset of symptoms. Angiographic no-reflow was diagnosed based on a post-PCI thrombolysis in myocardial infarction flow grade ≤ 2 without mechanical obstruction. According to a neutrophil count cut-off determined by receiver operating characteristic curve analysis, patients were divided into two groups: group A (neutrophil count < 9.14 × 109/L) and group B (neutrophil count ≥ 9.14 × 109/L). Results Compared to patients in the normal reflow group, patients with no-reflow had higher neutrophil counts (P < 0.05). The incidence rate of no-reflow in group A (18, 9.3%) was significantly lower than that in group B (38). Multivariate logistic regression analysis revealed that a neutrophil count ≥ 9.14 × 109/L was independently predictive for no-reflow (odds ratio = 4.474, 95% confidence interval: 1.610–12.433, P = 0.004) after adjusting for potential confounders. Conclusions A circulating neutrophil count ≥ 9.14 × 109/L is independently associated with no-reflow in patients with acute STEMI following primary PCI.
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7
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Lee M, Kong J. Current State of the Art in Approaches to Saphenous Vein Graft Interventions. Interv Cardiol 2017; 12:85-91. [PMID: 29588735 PMCID: PMC5808481 DOI: 10.15420/icr.2017:4:2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/20/2017] [Indexed: 12/13/2022] Open
Abstract
Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.
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8
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Durante A, Laricchia A, Benedetti G, Esposito A, Margonato A, Rimoldi O, De Cobelli F, Colombo A, Camici PG. Identification of High-Risk Patients After ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Imaging 2017; 10:e005841. [DOI: 10.1161/circimaging.116.005841] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/13/2017] [Indexed: 01/31/2023]
Abstract
Background—
The incidence of angiographic no reflow (NR) and microvascular obstruction (MVO) at cardiac magnetic resonance is significantly different. The aim of this study was to investigate the occurrence of NR and MVO in a cohort of consecutive patients with ST-segment–elevation myocardial infarction treated with primary percutaneous coronary interventions.
Methods and Results—
In this prospective study, 88 consecutive ST-segment–elevation myocardial infarction patients were enrolled within 12 hours from symptoms onset. All patients underwent cardiac magnetic resonance between 2 and 5 days after primary percutaneous coronary interventions. NR was defined as thrombolysis in myocardial infarction flow grade ≤2 and as myocardial blush grade <2. Presence of early or late MVO was assessed 4 and 10 to 15 minutes after gadolinium injection. Thirty-one patients (36%) had evidence of NR, whereas 58 (67%) had MVO. One NR patient did not have MVO. In contrast, NR was present in 30 of 58 MVO patients. MVO patients had higher troponin T peak (
P
<0.0001), larger late gadolinium enhancement area (
P
<0.0001), and lower left ventricular ejection fraction (
P
<0.001) because of an increased end-systolic volume (
P
=0.015). In contrast, patients with NR had higher troponin T peak (
P
=0.006) but similar late gadolinium enhancement area (
P
=0.24) compared with those without NR. Major cardiovascular adverse events–free survival was worse in patients with MVO (
P
=0.014), although it was similar in patients with and without NR (
P
=0.33). The independent predictors of major cardiovascular adverse events were MVO (hazard ratio, 3.418;
P
=0.046) and ischemic time (hazard ratio, 1.016;
P
<0.001). MVO was a strong predictor of target lesion revascularization occurrence (
P
=0.017 for log-rank test).
Conclusions—
Compared with coronary angiography performed soon after recanalization of the culprit artery, cardiac magnetic resonance performed during index hospitalization provides better prognostic stratification of ST-segment–elevation myocardial infarction patients treated with primary percutaneous coronary interventions. Another novel finding of our study is a significantly increased rate of clinically driven target lesion revascularization in the index event culprit vessel in patients with MVO.
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Affiliation(s)
- Alessandro Durante
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Alessandra Laricchia
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Giulia Benedetti
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Antonio Esposito
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Alberto Margonato
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Ornella Rimoldi
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Francesco De Cobelli
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Antonio Colombo
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
| | - Paolo G. Camici
- From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.)
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Hedgire SS, Osborne M, Verdini DJ, Ghoshhajra BB. Updates on Stress Imaging Testing and Myocardial Viability With Advanced Imaging Modalities. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:26. [PMID: 28316034 DOI: 10.1007/s11936-017-0525-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OPINION STATEMENT Non-invasive stress testing plays a key role in diagnosis and risk stratification in patients with coronary artery disease. Technical advances in CT, MRI, and PET have lead to increased utility of these modalities in myocardial perfusion imaging. The aim of the review is to provide a succinct update on CT, PET, and MRI for myocardial stress perfusion imaging.
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Affiliation(s)
- Sandeep S Hedgire
- Department of Radiology, Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Osborne
- Cardiac MR PET-CT Program, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02144, USA
| | - Daniel J Verdini
- Department of Radiology, Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Lee MS, Manthripragada G. Saphenous Vein Graft Interventions. Interv Cardiol Clin 2016; 5:135-141. [PMID: 28582199 DOI: 10.1016/j.iccl.2015.12.002] [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: 06/07/2023]
Abstract
Saphenous vein graft interventions compose a small but important subset of percutaneous coronary revascularization. Because of their unique biology, percutaneous angioplasty and stenting require tailored patient and lesion selection and modification of intervention technique to optimize outcomes. The use of embolic protection and appropriate adjunctive pharmacology can help minimize periprocedural complications, such as the no-reflow phenomenon. Recommendations for best practice in saphenous vein graft interventions continue to evolve with emerging research and therapy.
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Affiliation(s)
- Michael S Lee
- Cardiology Division, Department of Medicine, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, USA.
| | - Gopi Manthripragada
- Cardiology Division, Department of Medicine, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, USA
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Saeed M, Van TA, Krug R, Hetts SW, Wilson MW. Cardiac MR imaging: current status and future direction. Cardiovasc Diagn Ther 2015; 5:290-310. [PMID: 26331113 DOI: 10.3978/j.issn.2223-3652.2015.06.07] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/17/2015] [Indexed: 12/12/2022]
Abstract
Coronary artery disease is currently a worldwide epidemic with increasing impact on healthcare systems. Magnetic resonance imaging (MRI) sequences give complementary information on LV function, regional perfusion, angiogenesis, myocardial viability and orientations of myocytes. T2-weighted short-tau inversion recovery (T2-STIR), fat suppression and black blood sequences have been frequently used for detecting edematous area at risk (AAR) of infarction. T2 mapping, however, indicated that the edematous reaction in acute myocardial infarct (AMI) is not stable and warranted the use of edematous area in evaluating therapies. On the other hand, cine MRI demonstrated reproducible data on LV function in healthy volunteers and LV remodeling in patients. Noninvasive first pass perfusion, using exogenous tracer (gadolinium-based contrast media) and arterial spin labeling MRI, using endogenous tracer (water), are sensitive and useful techniques for evaluating myocardial perfusion and angiogenesis. Recently, new strategies have been developed to quantify myocardial viability using T1-mapping and equilibrium contrast enhanced MR techniques because existing delayed contrast enhancement MRI (DE-MRI) sequences are limited in detecting patchy microinfarct and diffuse fibrosis. These new techniques were successfully used for characterizing diffuse myocardial fibrosis associated with myocarditis, amyloidosis, sarcoidosis heart failure, aortic hypertrophic cardiomyopathy, congenital heart disease, restrictive cardiomyopathy, arrhythmogenic right ventricular dysplasia and hypertension). Diffusion MRI provides information regarding microscopic tissue structure, while diffusion tensor imaging (DTI) helps to characterize the myocardium and monitor the process of LV remodeling after AMI. Novel trends in hybrid imaging, such as cardiac positron emission tomography (PET)/MRI and optical imaging/MRI, are recently under intensive investigation. With the promise of higher spatial-temporal resolution and 3D coverage in the near future, cardiac MRI will be an indispensible tool in the diagnosis of cardiac diseases, coronary intervention and myocardial therapeutic delivery.
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Affiliation(s)
- Maythem Saeed
- 1 Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, San Francisco, CA, USA ; 2 Zentralinstitut für Medizintechnik, Technical University of Munich, Munich, Germany
| | - Tu Anh Van
- 1 Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, San Francisco, CA, USA ; 2 Zentralinstitut für Medizintechnik, Technical University of Munich, Munich, Germany
| | - Roland Krug
- 1 Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, San Francisco, CA, USA ; 2 Zentralinstitut für Medizintechnik, Technical University of Munich, Munich, Germany
| | - Steven W Hetts
- 1 Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, San Francisco, CA, USA ; 2 Zentralinstitut für Medizintechnik, Technical University of Munich, Munich, Germany
| | - Mark W Wilson
- 1 Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, San Francisco, CA, USA ; 2 Zentralinstitut für Medizintechnik, Technical University of Munich, Munich, Germany
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12
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Edema and fibrosis imaging by cardiovascular magnetic resonance: how can the experience of Cardiology be best utilized in rheumatological practice? Semin Arthritis Rheum 2014; 44:76-85. [PMID: 24582213 DOI: 10.1016/j.semarthrit.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/19/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis. METHOD CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies. RESULTS Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs. CONCLUSION The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.
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13
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Foster C, Zajarias A. Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead? Interv Cardiol Clin 2013; 2:323-337. [PMID: 28582139 DOI: 10.1016/j.iccl.2012.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.
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Affiliation(s)
- Corey Foster
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Alan Zajarias
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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14
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Dall'Armellina E, Karia N, Lindsay AC, Karamitsos TD, Ferreira V, Robson MD, Kellman P, Francis JM, Forfar C, Prendergast BD, Banning AP, Channon KM, Kharbanda RK, Neubauer S, Choudhury RP. Dynamic changes of edema and late gadolinium enhancement after acute myocardial infarction and their relationship to functional recovery and salvage index. Circ Cardiovasc Imaging 2011; 4:228-36. [PMID: 21447711 DOI: 10.1161/circimaging.111.963421] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Changes in the myocardium in acute ischemia are dynamic and complex, and the characteristics of myocardial tissue on cardiovascular magnetic resonance in the acute setting are not fully defined. We investigated changes in edema and late gadolinium enhancement (LGE) with serial imaging early after acute myocardial infarction, relating these to global and segmental myocardial function at 6 months. METHODS AND RESULTS Cardiovascular magnetic resonance scans were performed on 30 patients with ST-elevation--myocardial infarction treated by primary percutaneous coronary intervention at each of 4 time points: 12 to 48 hours; 5 to 7 days; 14 to 17 days; and 6 months. All patients showed edema at 24 hours. The mean volume of edema (% left ventricle) was 37±16 at 24 hours and 39±17 at 1 week, with a reduction to 24±13 (P<0.01) by 2 weeks. Myocardial segments with edema also had increased signal on LGE at 24 hours (κ=0.77; P<0.001). The volume of LGE decreased significantly between 24 hours and 6 months (27±15% versus 22±12%; P=0.002). Of segments showing LGE at 24 hours, 50% showed resolution by 6 months. In segments with such a reduction in LGE, 65% also showed improved wall motion (P<0.0001). The area of LGE measured at 6 months correlated more strongly with troponin at 48 hours (r=0.9; P<0.01) than LGE at 24 hours (r=0.7). The difference in LGE between 24 hours and 6 months had profound effects on the calculation of salvage index (26±21% at 24 hours versus 42±23% at 6 months; P=0.02). CONCLUSIONS Myocardial edema is maximal and constant over the first week after myocardial infarction, providing a stable window for the retrospective evaluation of area at risk. By contrast, myocardial areas with high signal intensity in LGE images recede over time with corresponding recovery of function, indicating that acutely detected LGE does not necessarily equate with irreversible injury and may severely underestimate salvaged myocardium.
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Affiliation(s)
- Erica Dall'Armellina
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
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Dall'Armellina E, Karamitsos TD, Neubauer S, Choudhury RP. CMR for characterization of the myocardium in acute coronary syndromes. Nat Rev Cardiol 2010; 7:624-36. [PMID: 20856263 DOI: 10.1038/nrcardio.2010.140] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The utility of cardiac magnetic resonance imaging (CMR) as a diagnostic technique is well established. CMR enables tissue characterization, distinction between myocardial scar tissue and viable tissue, and evaluation of myocardial perfusion and contractile function. To date, CMR has been mostly applied in the assessment of stable disease; however, a role for CMR in the acute setting is also emerging. An accurate appraisal of the myocardium with CMR in the first hours after the onset of chest pain could provide supporting information to standard diagnostic tools, such as electrocardiography and measurement of blood biomarkers, which could help guide the selection of appropriate treatment. The aims of this integrated approach include positive identification of an ischemic syndrome, estimation of downstream areas at risk of damage, evaluation of epicardial artery patency and small vessel integrity, quantification of infarct size, and determination of myocardial function. This Review critically evaluates both established and emerging CMR techniques, and relates the imaging findings to the underlying pathophysiological processes in acute coronary syndromes. A more thorough understanding of CMR techniques will clarify their potential clinical applications and limitations, and assess the practicality of CMR in the setting of acute coronary syndromes, where early intervention is crucial to save myocardium at risk of irreversible injury.
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Affiliation(s)
- Erica Dall'Armellina
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
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Son JW, Kim JS, Lee JM, Hong SJ, Jung MK, Kim DH, Kim JS, Choi D, Jang Y. Percutaneous cardiopulmonary support in refractory no-reflow with cardiogenic shock after coronary stenting in acute myocardial infarction. Yonsei Med J 2010; 51:599-601. [PMID: 20499430 PMCID: PMC2880277 DOI: 10.3349/ymj.2010.51.4.599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Coronary no-reflow is defined as inadequate myocardial perfusion of a given coronary segment without angiographic evidence of mechanical vessel obstruction. No-reflow is visualized angiographically as a reduction in thrombolysis in myocardial infarction (TIMI) flow grade and is typically accompanied by chest pain, electrocardiographic changes with ST-segment shift and possible hemodynamic compromise. No-reflow during primary percutaneous coronary intervention (PCI) results in increasing mortality and morbidity. Therefore, treatment of noreflow is associated with improved clinical outcomes. Generally, the treatment of no-reflow is based on pharmacotherapy. In this case, despite maximal pharmacotherapy and intraaortic balloon pump (IABP), refractory no-reflow accompanied with cardiogenic shock was successfully treated with percutaneous cardiopulmonary support (PCPS).
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Affiliation(s)
- Jung-Woo Son
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Myung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Kyu Jung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Duk-Hwan Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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Haeck JD, Verouden NJW, Henriques JPS, Koch KT. Current status of distal embolization in percutaneous coronary intervention: mechanical and pharmacological strategies. Future Cardiol 2009; 5:385-402. [PMID: 19656063 DOI: 10.2217/fca.09.25] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Distal embolization during percutaneous coronary intervention for acute myocardial infarction or saphenous vein graft disease may result in microvascular obstruction and the 'no-reflow' phenomenon. The incidence of distal embolization ranges from 2 to 42% in saphenous vein graft intervention and from 6 to 15% in primary percutaneous coronary intervention and is associated with impaired myocardial perfusion and poor outcome. Several mechanical and pharmacological strategies have been proposed to prevent or to treat embolization in percutaneous coronary intervention and have been tested in clinical trials. The pivotal role of distal embolization in the pathophysiology of microvascular obstruction will lead to the further development of preventive and therapeutic strategies. Strategies to counteract distal embolization and future directions are discussed in this review.
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Affiliation(s)
- Joost De Haeck
- Department of Cardiology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
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Lindstedt S, Johansson M, Hlebowicz J, Malmsjö M, Ingemansson R. Myocardial topical negative pressure increases blood flow in hypothermic, ischemic myocardium. SCAND CARDIOVASC J 2009; 42:345-53. [DOI: 10.1080/14017430801939225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Lindstedt S, Malmsjö M, Gesslein B, Ingemansson R. Evaluation of continuous and intermittent myocardial topical negative pressure. J Cardiovasc Med (Hagerstown) 2008; 9:813-9. [DOI: 10.2459/jcm.0b013e3282f85bda] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Lindstedt S, Paulsson P, Mokhtari A, Gesslein B, Hlebowicz J, Malmsjö M, Ingemansson R. A compare between myocardial topical negative pressure levels of -25 mmHg and -50 mmHg in a porcine model. BMC Cardiovasc Disord 2008; 8:14. [PMID: 18570679 PMCID: PMC2467401 DOI: 10.1186/1471-2261-8-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 06/22/2008] [Indexed: 11/23/2022] Open
Abstract
Background Topical negative pressure (TNP), widely used in wound therapy, is known to stimulate wound edge blood flow, granulation tissue formation, angiogenesis, and revascularization. We have previously shown that application of a TNP of -50 mmHg to the myocardium significantly increases microvascular blood flow in the underlying tissue. We have also shown that a myocardial TNP levels between -75 mmHg and -150 mmHg do not induce microvascular blood flow changes in the underlying myocardium. The present study was designed to elucidate the difference between -25 mmHg and -50 mmHg TNP on microvascular flow in normal and ischemic myocardium. Methods Six pigs underwent median sternotomy. The microvascular blood flow in the myocardium was recorded before and after the application of TNP using laser Doppler flowmetry. Analyses were performed before left anterior descending artery (LAD) occlusion (normal myocardium), and after 20 minutes of LAD occlusion (ischemic myocardium). Results A TNP of -25 mmHg significantly increased microvascular blood flow in both normal (from 263.3 ± 62.8 PU before, to 380.0 ± 80.6 PU after TNP application, * p = 0.03) and ischemic myocardium (from 58.8 ± 17.7 PU before, to 85.8 ± 20.9 PU after TNP application, * p = 0.04). A TNP of -50 mmHg also significantly increased microvascular blood flow in both normal (from 174.2 ± 20.8 PU before, to 240.0 ± 34.4 PU after TNP application, * p = 0.02) and ischemic myocardium (from 44.5 ± 14.0 PU before, to 106.2 ± 26.6 PU after TNP application, ** p = 0.01). Conclusion Topical negative pressure of -25 mmHg and -50 mmHg both induced a significant increase in microvascular blood flow in normal and in ischemic myocardium. The increase in microvascular blood flow was larger when using -25 mmHg on normal myocardium, and was larger when using -50 mmHg on ischemic myocardium; however these differences were not statistically significant.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden.
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Lindstedt S, Malmsjö M, Ingemansson R. The Effect of Different Topical Negative Pressures on Microvascular Blood Flow in Reperfused Myocardium during Hypothermia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2007. [DOI: 10.1177/155698450700200503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sandra Lindstedt
- Departments of Cardiothoracic Surgery and Lund University Hospital, Lund, Sweden
| | - Malin Malmsjö
- Departments of Medicine, Lund University Hospital, Lund, Sweden
| | - Richard Ingemansson
- Departments of Cardiothoracic Surgery and Lund University Hospital, Lund, Sweden
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The Effect of Different Topical Negative Pressures on Microvascular Blood Flow in Reperfused Myocardium during Hypothermia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2007; 2:231-6. [DOI: 10.1097/imi.0b013e31816207b3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Hypothermia is known to limit the extent of myocardial infarction. The earlier hypothermia is applied to an ischemic myocardium, the more tissue can be salvaged. Topical negative pressure (TNP) is known to increase blood flow and stimulate angiogenesis in subcutaneous tissue and skeletal muscle. We have previously shown that a myocardial TNP of −50 mm Hg significantly increases microvascular blood flow in the underlying myocardium in ischemic and reperfused porcine myocardium. The present study was designed to elucidate the effect of different TNP levels on microvascular blood flow in reperfused myocardium during hypothermia. Methods Seven pigs underwent median sternotomy. The microvascular blood flow in the myocardium was recorded before and after the application of −50, −75, −100, −125, and −150 mm Hg using laser Doppler velocimetry. Analysis was performed in the epicardium and at a depth of 6 to 8 mm in the myocardium after 40 minutes of occlusion of the left anterior descending artery followed by cooling to 31°C, and reperfusion for another 20 minutes. Results A TNP of −50 mm Hg significantly increased blood the flow in the epicardium, from 116.7 ± 10.0 PU to 244.5 ± 52.6 PU (*P < 0.05) at 31°C. A TNP of −50 mm Hg significantly increased microvascular blood flow in the myocardium, from 155.0 ± 8.4 PU to 236.7 ± 61.5 PU (*P < 0.05). Conclusions Only a TNP of −50 mm Hg, applied over the left anterior descending artery region in reperfused hypothermic myocardium significantly increased the microvascular blood flow in the epicardium and in the myocardium.
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