Did you mean: coronary revascularization
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Current Heart Failure Reports Dec 2022Heart failure (HF) after right ventricular myocardial infarction (RVMI) is common and complicates its clinical course. This review aims to provide a current overview on... (Review)
Review
PURPOSE OF REVIEW
Heart failure (HF) after right ventricular myocardial infarction (RVMI) is common and complicates its clinical course. This review aims to provide a current overview on the characteristic features of RV failure with focus on acute management.
RECENT FINDINGS
While HF after RVMI is classically seen after acute proximal right coronary artery occlusion, RV dysfunction may also occur after larger infarctions in the left coronary artery. Because of its different anatomy and physiology, the RV appears to be more resistant to permanent infarction compared to the LV with greater potential for recovery of ischemic myocardium. Hypotension and elevated jugular pressure in the presence of clear lung fields are hallmark signs of RV failure and should prompt confirmation by echocardiography. Management decisions are still mainly based on small studies and extrapolation of findings from LV failure. Early revascularization improves short- and long-term outcomes. Acute management should further focus on optimization of preload and afterload, maintenance of sufficient perfusion pressures, and prompt management of arrhythmias and concomitant LV failure, if present. In case of cardiogenic shock, use of vasopressors and/or inotropes should be considered along with timely use of mechanical circulatory support (MCS) in eligible patients. HF after RVMI is still a marker of worse outcome in acute coronary syndrome. Prompt revascularization, careful medical therapy with attention to the special physiology of the RV, and selected use of MCS provide the RV the time it needs to recover from the ischemic insult.
Topics: Humans; Heart Failure; Ventricular Dysfunction, Right; Myocardial Infarction; Heart Ventricles; Myocardium
PubMed: 36197627
DOI: 10.1007/s11897-022-00577-8 -
Circulation Apr 2021Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize... (Review)
Review
Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.
Topics: Acute Disease; American Heart Association; Female; Humans; Male; Myocardial Infarction; Shock, Cardiogenic; Treatment Outcome; United States
PubMed: 33657830
DOI: 10.1161/CIR.0000000000000959 -
Circulation Jan 2021Recent discoveries have indicated that, in the developing heart, sinus venosus and endocardium provide major sources of endothelium for coronary vessel growth that...
BACKGROUND
Recent discoveries have indicated that, in the developing heart, sinus venosus and endocardium provide major sources of endothelium for coronary vessel growth that supports the expanding myocardium. Here we set out to study the origin of the coronary vessels that develop in response to vascular endothelial growth factor B (VEGF-B) in the heart and the effect of VEGF-B on recovery from myocardial infarction.
METHODS
We used mice and rats expressing a VEGF-B transgene, VEGF-B-gene-deleted mice and rats, apelin-CreERT, and natriuretic peptide receptor 3-CreERT recombinase-mediated genetic cell lineage tracing and viral vector-mediated VEGF-B gene transfer in adult mice. Left anterior descending coronary vessel ligation was performed, and 5-ethynyl-2'-deoxyuridine-mediated proliferating cell cycle labeling; flow cytometry; histological, immunohistochemical, and biochemical methods; single-cell RNA sequencing and subsequent bioinformatic analysis; microcomputed tomography; and fluorescent- and tracer-mediated vascular perfusion imaging analyses were used to study the development and function of the VEGF-B-induced vessels in the heart.
RESULTS
We show that cardiomyocyte overexpression of VEGF-B in mice and rats during development promotes the growth of novel vessels that originate directly from the cardiac ventricles and maintain connection with the coronary vessels in subendocardial myocardium. In adult mice, endothelial proliferation induced by VEGF-B gene transfer was located predominantly in the subendocardial coronary vessels. Furthermore, VEGF-B gene transduction before or concomitantly with ligation of the left anterior descending coronary artery promoted endocardium-derived vessel development into the myocardium and improved cardiac tissue remodeling and cardiac function.
CONCLUSIONS
The myocardial VEGF-B transgene promotes the formation of endocardium-derived coronary vessels during development, endothelial proliferation in subendocardial myocardium in adult mice, and structural and functional rescue of cardiac tissue after myocardial infarction. VEGF-B could provide a new therapeutic strategy for cardiac neovascularization after coronary occlusion to rescue the most vulnerable myocardial tissue.
Topics: Animals; Cell Transdifferentiation; Cells, Cultured; Coronary Vessels; Endocardium; Mice; Mice, Transgenic; Myocardial Infarction; Myocytes, Cardiac; Rats; Rats, Transgenic; Regeneration; Vascular Endothelial Growth Factor B
PubMed: 33203221
DOI: 10.1161/CIRCULATIONAHA.120.050635 -
Nature May 2019Prompt coronary catheterization and revascularization have markedly improved the outcomes of myocardial infarction, but have also resulted in a growing number of...
Prompt coronary catheterization and revascularization have markedly improved the outcomes of myocardial infarction, but have also resulted in a growing number of surviving patients with permanent structural damage of the heart, which frequently leads to heart failure. There is an unmet clinical need for treatments for this condition, particularly given the inability of cardiomyocytes to replicate and thereby regenerate the lost contractile tissue. Here we show that expression of human microRNA-199a in infarcted pig hearts can stimulate cardiac repair. One month after myocardial infarction and delivery of this microRNA through an adeno-associated viral vector, treated animals showed marked improvements in both global and regional contractility, increased muscle mass and reduced scar size. These functional and morphological findings correlated with cardiomyocyte de-differentiation and proliferation. However, subsequent persistent and uncontrolled expression of the microRNA resulted in sudden arrhythmic death of most of the treated pigs. Such events were concurrent with myocardial infiltration of proliferating cells displaying a poorly differentiated myoblastic phenotype. These results show that achieving cardiac repair through the stimulation of endogenous cardiomyocyte proliferation is attainable in large mammals, however dosage of this therapy needs to be tightly controlled.
Topics: Animals; Cell Proliferation; Death, Sudden, Cardiac; Heart; Male; MicroRNAs; Myocardial Infarction; Myocytes, Cardiac; Regeneration; Sus scrofa
PubMed: 31068698
DOI: 10.1038/s41586-019-1191-6 -
The New England Journal of Medicine Aug 2019The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear.
METHODS
Among 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years.
RESULTS
CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P = 0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death.
CONCLUSIONS
The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595.).
Topics: Aged; Coronary Artery Bypass; Echocardiography, Stress; Female; Follow-Up Studies; Heart; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Ischemia; Proportional Hazards Models; Prospective Studies; Stroke Volume; Tomography, Emission-Computed, Single-Photon; Treatment Outcome; Ventricular Function, Left
PubMed: 31433921
DOI: 10.1056/NEJMoa1807365 -
European Heart Journal Jan 2022Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that those who have extensive areas...
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the future.
Topics: Coronary Artery Bypass; Humans; Myocardial Ischemia; Myocardial Revascularization; Myocardium; Prognosis; Ventricular Dysfunction, Left
PubMed: 34791132
DOI: 10.1093/eurheartj/ehab729 -
EuroIntervention : Journal of EuroPCR... May 2023Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and...
Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery.
Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.
Topics: Humans; Transcatheter Aortic Valve Replacement; Coronary Artery Disease; Aortic Valve Stenosis; Aortic Valve; Percutaneous Coronary Intervention; Cardiology; Treatment Outcome
PubMed: 36811935
DOI: 10.4244/EIJ-D-22-00958 -
Journal of the American College of... Apr 2021Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.
OBJECTIVES
This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.
METHODS
The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.
RESULTS
We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.
CONCLUSIONS
Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703).
Topics: Aged; Antibodies, Monoclonal, Humanized; Cardiac Imaging Techniques; Cardiovascular Agents; Coronary Occlusion; Coronary Vessels; Double-Blind Method; Female; Heart; Humans; Infusions, Intravenous; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Ischemia; Myocardium; Necrosis; Percutaneous Coronary Intervention; Receptors, Interleukin-6; ST Elevation Myocardial Infarction; Time-to-Treatment
PubMed: 33858620
DOI: 10.1016/j.jacc.2021.02.049 -
Annals of the Royal College of Surgeons... Sep 2018A summary of its uses in mitral valve surgery and coronary artery revascularisation. (Review)
Review
A summary of its uses in mitral valve surgery and coronary artery revascularisation.
Topics: Cardiac Surgical Procedures; Heart Valve Diseases; Humans; Minimally Invasive Surgical Procedures; Mitral Valve; Myocardial Revascularization; Robotic Surgical Procedures
PubMed: 30179050
DOI: 10.1308/rcsann.supp2.22 -
Nature Communications Jun 2023Although several tissues and chemokines orchestrate coronary formation, the guidance cues for coronary growth remain unclear. Here, we profile the juvenile zebrafish...
Although several tissues and chemokines orchestrate coronary formation, the guidance cues for coronary growth remain unclear. Here, we profile the juvenile zebrafish epicardium during coronary vascularization and identify hapln1a cells enriched with vascular-regulating genes. hapln1a cells not only envelop vessels but also form linear structures ahead of coronary sprouts. Live-imaging demonstrates that coronary growth occurs along these pre-formed structures, with depletion of hapln1a cells blocking this growth. hapln1a cells also pre-lead coronary sprouts during regeneration and hapln1a cell loss inhibits revascularization. Further, we identify serpine1 expression in hapln1a cells adjacent to coronary sprouts, and serpine1 inhibition blocks vascularization and revascularization. Moreover, we observe the hapln1a substrate, hyaluronan, forming linear structures along and preceding coronary vessels. Depletion of hapln1a cells or serpine1 activity inhibition disrupts hyaluronan structure. Our studies reveal that hapln1a cells and serpine1 are required for coronary production by establishing a microenvironment to facilitate guided coronary growth.
Topics: Animals; Hyaluronic Acid; Zebrafish; Heart; Coronary Vessels; Neovascularization, Pathologic; Morphogenesis
PubMed: 37311876
DOI: 10.1038/s41467-023-39323-6