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European Heart Journal May 2020
Topics: Blood Pressure; Cardiovascular Diseases; Heart Disease Risk Factors; Heart Failure; Humans; Myocardial Infarction; Myocardial Reperfusion; Myocardial Revascularization; Risk Factors; Ventricular Dysfunction, Left
PubMed: 32118261
DOI: 10.1093/eurheartj/ehaa054 -
Journal of Nuclear Medicine : Official... Dec 2004Assessment of perfusion defect extent is essential for determining prognosis after a myocardial infarction (MI), but quantification methods usually rely on segmental...
UNLABELLED
Assessment of perfusion defect extent is essential for determining prognosis after a myocardial infarction (MI), but quantification methods usually rely on segmental analysis, which may lack accuracy. We present an automated voxel-based and template-based approach for precise quantification of perfusion defect extent and reperfusion evolution.
METHODS
Coronary angiography and stress/reinjection (201)Tl tomography were performed prospectively on 49 patients with recent MI (45 men; mean age +/- SD, 54 +/- 10 y), before and 3 mo after revascularization (40 angioplasties and 9 bypasses). Perfusion defect extent was quantified using expert 16-segment visual scoring of the slices and a 3-dimensional (3D) method with spatial normalization between times 1 and 2. Briefly, the latter automatically extracted myocardial edges, matched them to a reference template, and compared the perfusion intensity in each voxel with the intensity of the corresponding voxel in a control population of 100 healthy subjects.
RESULTS
Reocclusion occurred in 12 patients within 3 mo of surgery (all had undergone angioplasty). The perfusion gain between times 1 and 2, assessed by visual analysis, was significantly higher in permeable patients than in reoccluded patients: 12.4% +/- 13.3% and 2.3% +/- 8.2% of the initial stress defect, respectively (P = 0.02). Proportional gains, measured with the quantitative 3D method, were 4.5% +/- 3.6% and 1.9% +/- 2.7%, respectively (P = 0.02). Furthermore, the 3D method allowed measurement within the initial ischemic defect (reversible part of the stress defect at time 1), the extent of myocardium whose perfusion improved at time 2 (reperfusion), and the extent of myocardium whose perfusion remained unchanged (residual ischemia). A voxel-by-voxel analysis of these regions revealed that the proportion of reperfusion was significantly higher in permeable patients than in reoccluded patients: 60.0% +/- 21.3% versus 40.0% +/- 22.5%, respectively (P = 0.008). This was cumbersome to quantify using visual analysis and did not reach statistical significance, likely because of segmental division (partial-volume effect) and absence of spatial normalization.
CONCLUSION
The 3D voxel-based quantification allows satisfying assessment of reperfusion 3 mo after MI. Moreover, the automated analysis using spatial normalization should facilitate a reproducible assessment of large populations over time.
Topics: Aged; Coronary Angiography; Humans; Image Processing, Computer-Assisted; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Myocardial Reperfusion; Myocardium; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon
PubMed: 15585471
DOI: No ID Found -
Journal of the American Heart... Aug 2015A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure compared with primary percutaneous coronary intervention (PPCI). We evaluated whether infarct size (IS) was related to this finding.
METHODS AND RESULTS
Using the peak cardiac biomarker in patients randomized to PI versus PPCI within the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, IS was divided into 3 groups: small (≤2 times the upper limit normal [ULN]), medium (>2 to ≤5 times the upper limit normal) and large (>5 times the upper limit normal). The association between IS and 30-day shock and congestive heart failure was subsequently examined. Data on 1701 of 1892 (89.9%) patients randomized to PI (n=853, 50.1%) versus PPCI (n=848, 49.9%) within STREAM were evaluated. A higher proportion of PPCI patients had a large IS (PI versus PPCI: small, 49.8% versus 50.2%; medium, 56.9% versus 43.1%; large, 48.4% versus 51.6%; P=0.035), despite comparable intergroup ischemic times for each reperfusion strategy. As IS increased, a parallel increment in shock and congestive heart failure occurred in both treatment arms, except for the small IS group. The difference in shock and congestive heart failure in the small IS group (4.4% versus 11.6%, P=0.026) in favor of PI likely relates to higher rates of aborted myocardial infarction with the PI strategy (72.7% versus 54.3%, P=0.005). After adjustment, a trend favoring PI persisted in this subgroup (relative risk 0.40, 95% CI 0.15 to 1.06, P=0.064); no difference in treatment-related outcomes was evident in the other 2 groups.
CONCLUSION
A PI strategy appears to alter the pattern of IS after ST-segment elevation myocardial infarction, resulting in more medium and fewer large infarcts compared with PPCI. Despite a comparable number of small infarcts, PI patients in this group had more aborted myocardial infarctions and less 30-day shock and congestive heart failure.
CLINICAL TRIAL REGISTRATION
URL: http://ClinicalTrials.gov. Unique identifier: NCT00623623.
Topics: Aged; Biomarkers; Coronary Angiography; Creatine Kinase, MB Form; Electrocardiography; Female; Heart Failure; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Reperfusion; Myocardium; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Prospective Studies; Risk Assessment; Risk Factors; Shock, Cardiogenic; Thrombolytic Therapy; Time Factors; Treatment Outcome
PubMed: 26304934
DOI: 10.1161/JAHA.115.002049 -
JACC. Cardiovascular Imaging Mar 2017The aim of this study was to review randomized controlled trials (RCTs) using cardiac magnetic resonance (CMR) to assess myocardial infarct (MI) size in reperfused... (Review)
Review
OBJECTIVES
The aim of this study was to review randomized controlled trials (RCTs) using cardiac magnetic resonance (CMR) to assess myocardial infarct (MI) size in reperfused patients with ST-segment elevation myocardial infarction (STEMI).
BACKGROUND
There is limited guidance on the use of CMR in clinical cardioprotection RCTs in patients with STEMI treated by primary percutaneous coronary intervention.
METHODS
All RCTs in which CMR was used to quantify MI size in patients with STEMI treated with primary percutaneous coronary intervention were identified and reviewed.
RESULTS
Sixty-two RCTs (10,570 patients, January 2006 to November 2016) were included. One-third did not report CMR vendor or scanner strength, the contrast agent and dose used, and the MI size quantification technique. Gadopentetate dimeglumine was most commonly used, followed by gadoterate meglumine and gadobutrol at 0.20 mmol/kg each, with late gadolinium enhancement acquired at 10 min; in most RCTs, MI size was quantified manually, followed by the 5 standard deviation threshold; dropout rates were 9% for acute CMR only and 16% for paired acute and follow-up scans. Weighted mean acute and chronic MI sizes (≤12 h, initial TIMI [Thrombolysis in Myocardial Infarction] flow grade 0 to 3) from the control arms were 21 ± 14% and 15 ± 11% of the left ventricle, respectively, and could be used for future sample-size calculations. Pre-selecting patients most likely to benefit from the cardioprotective therapy (≤6 h, initial TIMI flow grade 0 or 1) reduced sample size by one-third. Other suggested recommendations for standardizing CMR in future RCTs included gadobutrol at 0.15 mmol/kg with late gadolinium enhancement at 15 min, manual or 6-SD threshold for MI quantification, performing acute CMR at 3 to 5 days and follow-up CMR at 6 months, and adequate reporting of the acquisition and analysis of CMR.
CONCLUSIONS
There is significant heterogeneity in RCT design using CMR in patients with STEMI. The authors provide recommendations for standardizing the assessment of MI size using CMR in future clinical cardioprotection RCTs.
Topics: Contrast Media; Evidence-Based Medicine; Gadolinium; Humans; Magnetic Resonance Imaging; Myocardial Reperfusion; Myocardium; Predictive Value of Tests; Randomized Controlled Trials as Topic; Research Design; ST Elevation Myocardial Infarction; Treatment Outcome
PubMed: 28279370
DOI: 10.1016/j.jcmg.2017.01.008 -
Indian Heart Journal 2018Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown... (Review)
Review
Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown that 50% of muscle die of ischemia and another 50% die because of reperfusion. It is characterized by myocardial, vascular, or electrophysiological dysfunction that is induced by the restoration of blood flow to previously ischemic tissue. This phenomenon reduces the efficiency of the present modalities used to combat the ischemic myocardium. Moreover, despite an improved understanding of the pathophysiology of this process and encouraging preclinical trials of multiple agents, most of the clinical trials to prevent RI have been disappointing and leaves us at ground zero to explore newer approaches.
Topics: Animals; Diagnostic Imaging; Humans; Myocardial Reperfusion; Myocardial Reperfusion Injury; Myocytes, Cardiac
PubMed: 29961464
DOI: 10.1016/j.ihj.2017.11.009 -
Heart (British Cardiac Society) Mar 2002
Topics: Abciximab; Antibodies, Monoclonal; Anticoagulants; Cardiac Catheterization; Humans; Immunoglobulin Fab Fragments; Myocardial Infarction; Myocardial Reperfusion; Randomized Controlled Trials as Topic; Stents
PubMed: 11847146
DOI: 10.1136/heart.87.3.191 -
Circulation Sep 2008Past studies have clearly established that matrix metalloproteinases (MMPs) contribute to adverse myocardial remodeling with ischemia and reperfusion. However, these...
BACKGROUND
Past studies have clearly established that matrix metalloproteinases (MMPs) contribute to adverse myocardial remodeling with ischemia and reperfusion. However, these studies measured MMP levels in extracted samples, and therefore whether and to what degree actual changes in interstitial MMP activity occur within the human myocardium in the context of ischemia/reperfusion remained unknown.
METHODS AND RESULTS
The present study directly quantified MMP interstitial activity within the myocardium of patients (n=14) undergoing elective cardiac surgery during steady-state conditions, as well as during and following an obligatory period of myocardial arrest and reperfusion achieved by cardiopulmonary bypass. Interstitial MMP activity was continuously monitored using a validated MMP fluorogenic substrate, a microdialysis system placed within the myocardium, and in-line fluorescent detection system. MMP activity, as measured by fluorescent emission, reached a stable steady state level by 10 minutes after deployment of the microdialysis system. During initiation of cardiopulmonary bypass, MMP activity increased by 20% from baseline values (P<0.05), and then rapidly fell with cardiac arrest and longer periods of cardiopulmonary bypass. However, with restoration of myocardial blood flow and separation from cardiopulmonary bypass, MMP interstitial activity increased by over 30% from baseline (P<0.05).
CONCLUSIONS
The present study directly demonstrated that MMP proteolytic activity exists within the human myocardial interstitium and is a dynamic process under conditions such as myocardial arrest and reperfusion.
Topics: Aged; Cardiopulmonary Bypass; Coronary Artery Bypass; Heart Arrest, Induced; Homeostasis; Humans; Male; Matrix Metalloproteinases; Microdialysis; Middle Aged; Myocardial Reperfusion; Myocardium
PubMed: 18824748
DOI: 10.1161/CIRCULATIONAHA.108.786640 -
Heart (British Cardiac Society) Apr 2002Myocardial capillary perfusion is a prerequisite of myocellular viability after reperfusion of acute myocardial infarction. It was hypothesised that the magnitude of...
Myocardial blood volume and the amount of viable myocardium early after mechanical reperfusion of acute myocardial infarction: prospective study using venous contrast echocardiography.
BACKGROUND
Myocardial capillary perfusion is a prerequisite of myocellular viability after reperfusion of acute myocardial infarction. It was hypothesised that the magnitude of myocardial capillary perfusion, assessed by transmural signal intensity in venous contrast echocardiography as a corollary of the blood volume of myocardial capillaries, and the amount of viable myocardium, represented by differential levels of contractile function two weeks after reperfusion, are correlated.
OBJECTIVES
To evaluate the role of venous contrast echocardiography for the identification of viable myocardium in patients with acute myocardial infarction early after successful mechanical reperfusion.
METHODS
60 patients with a first acute myocardial infarction underwent venous contrast echocardiography several hours after successful mechanical reperfusion (median time interval 190 min.). The relative transmural videointensity (median (25th, 75th percentiles)) of akinetic segments was determined. After two weeks, contractile function was re-evaluated at rest and during dobutamine infusion if segments without functional recovery were present.
RESULTS
Relative videointensity early after reperfusion differed significantly between functional groups after two weeks: normokinesia (88% (77%, 100%)), hypokinesia (74% (54%, 99%)), and akinesia with (61% (48%, 76%)) and without contractile reserve (31% (22%, 46%)). Relative videointensity and contractile function were significantly correlated (r = -0.67). The diagnostic accuracy of relative videointensity > 50% for prediction of contractility of initially akinetic segments at rest or during dobutamine was 82% (chi2 = 76.2, p < 0.001).
CONCLUSIONS
Early after successful mechanical reperfusion of acute myocardial infarction, the magnitude of capillary perfusion in the perfusion territory of an infarct related artery is correlated with the amount of viable myocardium. Quantitative venous contrast echocardiography can be used for accurate identification of viable myocardium.
Topics: Blood Volume; Capillaries; Cardiotonic Agents; Coronary Vessels; Dobutamine; Echocardiography; Echocardiography, Stress; Female; Humans; Male; Middle Aged; Myocardial Contraction; Myocardial Infarction; Myocardial Reperfusion; Prospective Studies; Ventricular Function, Left
PubMed: 11907010
DOI: 10.1136/heart.87.4.350 -
Journal of the American College of... Nov 1998We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK)... (Comparative Study)
Comparative Study
OBJECTIVES
We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK) after thrombolytic therapy differentiates among patients with early recanalization between those with and those without adequate tissue (myocardial) reperfusion.
BACKGROUND
Early recanalization of the epicardial infarct-related artery (IRA) during AMI does not ensure adequate reperfusion on the myocardial level. While early peak CK after thrombolysis results from early and abrupt restoration of the coronary flow to the infarcted area, rapid ST-segment resolution, which is another clinical marker of successful reperfusion, reflects changes of the myocardial tissue itself.
METHODS
We compared the clinical and the angiographic results of 162 AMI patients with early peak CK (< or =12 h) after thrombolytic therapy with (group A) and without (group B) concomitant rapid resolution of ST-segment elevation.
RESULTS
Patients in groups A and B had similar patency rates of the IRA on angiography (anterior infarction: 93% vs. 93%; inferior infarction: 89% vs. 77%). Nevertheless, group A versus B patients had lower peak CK (anterior infarction: 1,083+/-585 IU/ml vs. 1,950+/-1,216, p < 0.01; and inferior infarction: 940+/-750 IU/ml vs. 1,350+/-820, p=0.18) and better left ventricular ejection fraction (anterior infarction: 49+/-8, vs. 44+/-8, p < 0.01; inferior infarction: 56+/-12 vs. 51+/-10, p=0.1). In a 2-year follow-up, group A as compared with group B patients had a lower rate of congestive heart failure (1% vs. 13%, p < 0.01) and mortality (2% vs. 13%, p < 0.01).
CONCLUSIONS
Among patients in whom reperfusion appears to have taken place using an early peak CK as a marker, the coexistence of rapid resolution of ST-segment elevation further differentiates among patients with an opened culprit artery between the ones with and without adequate myocardial reperfusion.
Topics: Angioplasty, Balloon, Coronary; Biomarkers; Coronary Angiography; Coronary Vessels; Creatine Kinase; Electrocardiography; Female; Follow-Up Studies; Heart Failure; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Myocardial Reperfusion; Pericardium; Recurrence; Stroke Volume; Survival Rate; Thrombolytic Therapy; Treatment Outcome; Ventricular Function, Left
PubMed: 9809943
DOI: 10.1016/s0735-1097(98)00417-3 -
Arquivos Brasileiros de Cardiologia Apr 2021
Topics: Female; Gender Equity; Humans; Myocardial Infarction; Myocardial Reperfusion; ST Elevation Myocardial Infarction
PubMed: 33886714
DOI: 10.36660/abc.20210082