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Zeitouni M, Silvain J, Guedeney P, Kerneis M, Yan Y, Overtchouk P, Barthelemy O, Hauguel-Moreau M, Choussat R, Helft G, Le Feuvre C, Collet JP, Montalescot G. Periprocedural myocardial infarction and injury in elective coronary stenting. Eur Heart J 2018; 39:1100-1109. [DOI: 10.1093/eurheartj/ehx799] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/21/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michel Zeitouni
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Johanne Silvain
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Paul Guedeney
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Mathieu Kerneis
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Yan Yan
- Department of Cardiology, Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Anzhen Rd, Chaoyang Qu, 100029 Beijing, China
| | - Pavel Overtchouk
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Olivier Barthelemy
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Marie Hauguel-Moreau
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Rémi Choussat
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Gérard Helft
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Claude Le Feuvre
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Jean-Philippe Collet
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
| | - Gilles Montalescot
- Department of Cardiology, ACTION Study Group, Sorbonne Université - Univ Paris 06 (UPMC), INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Bureau 2-278, 47-83 bld de l'Hôpital, 75013 Paris, France
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Arri SS, Patterson T, Williams RP, Moschonas K, Young CP, Redwood SR. Myocardial revascularisation in high-risk subjects. Heart 2017; 104:166-179. [PMID: 29180542 DOI: 10.1136/heartjnl-2016-310487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Satpal S Arri
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tiffany Patterson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rupert P Williams
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christopher P Young
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon R Redwood
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Roifman I, Ghugre NR, Vira T, Zia MI, Zavodni A, Pop M, Connelly KA, Wright GA. Assessment of the longitudinal changes in infarct heterogeneity post myocardial infarction. BMC Cardiovasc Disord 2016; 16:198. [PMID: 27741939 PMCID: PMC5064965 DOI: 10.1186/s12872-016-0373-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/30/2016] [Indexed: 11/17/2022] Open
Abstract
Background Infarct heterogeneity, as assessed by determination of the peri-infarct zone (PIZ) by cardiac magnetic resonance imaging, has been shown to be an independent predictor for the development of cardiac arrhythmias and mortality post myocardial infarction (MI). The temporal evolution of the PIZ post MI is currently unknown. Thus, the main objective of our study was to describe the temporal evolution of the PIZ over a 6 month time period in contemporarily managed ST elevation myocardial infarction (STEMI) patients. Further, given the poor prognosis associated with microvascular obstruction (MVO) post STEMI, we sought to compare the temporal evolution of the PIZ in patients with and without MVO. We hypothesized that patients with MVO would show a relative persistence of PIZ over time when compared to those without MVO. Methods Twenty-one patients post primary percutaneous coronary intervention were enrolled and treated with evidence based therapy. Each patient had three cardiac MRI scans at 48 h, 3 weeks and 6 months post infarction. Repeated Measures Analysis of Variance (ANOVA) was used to assess the evolution of core infarct size and peri-infarct zone size across the three time frames. Results The patients in this study were predominantly male, with ~40 % LAD territory infarction and a mean LVEF of 46 ± 7 %. Core infarct size and PIZ size both decreased significantly across the three time frames. The presence of microvascular obstruction (MVO), a known adverse prognostic factor, influenced PIZ size. Both patients with and without MVO had a significant reduction in core infarct size over time. Patients with MVO did not have a significant change in PIZ size over time (11.9 ± 6.8 %, 12.2 ± 7.5 %, 10.7 ± 6.6 % p = 0.77). In contrast, non-MVO patients did have a significant decrease in PIZ size over time (7.0 ± 5.5 %, 7.1 ± 6.5 %, 2.7 ± 2.6 %, p = 0.01). Conclusions Peri-infarct zone size, like core infarct size, varies depending upon the timing of measurement. Patients with MVO displayed a persistence of the PIZ over time.
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Affiliation(s)
- Idan Roifman
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.
| | - Nilesh R Ghugre
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Tasnim Vira
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada
| | - Mohammad I Zia
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada
| | - Anna Zavodni
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Division of Cardiothoracic Imaging, Department of Medical Imaging, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Mihaela Pop
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, The University of Toronto, Toronto, ON, Canada
| | - Graham A Wright
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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Kizilirmak F, Gunes HM, Demir GG, Gokdeniz T, Guler E, Cakal B, Omaygenç MO, Yılmaz F, Savur U, Barutcu I. Impact of Intracoronary Adenosine on Myonecrosis in Patients with Unstable Angina Pectoris Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2015; 29:519-526. [DOI: 10.1007/s10557-015-6631-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Do L, Wilson MW, Krug R, Hetts SW, Saeed M. MRI monitoring of function, perfusion and viability in microembolized moderately ischemic myocardium. Int J Cardiovasc Imaging 2015; 31:1179-90. [PMID: 25951916 DOI: 10.1007/s10554-015-0673-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/02/2015] [Indexed: 01/25/2023]
Abstract
Assessment of microembolization after coronary interventions is clinically challenging, thus we longitudinally investigated microemboli effects on moderately ischemic myocardium using MRI and histopathology. Twenty-four pigs (8/group) were divided into: group I (no intervention), group II (45 min LAD occlusion) and group III (45 min LAD occlusion with microembolization). Cine, perfusion and delayed contrast enhanced MRI (DE-MRI), using 1.5T MRI, were used for assessment at 3 days and 5 weeks. Triphenyltetrazolium-chloride (TTC) and Masson-trichrome were used as gold standard references for macro and microscopic quantification of myocardial infarction (MI). Cine MRI showed differential increase in end systolic volume (1.3 ± 0.08 ml/kg group II and 1.6 ± 0.1 ml/kg group III) and decrease in ejection fraction (45 ± 2 and 36 ± 2%, respectively) compared with controls at 3 days (2.1 ± 0.1 ml ESV and 50 ± 1% EF, P < 0.05). At 5 weeks group III, but not II, showed persistent perfusion deficits, wall thinning in the LAD territory and compensatory hypertrophy in remote myocardium. DE-MRI MI at 3 days was significantly smaller in group II (3.3 ± 2.2 g) than III (9.8 ± 0.6 g), at 5 weeks, MI were smaller by 60% (1.3 ± 0.9 g) and 22% (7.7 ± 0.5 g), respectively. TTC MI was similar to DE-MRI in group II (1.6 ± 1.0 g) and III (9.2 ± 1.6 g), but not microscopy (2.8 ± 0.4 and 10.5 ± 1.5 g, respectively). The effects of moderate ischemia with and without microembolization on myocardium could be differentiated using multiple MRI sequences. MRI demonstrated that microemboli in moderately ischemic myocardium, but not solely ischemia, prolonged ventricular dysfunction, created perfusion deficits, poor infarct resorption and enhanced compensatory hypertrophy, while moderate ischemia alone caused minor LV changes.
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Affiliation(s)
- Loi Do
- University of California, San Francisco, San Francisco, CA, USA
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Bajwa HZ, Do L, Suhail M, Hetts SW, Wilson MW, Saeed M. MRI demonstrates a decrease in myocardial infarct healing and increase in compensatory ventricular hypertrophy following mechanical microvascular obstruction. J Magn Reson Imaging 2014; 40:906-14. [PMID: 24449356 DOI: 10.1002/jmri.24431] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/28/2013] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To provide direct evidence that mechanical obstruction of microvessels inhibits infarct resorption (healing) and enhances left ventricular (LV) remodeling using MRI. MATERIALS AND METHODS Animals (n = 20 pigs) served as controls (group I) or were subjected to either 90 min left anterior descending (LAD) coronary artery occlusion/reperfusion (group II) or 90 min LAD occlusion/ microemboli delivery/reperfusion (group III). MRI (cine and delayed contrast enhanced MRI, DE-MRI) was performed at 3 days and 5 weeks after interventions and used for assessing LV function, mass, and extent of myocardial damage and microvascular obstruction (MVO) using semi-automated threshold method. RESULTS Persistent MVO in the core of contiguous infarct was larger and more frequent (n = 8/8) in group III than group II (4/8) on DE-MRI at 3 days. Furthermore, patchy microinfarct, as a result of microembolization, was visible as hyperenhanced zone at the borders of the contiguous infarct. The reduction in ejection fraction and increase in LV volumes on cine MRI were greater in group III than group II at 3 days and 5 weeks, which may be attributed to the slow infarct resorption, MVO extents and patchy microinfarct at the borders. CONCLUSION This MRI study illustrates the recently raised conjecture that MVO delays/inhibits infarct resorption (healing), accentuates LV hypertrophy and pathological remodeling.
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Affiliation(s)
- Hisham Z Bajwa
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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Suhail MSA, Wilson MW, Hetts SW, Saeed M. Magnetic resonance imaging characterization of circumferential and longitudinal strain under various coronary interventions in swine. World J Radiol 2013; 5:472-483. [PMID: 24379934 PMCID: PMC3874504 DOI: 10.4329/wjr.v5.i12.472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/18/2013] [Accepted: 12/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the acute changes in circumferential and longitudinal strain after exposing a coronary artery to various interventions in swine.
METHODS: Percutaneous balloon angioplasty catheter was guided to location aid device (LAD) under X-ray fluoroscopy to create different patterns of ischemic insults. Pigs (n = 32) were equally divided into 4 groups: controls, 90 min LAD occlusion/reperfusion, LAD microembolization, and combined LAD occlusion/microembolization/reperfusion. Three days after interventions, cine, tagged and viability magnetic resonance imaging (MRI) were acquired to measure and compare left and right circumferential strain, longitudinal strain and myocardial viability, respectively. Measurements were obtained using HARP and semi-automated threshold method and statistically analyzed using unpaired t-test. Myocardial and vascular damage was characterized microscopically.
RESULTS: Coronary microemboli caused greater impairment in l left ventricular (LV) circumferential strain and dyssynchrony than LAD occlusion/reperfusion despite the significant difference in the extent of myocardial damage. Microemboli also caused significant decrease in peak systolic strain rate of remote myocardium and LV dyssynchrony. Cine MRI demonstrated the interaction between LV and right ventricular (RV) at 3 d after interventions. Compensatory increase in RV free wall longitudinal strain was seen in response to all interventions. Viability MRI, histochemical staining and microscopy revealed different patterns of myocardial damage and microvascular obstruction.
CONCLUSION: Cine MRI revealed subtle changes in LV strain caused by various ischemic insults. It also demonstrated the interaction between the right and left ventricles after coronary interventions. Coronary microemboli with and without acute myocardial infarction (AMI) cause complex myocardial injury and ventricular dysfunction that is not replicated in solely AMI.
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Evaluation of XIENCE V everolimus-eluting and Taxus Express2 paclitaxel-eluting coronary stents in patients with jailed side branches from the SPIRIT IV trial at 2 years. Am J Cardiol 2013; 111:1580-6. [PMID: 23499270 DOI: 10.1016/j.amjcard.2013.01.330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/24/2013] [Accepted: 01/24/2013] [Indexed: 11/24/2022]
Abstract
The aim of this study was to determine whether patients from the Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary Artery Lesions (SPIRIT) IV trial who underwent percutaneous coronary intervention, who had target lesions with jailed side branches, had improved clinical outcomes when treated with the XIENCE V versus Taxus Express(2) drug-eluting stent. In the SPIRIT III randomized trial, patients with target lesions with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had lower 2-year rates of major adverse cardiac events. The SPIRIT IV trial represents a larger more diverse patient population compared with SPIRIT III. In the large-scale, prospective, multicenter, randomized SPIRIT IV trial, 3,687 patients who underwent coronary stenting with up to 3 de novo native coronary artery lesions were randomized 2:1 to receive XIENCE V versus Taxus Express(2) stents. Two-year clinical outcomes of patients with or without jailed side branches after stenting were compared. A jailed side branch was defined as any side branch >1.0 mm in diameter within the target segment being stented, excluding bifurcations deemed to require treatment. Of the 3,687 patients in SPIRIT IV, a total of 1,426 had side branches that were jailed during angioplasty of the target lesion. Patients with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had significantly lower 2-year rates of target lesion failure (6.5% vs 11.9%, p = 0.001), major adverse cardiac events (6.6% vs 12.2%, p = 0.0008), ischemia-driven target vessel revascularization (4.1% vs 7.9%, p = 0.004), and stent thrombosis (0.6% vs 2.8%, p = 0.001). In conclusion, patients with jailed side branches after stenting with XIENCE V compared to Taxus Express(2) devices had superior clinical outcomes at 2 years in the large-scale randomized SPIRIT IV trial.
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Saeed M, Hetts SW, Do L, Wilson MW. Coronary microemboli effects in preexisting acute infarcts in a swine model: cardiac MR imaging indices, injury biomarkers, and histopathologic assessment. Radiology 2013; 268:98-108. [PMID: 23592769 DOI: 10.1148/radiol.13122286] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To use cardiac magnetic resonance (MR) imaging indices, injury biomarkers, and microscopy for quantifying the effects of defined microemboli volume and sizes on viability, left ventricular (LV) function, and perfusion in preexisting acute myocardial infarcts in a swine model. MATERIALS AND METHODS Institutional approval was obtained to perform x-ray fluoroscopy and 90-minute left anterior descending coronary artery occlusion-reperfusion (single ischemic insult) in 16 pigs and coronary embolization in eight of the 16 pigs (32 mm(3), 40-120 μm microemboli) (double ischemic insults). Another eight pigs served as controls. Cardiac MR imaging results (viability, function, and perfusion), injury biomarkers (creatine-kinase-MB and troponin I), and histopathologic evaluations were quantified. Analysis of variance was performed, and a P value less than .02 was considered to indicate a significant difference. RESULTS Delayed contrast material-enhanced MR imaging allowed simultaneous visualization of hyperenhanced large infarcts, hypoenhanced microvascular obstruction (MVO) zones, and moderately enhanced patchy microinfarcts in border zones, which represent different degrees of contraction and perfusion in the respective regions, in pigs subjected to double ischemic insults. The increase in myocardial damage was smaller in pigs with double insults (15.7% ± 1.1% of total LV mass) than in those with a single insult (12.4% ± 1.2%, P < .02), but the reduction in LV ejection fraction was disproportional (32% ± 0.6% and 38% ± 1%, P < .02, respectively). Delayed contrast-enhanced imaging can allow quantification of the MVO zone but can result in underestimation of the extent of myocardial damage compared with microscopy in animals subjected to double insults (18.2 ± 1.6, P < .02). A significant increase in cardiac injury biomarkers was observed at 18-24 hours in both cohorts. The additional effect of microemboli on troponin I was demonstrated at 68-72 hours (3.2 ng/mL ± 0.85 [3.20 μg/L ± 0.85] vs 1.34 ng/mL ± 0.43 [1.34 μg/L ± 0.43], P < .02). CONCLUSION MR imaging has the potential to allow visualization of acute myocardial infarcts, MVO zones, and patchy microinfarcts simultaneously. The accentuated LV dysfunction caused by double ischemic insults was linked to expansion of the MVO zone, perfusion deficits, and myocardial damage.
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Affiliation(s)
- Maythem Saeed
- Department of Radiology and Biomedical Imaging, School of Medicine, University of California San Francisco, 185 Berry St, Suite 350, Campus Box 0946, San Francisco, CA 94107-5705, USA.
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Saeed M, Hetts SW, Do L, Sullivan S, Wilson MW. MDCT has the potential to predict percutaneous coronary intervention outcome in swine model: microscopic validation. Acta Radiol 2012; 53:987-94. [PMID: 22993269 DOI: 10.1258/ar.2012.120407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Volumes and sizes of dislodged coronary microemboli vary during PCI so their effects at the left ventricular (LV) and cellular levels cannot be quantified. Furthermore, biopsy for tissue characterization is not an option in PCI patients. PURPOSE To characterize and validate microinfarct size, LAD territory where microinfarct were found using multidetector computed tomography (MDCT), histochemical staining and microscopy as a function of microemboli volumes and to scale the effects of microemboli volumes on LV function. MATERIAL AND METHODS Under X-ray guidance, a 3F catheter was inserted into LAD coronary artery of 14 pigs for delivering 16 mm(3) or 32 mm(3) of 40-120 μm microemboli. MDCT imaging/histochemical staining/microscopy were performed 3 days later and used to characterize regional and global structural and functional changes in LV by threshold/planimetric methods. RESULTS MDCT and ex-vivo methods were able to quantify microinfarct size and LAD territory where microinfarct was found as a function of volumes. However, MDCT and histochemical staining significantly underestimated microinfarct size and territory where microinfarct was found compared with microscopy. MDCT demonstrated the functional changes and showed a moderate correlation between LV ejection fraction and microinfarct size (r = 0.53). Microscopy provided higher spatial resolution for measuring islands of necrotic cells, which explains the difference in measuring structural changes. CONCLUSION MDCT showed the difference in microinfarct size and LAD territory as a function of microemboli volumes and scaled the changes in LV function. This experimental study gives clinicians a reference for the effects of defined microemboli volumes on myocardial viability and LV function and the under-estimation of microinfarct on MDCT.
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Affiliation(s)
- Maythem Saeed
- Interventional Radiology Laboratory, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Steven W Hetts
- Interventional Radiology Laboratory, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Loi Do
- Interventional Radiology Laboratory, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Sammir Sullivan
- Interventional Radiology Laboratory, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Mark W Wilson
- Interventional Radiology Laboratory, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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Effect of myocardial protection of intracoronary adenosine and nicorandil injection in patients undergoing non-urgent percutaneous coronary intervention: A randomized controlled trial. Int J Cardiol 2012; 158:88-92. [DOI: 10.1016/j.ijcard.2011.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 12/27/2010] [Accepted: 01/04/2011] [Indexed: 11/18/2022]
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Sardella G, Lucisano L, Mancone M, Canali E, De Carlo C, Stio RE, Calcagno S, Brasolin B, Fedele F. Effect of adenosine intracoronary bolus on myonecrosis occurrence in elective PCI (RACE trial). Int J Cardiol 2012; 155:456-9. [DOI: 10.1016/j.ijcard.2011.12.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 12/15/2011] [Accepted: 12/17/2011] [Indexed: 11/24/2022]
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De Luca G, Iorio S, Venegoni L, Marino P. Evaluation of intracoronary adenosine to prevent periprocedural myonecrosis in elective percutaneous coronary intervention (from the PREVENT-ICARUS Trial). Am J Cardiol 2012; 109:202-7. [PMID: 22000773 DOI: 10.1016/j.amjcard.2011.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 08/30/2011] [Accepted: 08/30/2011] [Indexed: 10/16/2022]
Abstract
Great interest has focused on pharmacotherapy to prevent periprocedural myocardial injury during elective percutaneous coronary intervention (PCI). The aim of the present trial was to investigate the benefits of preprocedural intracoronary administration of high-dose adenosine during elective PCI. This was a single-center, double-blind, randomized trial of patients undergoing elective PCI. The patients were randomized (1:1) by sealed envelops to intracoronary adenosine (120 μg for the right coronary artery and 180 μg for the left coronary artery) or placebo. The primary study end point was a periprocedural increase in troponin I >3 times the upper limit of normal. The secondary study end points were (1) the corrected Thrombolysis In Myocardial Infarction frame count; (2) troponin I release >10 times the upper limit of normal; (3) creatine kinase-MB mass release ≥3 times the upper limit of normal; and (4) the combined cumulative incidence of in-hospital death, periprocedural myocardial infarction, and in-hospital urgent target vessel revascularization. The safety end point was the occurrence of bradycardia and ventricular arrhythmias during study drug administration. From November 2009 to September 2010, we randomized 260 patients who were undergoing elective PCI to intracoronary adenosine (n = 130) or placebo (n = 130). A greater prevalence of calcified lesions was observed in the adenosine group (p = 0.002). In contrast, a greater prevalence of type C lesions (p = 0.091), chronic occlusions (p = 0.015), worse preprocedural Thrombolysis In Myocardial Infarction flow (p = 0.038), and more severely stenotic lesions (p = 0.005) were observed in the placebo group. No difference was found in the primary (67.7% vs 70%, p = 0.69) or secondary end points. No serious side effects were observed with adenosine. In conclusion, our randomized trial showed that preprocedural intracoronary administration of a single high-dose bolus of adenosine does not provide any benefit in terms of periprocedural myonecrosis in patients undergoing elective PCI.
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Lansky AJ, Yaqub M, Hermiller JB, Smith RS, Farhat N, Caputo R, Williams JE, Sanz M, Koo K, Sood P, Sudhir K, Stone GW. Side branch occlusion with everolimus-eluting and paclitaxel-eluting stents: three-year results from the SPIRIT III randomised trial. EUROINTERVENTION 2012; 6 Suppl J:J44-52. [PMID: 21930490 DOI: 10.4244/eijv6supja8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS AND METHODS The rates of side branch occlusion and subsequent periprocedural MI during everolimus-eluting stent (EES) and paclitaxel-eluting stent (PES) placement were examined in the randomised SPIRIT III trial. Periprocedural myocardial infarction (MI) following drug-eluting stent placement is associated with long-term adverse outcomes. Occlusion of side branches may be an important factor contributing to periprocedural MIs. Consecutive procedural angiograms of patients randomly assigned to EES (n=669) or PES (n=333) were analysed by an independent angiographic core laboratory. Side branch occlusion was defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1. Clinical outcomes through three years were compared by stent type and presence of side branch occlusion. CONCLUSIONS A total of 2,048 side branches were evaluated (EES N=1,345 side branches in 688 stented lesions, PES N=703 side branches in 346 stented lesions). Patients with compared to those without transient or final side branch occlusion had significantly higher non-Q-wave MI (NQMI) rates in-hospital (9.0% vs. 0.5%, p<0.0001). By multivariable analysis side branch occlusion was an independent predictor of NQMI (OR 4.45; 95% CI [1.82, 10.85]). Transient or final side branch occlusion occurred less frequently in patients receiving EES compared to PES (2.8% vs. 5.2%, p=0.009), contributing to the numerically lower rates of in-hospital NQMI with EES arm compared to PES (0.7% vs. 2.3%, p=0.05). Patients treated with EES rather than PES were less likely to develop side branch occlusion during stent placement, contributing to lower rates of periprocedural MI with EES compared to PES.
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Saeed M, Hetts SW, Ursell PC, Do L, Kolli KP, Wilson MW. Evaluation of the acute effects of distal coronary microembolization using multidetector computed tomography and magnetic resonance imaging. Magn Reson Med 2011; 67:1747-57. [PMID: 21956356 DOI: 10.1002/mrm.23149] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 07/19/2011] [Accepted: 07/21/2011] [Indexed: 12/16/2022]
Abstract
The purpose of this study was to test the potential of clinical imaging modalities, 64-slice multidetector computed tomography (MDCT) and 1.5T magnetic resonance imaging (MRI) for qualitative and quantitative evaluation of acute microinfarcts and to determine the effects of <120 μm microemboli on left ventricular function, perfusion, cardiac injury biomarkers, arrhythmia, and cellular and vascular structures. Under X-ray fluoroscopy, 40-120 μm (16 mm(3) ) microemboli were delivered to embolize the left anterior descending (LAD) coronary artery of nine pigs. MDCT/MRI were performed at 72 h in a single session. Microinfarcts were visible in six of nine animals on delayed contrast-enhanced MDCT/MR images but measurable in all animals using semiautomated threshold methods. Other MDCT and MRI sequences demonstrated decline in left ventricular ejection fraction, regional strain and perfusion in visible and invisible microinfarcted regions. Microemboli caused significant elevation in cardiac injury enzymes and arrhythmias. Various sizes of microinfarcts appeared microscopically as distinct aggregates of macrophages replacing myocardium. Semiautomated threshold methods are necessary to measure and confirm/deny the presence of myocardial microinfarcts. This study offers support for alternative applications of MDCT/MRI in assessing clinical cases in which microemboli <120 μm escape protective devices during percutaneous coronary interventions. Although microembolization resulted in no mortality, it caused left ventricular dysfunction, perfusion deficit, cellular damage increase in cardiac injury enzymes, and arrhythmias.
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Affiliation(s)
- Maythem Saeed
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California 94107-5705, USA.
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MRI study on volume effects of coronary emboli on myocardial function, perfusion and viability. Int J Cardiol 2011; 165:93-9. [PMID: 21872947 DOI: 10.1016/j.ijcard.2011.07.096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 06/16/2011] [Accepted: 07/27/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND Coronary filtration devices showed inadequate protection during PCI due to the inability to filter microemboli <120 μm in diameter. The purpose of this study was to determine the impact of two volumes of <120 μm microemboli on LV function, perfusion and viability using magnetic resonance imaging (MRI). METHODS Under X-ray guidance, pigs (n = 18) received two different volumes (16 mm(3) or 32 mm(3)) of 40-120 μm microemboli (intracoronary). At 3 days, regional myocardial perfusion and LV function were assessed using first pass perfusion and cine MRI. Viability MRI was performed in beating and non-beating hearts to delineate microinfarcts and compare with histochemical triphenyltetrazolium chloride stain, using semi-automatic threshold method. Histology and cardiac injury enzymes were used to confirm the presence of microinfarcts and characterize cellular and vascular changes. RESULTS Microinfarcts were visible as enhanced specks on DE-MRI in all animals that received 32 mm(3), but only two-third of the animals that received 16 mm(3), volume. The decline in ejection fraction and increase in LV volumes and microinfarcts were volume dependent. Regional perfusion and contractility were significantly reduced in the LAD territory compared with remote myocardium. Histology showed apoptosis, edema, inflammation and vascular thrombosis. CONCLUSIONS Microemboli of <120 μm have deleterious effects on LV function, perfusion and viability and the effects are dependent on microemboli volume. Microinfarct visualization is crucial to ensure that myocardial dysfunction is related to dislodged microemboli and not only to pre-procedural stunning or hibernation. This noninvasive MRI method may help in evaluating the effectiveness of coronary filtration devices in protecting myocardium from microemboli.
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Saeed M, Hetts SW, English J, Do L, Wilson MW. Quantitative and qualitative characterization of the acute changes in myocardial structure and function after distal coronary microembolization using MDCT. Acad Radiol 2011; 18:479-87. [PMID: 21237677 DOI: 10.1016/j.acra.2010.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/23/2010] [Accepted: 11/25/2010] [Indexed: 12/30/2022]
Abstract
RATIONALE AND OBJECTIVES To determine the potential of multidetector computed tomography (MDCT) in assessing, at 72 hours, the effects of distal coronary microembolization on myocardial structure and function. MATERIALS AND METHODS Microembolic material (total volume=16 mm(3) of 40-120 μm diameter) was selectively delivered in the left anterior descending coronary artery under x-ray fluoroscopy (n = 6 pigs). After 72 hours, 64-slice MDCT was used to assess LV function, perfusion, and viability. For comparison between the measurements at 80 kV, 120 kV, and postmortem we used Bland-Altman and Pearson correlation. Histochemical and histopathological staining was used for quantitative and qualitative characterization of microinfarct. RESULTS Cine MDCT showed the deleterious effects of microembolization on systolic wall thickening, LV volumes, and ejection fraction. Perfusion parameters, such as max upslope, peak attenuation, and time to peak, differed between microinfarct territory and remote myocardium. Inconsistency in visualizing microinfarct was observed using tube voltages of 80 kV and 120 kV. The extent of heterogeneous microinfarct was 4.5 ± 1.0 % of LV mass at 80 kV, 6.1 ± 0.9% LV at 120 kV, and 5.9 ± 1.1% LV on postmortem. There was significant difference in the extent of microinfarct measured on 80 kV MDCT compared with 120 kV and postmortem. Microscopic examination revealed the random distribution of obstructed microvessels surrounded by myocardial necrosis and inflammatory cells in all animals. CONCLUSION Both visible and nonvisible microinfarct cause perfusion deficit and LV dysfunction. MDCT is sensitive for quantifying early functional changes in LV caused by microembolization. Further improvement in spatial resolution of this technology is needed to improve visualization of microinfarct.
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Affiliation(s)
- Maythem Saeed
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 94107-5705, USA.
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18
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Applegate R, Hermiller J, Williams J, Gordon P, Doostzadeh J, Cao S, Su X, Sudhir K, Lansky A, Simonton C, Stone G. Evaluation of the effects of everolimus-eluting and paclitaxel-eluting stents on target lesions with jailed side branches: 2-year results from the SPIRIT III randomized trial. Catheter Cardiovasc Interv 2011; 76:644-51. [PMID: 20506356 DOI: 10.1002/ccd.22606] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate whether an everolimus-eluting stent (EES) with thinner stent struts and polymer results in less periprocedural myonecrosis and adverse outcomes. BACKGROUND Higher periprocedural myocardial infarction (MI) rates have been reported with the TAXUS® EXPRESS(2) paclitaxel-eluting stent (PES) compared to the bare metal EXPRESS(2)® stent due to more frequent side branch compromise, presumably attributable to the thickness of the stent/polymer on the PES. METHODS In the SPIRIT III trial, we identified 113 patients in the XIENCE V® EES group and 63 patients in the TAXUS EXPRESS(2) PES group who met the criteria of having a lesion with a jailed side branch (<2 mm diameter, and <50% stenosis). Two-year clinical outcomes were evaluated. RESULTS A periprocedural increase in Creatine Kinase-MB >1× upper normal level occurred in 9.0% of EES compared to 29.7% of PES patients with jailed side branches, P = 0.01. Through 2 years, major adverse cardiac events (MACE; cardiac death, MI, or target lesion revascularization [TLR]) occurred in 6.8% of EES and 19.0% of PES jailed side branch patients (P = 0.03), with numerically lower rates of MI (2.9% vs. 10.3%, P = 0.07) and TLR (3.9% vs. 10.3%, P = 0.17) in the EES group, with comparable rates of cardiac death (1.9% vs. 1.7%, P = 1.00). CONCLUSIONS In this post-hoc analysis of the SPIRIT III RCT, patients undergoing stenting of target lesions with jailed side branches with the thin strut and polymer XIENCE V EES compared to the thicker strut TAXUS PES had lower rates of MACE through 2 years due to fewer MIs and TLRs. © 2010 Wiley-Liss, Inc.
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Affiliation(s)
- Robert Applegate
- Wake Forrest University School of Medicine, Winston-Salem, NC, USA.
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American College of Cardiology Foundation Task Force on Expert Consensus Documents, Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, Friedrich MG, Ho VB, Jerosch-Herold M, Kramer CM, Manning WJ, Patel M, Pohost GM, Stillman AE, White RD, Woodard PK. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010; 55:2614-62. [PMID: 20513610 PMCID: PMC3042771 DOI: 10.1016/j.jacc.2009.11.011] [Citation(s) in RCA: 473] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Collaborators] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Collaborators
Robert A Harrington, Jeffrey L Anderson, Eric R Bates, Charles R Bridges, Mark J Eisenberg, Victor A Ferrari, Cindy L Grines, Mark A Hlatky, Alice K Jacobs, Sanjay Kaul, Robert C Lichtenberg, Jonathan R Lindner, David J Moliterno, Debabrata Mukherjee, Gerald M Pohost, Robert S Rosenson, Richard S Schofield, Samuel J Shubrooks, James H Stein, Cynthia M Tracy, Howard H Weitz, Deborah J Wesley,
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American College of Cardiology Foundation Task Force on Expert Consensus Documents, Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, Friedrich MG, Ho VB, Jerosch-Herold M, Kramer CM, Manning WJ, Patel M, Pohost GM, Stillman AE, White RD, Woodard PK. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation 2010; 121:2462-508. [PMID: 20479157 PMCID: PMC3034132 DOI: 10.1161/cir.0b013e3181d44a8f] [Citation(s) in RCA: 237] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Collaborators] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Collaborators
Robert A Harrington, Jeffrey L Anderson, Eric R Bates, Charles R Bridges, Mark J Eisenberg, Victor A Ferrari, Cindy L Grines, Mark A Hlatky, Alice K Jacobs, Sanjay Kaul, Robert C Lichtenberg, Jonathan R Lindner, David J Moliterno, Debabrata Mukherjee, Gerald M Pohost, Robert S Rosenson, Richard S Schofield, Samuel J Shubrooks, James H Stein, Cynthia M Tracy, Howard H Weitz, Deborah J Wesley,
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Saeed M, Hetts S, Wilson M. Reperfusion injury components and manifestations determined by cardiovascular MR and MDCT imaging. World J Radiol 2010; 2:1-14. [PMID: 21160735 PMCID: PMC2999314 DOI: 10.4329/wjr.v2.i1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 01/06/2010] [Accepted: 01/13/2010] [Indexed: 02/06/2023] Open
Abstract
Advances in magnetic resonance (MR) and computed tomography (CT) imaging have improved visualization of acute and scar infarct. Over the past decade, there have been and continues to be many significant technical advancements in cardiac MR and multi-detector computed tomography (MDCT) technologies. The strength of MR imaging relies on a variety of pulse sequences and the ability to noninvasively provide information on myocardial structure, function and perfusion in a single imaging session. The recent technical developments may also allow CT technologies to rise to the forefront for evaluating clinical ischemic heart disease. Components of reperfusion injury including myocardial edema, hemorrhage, calcium deposition and microvascular obstruction (MO) have been demonstrated using MR and CT technologies. MR imaging can be used serially and noninvasively in assessing acute and chronic consequences of reperfusion injury because there is no radiation exposure or administration of radioactive materials. MDCT is better suited for assessing coronary artery stenosis and as an alternative technique for assessing viability in patients where MR imaging is contraindicated. Changes in left ventricular (LV) volumes and function measured on cine MR are directly related to infarct size measured on delayed contrast enhanced images. Recent MR studies found that transmural infarct, MO and peri-infarct zone are excellent predictors of poor post-infarct recovery and mortality. Recent MR studies provided ample evidence that growth factor genes and stem cells delivered locally have beneficial effects on myocardial viability, perfusion and function. The significance of deposited calcium in acute infarct detected on MDCT requires further studies. Cardiac MR and MDCT imaging have the potential for assessing reperfusion injury components and manifestations.
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22
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Breuckmann F, Nassenstein K, Bucher C, Konietzka I, Kaiser G, Konorza T, Naber C, Skyschally A, Gres P, Heusch G, Erbel R, Barkhausen J. Systematic analysis of functional and structural changes after coronary microembolization: a cardiac magnetic resonance imaging study. JACC Cardiovasc Imaging 2009; 2:121-30. [PMID: 19356544 DOI: 10.1016/j.jcmg.2008.10.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 10/21/2008] [Accepted: 10/27/2008] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Our study aimed to detect the morphological und functional effects of coronary microembolization (ME) in vivo by cardiac magnetic resonance (CMR) imaging in an established experimental animal model. BACKGROUND Post-mortem morphological alterations of coronary ME include perifocal inflammatory edema and focal microinfarcts. Clinically, the detection of ME after successful coronary interventions identifies a population with a worse long-term prognosis. METHODS In 18 minipigs, ME was performed by intracoronary infusion of microspheres followed by repetitive in vivo imaging on a 1.5-T MR system from 30 min to 8 h after ME. Additionally, corresponding ex vivo CMR imaging and histomorphology were performed. RESULTS Cine CMR imaging demonstrated a time-dependent increase of wall motion abnormalities from 9 of 18 animals after 30 min to all animals after 8 h (0.5 h, 50%; 2 h, 78%; 4 h, 75%; 8 h, 100%). Whereas T2 images were negative 30 min after ME, 4 of 18 animals showed myocardial edema at follow-up (0.5 h, 0%; 2 h, 6%; 4 h, 25%; 8 h, 17%). In vivo late gadolinium enhancement (LGE) was observed in none of the animals after 30 min, but in 33%, 50%, and 83% of animals at 2 h, 4 h, and 8 h, respectively, after ME. Ex vivo CMR imaging showed patchy areas of LGE in all but 1 animal (2 h, 83%; 4 h, 100%; 8 h, 100%). A significant correlation was seen between the maximum troponin I level and LGE in vivo (r = 0.63) and the spatial extent of ex vivo LGE (r = 0.76). CONCLUSIONS Our results show that in vivo contrast-enhanced CMR imaging allows us to detect functional and structural myocardial changes after ME with a high sensitivity. Ex vivo, the pattern of LGE of high-resolution, contrast-enhanced CMR imaging is different from the well-known pattern of LGE in compact myocardial damage. Thus, improvements in spatial resolution are thought to be necessary to improve its ability to visualize ME-induced structural alterations even in vivo.
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, West German Heart Center, Essen, Germany.
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23
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Popma JJ, Mauri L, O'Shaughnessy C, Overlie P, McLaurin B, Almonacid A, Kirtane A, Leon MB. Frequency and Clinical Consequences Associated With Sidebranch Occlusion During Stent Implantation Using Zotarolimus-Eluting and Paclitaxel-Eluting Coronary Stents. Circ Cardiovasc Interv 2009; 2:133-9. [DOI: 10.1161/circinterventions.108.832048] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey J. Popma
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Laura Mauri
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Charles O'Shaughnessy
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Paul Overlie
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Brent McLaurin
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Alexandra Almonacid
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Ajay Kirtane
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
| | - Martin B. Leon
- From the Department of Internal Medicine, Cardiology Divisions (J.J.P.) of the Beth Israel Deaconess Medical Center, Boston, Mass; Brigham and Women’s Hospital (L.M., A.A.), Boston, Mass; Elyria Memorial Hospital (C.S.), Elyria, Ohio; Lubbock Heart Hospital (P.O.), Lubbock, Tex; Anderson Medical Center (B.M.L.), Anderson, SC; and Columbia University Medical Center (A.K., M.B.L.), New York, NY
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Krittayaphong R, Maneesai A, Chaithiraphan V, Saiviroonporn P, Chaiphet O, Udompunturak S. Comparison of diagnostic and prognostic value of different electrocardiographic criteria to delayed-enhancement magnetic resonance imaging for healed myocardial infarction. Am J Cardiol 2009; 103:464-70. [PMID: 19195503 DOI: 10.1016/j.amjcard.2008.10.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Revised: 10/02/2008] [Accepted: 10/02/2008] [Indexed: 10/21/2022]
Abstract
The accuracy of various electrocardiographic (ECG) criteria for the diagnosis of healed myocardial infarction (MI) has never been validated. The objective of this study was to determine the accuracy and prognostic value of standard ECG criteria for the diagnosis of healed MI compared with cardiac magnetic resonance (CMR). Consecutive patients with known or suspected coronary artery disease who were referred for CMR were studied. Twelve-lead electrocardiography and CMR were performed the same day. A standard CMR protocol including a delayed-enhancement (DE) technique was performed. The prognostic value of using various ECG criteria and DE-CMR was assessed for the occurrence of cardiac death, nonfatal MI, or major adverse cardiac events. We studied 1,366 patients. Average follow-up was 31.4 +/- 15.8 months. Myocardial scar was detected in 507 patients (37.1%) using DE-CMR. Healed MI using various ECG criteria had sensitivity, specificity, and accuracy of 44% to 59%, 91% to 95%, and 75% to 79% compared with DE-CMR, respectively. Multivariable Cox regression analysis showed that myocardial scar using DE-CMR was the most powerful predictor for cardiac events, followed by left ventricular ejection fraction. In the absence of DE-CMR data, MI using European Society of Cardiology/American College of Cardiology (ESC/ACC) 2000 criteria was the most powerful predictor. In conclusion, various ECG criteria had limited sensitivity, but high specificity, for the diagnosis of healed MI compared with myocardial scar using DE-CMR. Myocardial scar, left ventricular ejection fraction, and MI using ESC/ACC 2000 criteria were important predictors for cardiac events.
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Grayburn PA, Choi JW. Advances in the assessment of no-reflow after successful primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: now that we can diagnose it, what do we do about it? J Am Coll Cardiol 2008; 51:566-8. [PMID: 18237686 DOI: 10.1016/j.jacc.2007.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 10/02/2007] [Indexed: 10/22/2022]
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Association of impaired thrombolysis in myocardial infarction myocardial perfusion grade with ventricular tachycardia and ventricular fibrillation following fibrinolytic therapy for ST-segment elevation myocardial infarction. J Am Coll Cardiol 2008; 51:546-51. [PMID: 18237683 DOI: 10.1016/j.jacc.2007.08.061] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 08/24/2007] [Accepted: 08/27/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The goal of this analysis was to evaluate the association of impaired Thrombolysis In Myocardial Infarction myocardial perfusion grade (TMPG) with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). BACKGROUND Impaired TMPG after successful restoration of epicardial flow among patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) has been associated with adverse clinical outcomes, but its relationship to VT/VF has not been evaluated. METHODS In the CLARITY-TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28) study, 3,491 patients underwent angiography a median of 3.5 days after fibrinolytic administration for STEMI; TMPG was assessed, and its association with VT/VF was evaluated. RESULTS We observed VT/VF in 4.8% of patients. Impaired myocardial perfusion (TMPG 0/1/2) was associated with an increased incidence of VT/VF (7.1% vs. 2.6% with TMPG 3; log-rank p < 0.001). Among patients with restoration of normal epicardial flow (Thrombolysis In Myocardial Infarction flow grade 3), the incidence of VT/VF was increased among patients with impaired TMPG (4.7% vs. 2.7%; p = 0.02). Among patients with left ventricular ejection fraction >or=30%, impaired TMPG remained associated with an increased incidence of VT/VF (4.7% vs. 2.5%; p = 0.03). We found that VT/VF was associated with increased mortality (25.2% vs. 3.5%; p < 0.0001). Furthermore, among patients with VT/VF, impaired TMPG was associated with increased mortality (17.1% vs. 2.3%; p = 0.02). All but 1 death among patients who had VT/VF were among patients with impaired myocardial perfusion. CONCLUSIONS Despite restoration of normal epicardial flow or a left ventricular ejection fraction >or=30%, impaired myocardial perfusion on angiography 3.5 days after fibrinolytic administration for STEMI is associated with an increased incidence of VT/VF.
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Selvanayagam JB, Cheng ASH, Jerosch-Herold M, Rahimi K, Porto I, van Gaal W, Channon KM, Neubauer S, Banning AP. Effect of Distal Embolization on Myocardial Perfusion Reserve After Percutaneous Coronary Intervention. Circulation 2007; 116:1458-64. [PMID: 17785626 DOI: 10.1161/circulationaha.106.671909] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background—
Studies have shown that a subset of patients demonstrate persistent impairment in microcirculatory function after percutaneous coronary intervention (PCI). Distal embolization of plaque contents has been postulated as the main mechanism for this. We sought to investigate this further by evaluating PCI-induced changes in myocardial perfusion reserve index (MPRI) over time in segments with “distal-type” procedure-related myonecrosis using high-resolution quantitative cardiovascular magnetic resonance imaging.
Methods and Results—
Forty patients undergoing PCI were studied with pre-PCI and 24-hour post-PCI delayed-enhancement magnetic resonance imaging and first-pass perfusion magnetic resonance imaging at rest and stress. Twenty patients underwent a third magnetic resonance imaging scan at 6 months. For perfusion imaging, 3 short-axis images were acquired during every heartbeat with a T1-weighted turboFLASH sequence. MPRI was calculated as the ratio of hyperemic to resting myocardial blood flow and subdivided according to the presence and location of new delayed hyperenhancement. Twenty-one patients demonstrated new distal hyperenhancement after PCI. Mean MPRI in revascularized myocardial segments not demonstrating new HE was significantly increased after the procedure (2.06 [95% CI, 1.99 to 2.13] before PCI and 2.52 [95% CI, 2.42 to 2.62] after PCI;
P
<0.001). In contrast, MPRI in segments with distal hyperenhancement was reduced after PCI (2.16 [95% CI, 1.95 to 2.37] before PCI; 2.00 [95% CI, 1.82 to 2.19] after PCI; mixed-model
z
=−4.82;
P
<0.001). Changes in mean MPRI 24 hours after PCI in segments upstream to new injury were not significantly different compared with perfusion changes in remote myocardium (
z
=−0.68;
P
=0.50). At 6 months after the procedure, mean MPRI in segments with new injury improved significantly compared with MPRI measured in these segments at 24 hours after PCI.
Conclusions—
MPRI is reduced in myocardial segments that demonstrate new distal irreversible injury at 24 hours after PCI. These reductions are confined to the segments with injury and do not affect the entire supply territory of the culprit vessel.
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Affiliation(s)
- Joseph B Selvanayagam
- University of Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford, UK.
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Gibson CM, Kirtane AJ, Morrow DA, Palabrica TM, Murphy SA, Stone PH, Scirica BM, Jennings LK, Herrmann HC, Cohen DJ, McCabe CH, Braunwald E. Association between thrombolysis in myocardial infarction myocardial perfusion grade, biomarkers, and clinical outcomes among patients with moderate- to high-risk acute coronary syndromes: observations from the randomized trial to evaluate the relative PROTECTion against post-PCI microvascular dysfunction and post-PCI ischemia among antiplatelet and antithrombotic agents-Thrombolysis In Myocardial Infarction 30 (PROTECT-TIMI 30). Am Heart J 2006; 152:756-61. [PMID: 16996854 DOI: 10.1016/j.ahj.2006.04.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 04/13/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND A variety of imaging modalities have implicated impaired myocardial perfusion in the pathogenesis of acute coronary syndromes (ACSs). METHODS We hypothesized that an abnormal TIMI myocardial perfusion grade (TMPG 0/1/2) and an impaired coronary flow reserve (CFR) as assessed angiographically using the TIMI frame count would be associated with biomarker release, ischemia on Holter monitoring, and adverse clinical outcomes in the PROTECT-TIMI 30 trial of patients with non-ST-elevation ACS undergoing percutaneous coronary intervention (PCI). RESULTS The pre-PCI TMPG was correlated with the baseline as well as peak levels of troponin I (P < .001) and creatine kinase-MB (P < .001) and the post-PCI rise in troponin I (P = .03). The incidence of an ischemic event on Holter by 48 hours was more common among patients with an abnormal post-PCI TMPG (12.5% vs 7.0%, P = .013), and the mean normalized duration of ischemia by 24 hours after PCI on Holter monitoring trended longer among patients with an abnormal post-PCI TMPG (8.9 vs 3.2 minutes, P = .068). In multivariable analyses, an abnormal post-PCI TMPG was the strongest correlate of death, myocardial infarction, or an ischemic event by 48 hours after randomization. In contrast, the post-PCI CFR as assessed angiographically using the TIMI frame count was not associated with the baseline, peak, or absolute rise of any biomarker, Holter findings, or clinical events. CONCLUSIONS An abnormal TMPG, but not an angiographic CFR, is associated with biomarker status, the occurrence and duration of Holter ischemia, and adverse clinical outcomes among patients with moderate- to high-risk non-ST-elevation ACS undergoing PCI.
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Affiliation(s)
- C Michael Gibson
- TIMI Study Group, Cardiovascular Division, Brigham & Women's Hospital, Boston, MA, USA.
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Larose E. Below radar: contributions of cardiac magnetic resonance to the understanding of myonecrosis after percutaneous coronary intervention. Circulation 2006; 114:620-2. [PMID: 16908784 DOI: 10.1161/circulationaha.106.644732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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30
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Porto I, Selvanayagam JB, Van Gaal WJ, Prati F, Cheng A, Channon K, Neubauer S, Banning AP. Plaque volume and occurrence and location of periprocedural myocardial necrosis after percutaneous coronary intervention: insights from delayed-enhancement magnetic resonance imaging, thrombolysis in myocardial infarction myocardial perfusion grade analysis, and intravascular ultrasound. Circulation 2006; 114:662-9. [PMID: 16894040 DOI: 10.1161/circulationaha.105.593210] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Myocardial necrosis can occur during percutaneous coronary intervention (PCI) despite optimal adjunctive pharmacology and careful technique. We investigated the mechanisms of procedural infarction using angiographic analysis, intravascular ultrasound, and delayed-enhancement magnetic resonance imaging. METHODS AND RESULTS Fifty-two patients (64 vessels) who underwent complex PCI were studied. All patients were preloaded with clopidogrel and received glycoprotein IIb/IIIa inhibitors. "Adjacent" myonecrosis was defined as the presence of an area of new gadolinium hyperenhancement close to the stent. "Distal" myonecrosis was defined as situated at least 10 mm downstream from the stent. Fifteen vessels (23%) had evidence of new hyperenhancement after PCI. Of these, 8 (12%) had the distal type, and 7 (11%) had the adjacent type. Intravascular ultrasound showed a significantly greater reduction in plaque volume (91.6+/-51.5 versus 8+/-14 versus 20+/-35 mm3; P < 0.001) in the group with distal hyperenhancement compared with patients without new hyperenhancement or adjacent hyperenhancement. In the entire sample, a significant correlation was seen between changes in plaque volume (rho = 0.58, P < 0.001) after PCI and the mass of new necrosis measured by magnetic resonance imaging. Thrombolysis in Myocardial Infarction perfusion grade assessment of a closed microvasculature after PCI carried an odds ratio of 8.0 (95% confidence interval, 1.4 to 46.1; P = 0.02) for the occurrence of hyperenhancement, whereas side-branch occlusion was associated with an odds ratio of 16.2 (95% confidence interval, 2.6 to 102.5; P = 0.03). However, a closed microvasculature was associated with distal hyperenhancement (P = 0.02), and side-branch occlusion was associated with adjacent hyperenhancement (P < 0.001). CONCLUSIONS These data suggest that distal embolization of plaque material occurs in contemporary PCI of native coronary arteries. Efforts to minimize procedural necrosis may require careful review of side branch anatomy and/or use of distal protection during extensive coronary stenting.
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Affiliation(s)
- Italo Porto
- Department of Cardiology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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31
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Abstract
During the past three decades, percutaneous coronary intervention has become one of the cardinal treatment strategies for stenotic coronary artery disease. Technical advances, including the introduction of new devices such as stents, have expanded the interventional capabilities of balloon angioplasty. At the same time, there has been a decline in the rate of major adverse cardiac events, including Q-wave acute myocardial infarction, emergency coronary artery bypass grafting, and cardiac death. Despite these advances, the incidence of post-procedural cardiac marker elevation has not substantially decreased since the first serial assessment 20 years ago. As of now, these post-procedural cardiac marker elevations are considered to represent peri-procedural myocardial injury (PMI) with worse long-term outcome potential. Recent progress has been made for the identification of two main PMI patterns, one near the intervention site (proximal type, PMI type I) and one in the distal perfusion territory of the treated coronary artery (distal type, PMI type II) as well as for preventive strategies. Integrating these new developments into the wealth of clinical information on this topic, this review aims at giving a current perspective on the entity of PMI.
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Affiliation(s)
- Joerg Herrmann
- Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street S.W., Rochester, MN 55905, USA.
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Chen WH, Lee PY, Ng W, Kwok JYY, Cheng X, Lee SWL, Tse HF, Lau CP. Relation of aspirin resistance to coronary flow reserve in patients undergoing elective percutaneous coronary intervention. Am J Cardiol 2005; 96:760-3. [PMID: 16169354 DOI: 10.1016/j.amjcard.2005.04.056] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Revised: 04/25/2005] [Accepted: 04/25/2005] [Indexed: 11/17/2022]
Abstract
Previous studies have shown that more complete platelet inhibition improves the coronary flow reserve (CFR), a measure of microvascular integrity, in patients undergoing percutaneous coronary intervention (PCI). We hypothesized that patients with aspirin resistance would have impaired CFR after elective PCI. We used VerifyNow Aspirin to determine the response to aspirin in 117 consecutive patients who underwent elective single-lesion PCI. The assay results are expressed quantitatively in Aspirin Reaction Units based on the degree of platelet aggregation. All patients received a 300-mg loading dose of clopidogrel >12 hours before and a 75-mg maintenance dose the morning of PCI. CFR was estimated using the Thrombolysis In Myocardial Infarction frame count method. Of the 117 patients, 22 (18.8%) were aspirin resistant. The clinical, angiographic, and procedural characteristics of the aspirin-sensitive and -resistant patients were balanced. All patients underwent successful PCI with <50% residual diameter stenosis and Thrombolysis In Myocardial Infarction grade 3 flow after PCI. Aspirin-resistant patients had a lower CFR than the aspirin-sensitive patients (1.42 +/- 0.35 vs 1.80 +/- 0.64, p = 0.018). Univariate correlates of CFR included the Aspirin Reaction Unit (r = -0.227, p = 0.014) and post-PCI creatine kinase-MB elevation (p = 0.048). Multivariate linear regression analysis revealed the Aspirin Reaction Unit to be the only independent determinant of CFR after PCI (r2 = 0.051, p = 0.014). Thus, aspirin resistance was associated with impaired CFR in patients who underwent elective PCI, implicating insufficient aspirin-induced platelet inhibition as a cause of microvascular dysfunction by distal atherothrombotic embolization and/or spasm.
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Affiliation(s)
- Wai-Hong Chen
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
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Affiliation(s)
- Deepak L Bhatt
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195, USA.
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