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Appearance of microvascular obstruction on high resolution first-pass perfusion, early and late gadolinium enhancement CMR in patients with acute myocardial infarction
Adam N Mather, Timothy Lockie, Eike Nagel, Michael Marber, Divaka Perera, Simon Redwood, Aleksandra Radjenovic, Ansuman Saha, John P Greenwood, Sven Plein
Journal of Cardiovascular Magnetic Resonance , 2009, DOI: 10.1186/1532-429x-11-33
Abstract: 34 patients with acute ST elevation myocardial infarction, treated successfully with primary percutaneous coronary intervention (PPCI), underwent CMR within 72 hours of admission. k-t SENSE accelerated first-pass perfusion MR (7 fold acceleration, spatial resolution 1.5 mm × 1.5 mm × 10 mm, 8 slices acquired over 2 RR intervals, 0.1 mmol/kg Gd-DTPA), EGE (1-4 minutes after injection with a fixed TI of 440 ms) and LGE images (10-12 minutes after injection, TI determined by a Look-Locker scout) were acquired. MO volume was determined for each technique by manual planimetry and summation of discs methodology.k-t SENSE first-pass perfusion detected more cases of MO than EGE and LGE (22 vs. 20 vs. 14, respectively). The extent of MO imaged by first-pass perfusion (median mass 4.7 g, IQR 6.7) was greater than by EGE (median mass 2.3 g, IQR 7.1, p = 0.002) and LGE (median mass 0.2 g, IQR 2.4, p = 0.0003). The correlation coefficient between MO mass measured by first-pass perfusion and EGE was 0.91 (p < 0.001).The extent of MO following acute myocardial infarction appears larger on high-resolution first-pass perfusion CMR than on EGE and LGE. Given the inevitable time delay between gadolinium administration and acquisition of either EGE or LGE images, high resolution first-pass perfusion imaging may be the most accurate method to quantify MO.The basic aim of reperfusion therapy in acute myocardial infarction (AMI) is to restore normal blood flow to the ischemic myocardium as quickly as possible. Recanalisation of the infarct-related artery by primary percutaneous coronary intervention (PPCI), in particular, has seen significant reductions in mortality after AMI by limiting the amount of myocardial necrosis [1,2]. However, restoration of patency in the epicardial coronary artery sometimes fails to translate into recovery of myocardial function and in up to 30% of patients, reperfusion of the ischemic territory is incomplete due to myocardial microvascular obstruction (MO), w
The Value of Myocardial Perfusion Imaging with Tc-99m MIBI for the Prediction of Perfusion Improvement after Percutaneous Transluminal Coronary Angioplasty
Armaghan Fard-Esfahani,Babak Fallahi,Abbas Mohagheghi,Majid Assadi
Iranian Journal of Nuclear Medicine , 2010,
Abstract: Introduction: Percutaneous transluminal coronary angioplasty (PTCA) is an effective method for revascularizing of stenotic coronary vessels. Lack of response to this treatment, either in symptomatic or asymptomatic patients, is usually due to incomplete revascularization, restenosis, and/or irreversibility of myocardial perfusion. Introduction of a noninvasive method with high predictive value for diagnosis of reversibility in ischemic myocardium is of high importance to determine the patients who will benefit from PTCA. Methods: Sixty patients with one or two vessel disease, who were candidates for PTCA and had a successful PTCA (proved by post- revascularization angiography), enrolled the study. For all patients myocardial perfusion imaging (MPI) was performed before PTCA in stress and rest phases. MPI was repeated in stress and rest phases within 6 months after PTCA. The predictive values of pre-PTCA scan for the diagnosis of reversibility and prediction of perfusion improvement after PTCA were evaluated. Results: Perfusion improvement after PTCA was noted in 52 of 60 patients (86.7%). The positive predictive value of pre-intervention MPI for diagnosis of reversibility was 94.3% and the corresponding negative predictive value was 71.4%. Conclusion: Myocardial perfusion imaging may play an important role for accurate prediction of perfusion improvement after percutaneous transluminal coronary angioplasty.
Utility of Cardiac Magnetic Resonance to assess association between admission hyperglycemia and myocardial damage in patients with reperfused ST-Segment Elevation Myocardial Infarction
Alexandre Cochet, Marianne Zeller, Alain Lalande, Isabelle L'Huillier, Paul M Walker, Claude Touzery, Bruno Verges, Jean-Eric Wolf, Fran?ois Brunotte, Yves Cottin
Journal of Cardiovascular Magnetic Resonance , 2008, DOI: 10.1186/1532-429x-10-2
Abstract: We analyzed 113 patients with STEMI treated with successful primary percutaneous coronary intervention. Admission hyperglycemia was defined as a glucose level ≥ 7.8 mmol/l. Contrast-enhanced CMR was performed between 3 and 7 days after reperfusion to evaluate left ventricular function and perfusion data after injection of gadolinium-DTPA. First-pass images (FP), providing assessment of microvascular obstruction and Late Gadolinium Enhanced images (DE), reflecting the extent of infarction, were investigated and the extent of transmural tissue damage was determined by visual scores.Patients with a supramedian FP and DE scores more frequently had left anterior descending culprit artery (p = 0.02 and <0.001), multivessel disease (p = 0.02 for both) and hyperglycemia (p < 0.001). Moreover, they were characterized by higher levels of HbA1c (p = 0.01 and 0.04), peak plasma Creatine Kinase (p < 0.001), left ventricular end-systolic volume (p = 0.005 and <0.001), and lower left ventricular ejection fraction (p = 0.001 and <0.001).In a multivariate model, admission hyperglycemia remains independently associated with increased FP and DE scores.Our results show the existence of a strong relationship between glucose metabolism impairment and myocardial damage in patients with STEMI. Further studies are needed to show if aggressive glucose control improves myocardial perfusion, which could be assessed using CMR.Admission hyperglycemia is associated with increased short and long term risk of death in patients with ST-segment elevation myocardial infarction (STEMI), independently of the presence of Diabetes Mellitus [1-3]; this increased mortality might be explained by a higher incidence of congestive heart failure and cardiogenic shock [2,4]. Moreover, a recent study suggested an association between admission hyperglycemia and the no-reflow phenomenon as assessed by myocardial contrast echocardiography [5]. In contrast, the association between hyperglycemia and the extent of myoca
Impaired myocardial perfusion score and inflammatory markers in patients undergoing primary angioplasty for acute myocardial infarction
Exaire, J Emilio;Fathi, Robert B;Brener, Sorin J;Karha, Juhana;Ellis, Stephen G;Bhatt, Deepak L;
Archivos de cardiología de México , 2006,
Abstract: background: microcirculatory dysfunction during acute myocardial infarction is mediated by various mechanisms including inflammation, thrombus, or plaque embolization. we hypothesize that patients with acute myocardial infarction and admission thrombolysis in myocardial infarction (tlml) myocardial perfusión grade (tmp) < 2 had increased inflammatory status as measured by high sensitivity c-reactive protein (hs-crp). methods: from january 2002 to december 2003, 166 patients (178 lesions) were referred for primary percutaneous coronary intervention. patients were stratified based on pre-pci tmp < 2 or tmp 3 2. univariate and multi-variate predictors of in-hospital and 30-day death were determined with logistic regression. results: pre-pci tmp < 2 was found in 66% vs 34% with tmp 3 2 (p < .001). hs-crp levels were high in both groups but not significantly different (37.9 ± 6 vs 33.7 ± 6 mg/l, p = .63). patients with tmp < 2 had higher wbc (12.83 ± 4.55 * 103 vs 10.83 ± 3.00 * 103, p = .04), lower ejection fraction (40 ± 11% vs 46 ± 12%, p < .001), and higher admission ck-mb levels (116 ± 13 ng/ml vs 55 ± 13 ng/ml, p = .006). death occurred in 12% in the poor tmp group vs 1.8% in the good tmp group (p = .03). advanced age, use of an intra-aortic balloon pump, and elevated admission wbc were independently associated with in-hospital and 30-day death. conclusions: high hs-crp levels were not associated with impaired myocardial perfusion score. microcirculatory impairment may be related to an increased inflammatory process, independent from high hs-crp levels.
The Relationship Between The Level Of Serum Uric Acid And No-Reflow Phenomenon After Primary Percutaneous Coronary Intervention n Patients With St Segment Elevated Myocardial Infarction  [PDF]
?smail ERDEN, Emine ?akcak ERDEN, Serhat Bahad?r S?ZEN, Osman Kayap?nar, Sabri Onur ?A?LAR, Cengiz BA?AR
Duzce Universitesi Tip Fakültesi Dergisi , 2010,
Abstract: No-reflow phenomenon is the absence of myocardial perfusion despite adequate dilatation ofthe infarct related coronary artery during percutaneous coronary intervention. Uric acid (UA)release during ischemia and washout from the ischemic zone during reperfusion is adeninenucleotide breakdown product. Therefore uric acid may play reperfusion injury and no-reflow. n this study, we aimed to compare serum uric acid value of ST segment elevated M patientsgroups whith no-reflow phenomenon and normal miyocardial perfusion after primary coronaryintervention.47 patients was enrolled consecutively to this study. During hospital admission, patients bloodsamples were taken for serum uric acid value. Patients was grouped as no reflow and normalperfusion groups according to myocardial blush grades (MBG). Patient with myocardial blushgrades 0-1 were accepted as no-reflow group, patients with MBG 2-3 normal perfusion group.When the serum uric acid value of no-reflow and normal perfusion groups was compared, therewas statistificaly significant difference (respectively 6,680±1,11 mg/dl versus 5,066±0,68 mg/dl.p<0,05). A significant correlation was found between the serum uric acid level and the presenceof no-reflow phenomenon (r=0.598; p<0.025). Multivariate logistic regression analysis showedan independent relationship between no-reflow phenomenon and serum uric acid level (OR1.815; 95% CI 1.098-1.493; p<0.031).In ST segment elevated M patients with higher serum uric acid value before primary coronaryintervention, no-reflow phenomenon is developed more frequently. Uric acid may play importantrole in mechanism of no-reflow phenomenon.
The role of scintigraphic perfusion imaging in the evaluation of patients before and after percutaneous transluminal coronary angioplasty (PTCA)
A. Fard-Esfahani,A. Mohagheghi,M. Assadi,B. Fallahi
Iranian Journal of Nuclear Medicine , 2006,
Abstract: Objectives: We studied the value of myocardial perfusion imaging (MPI) for evaluation of myocardial perfusion improvement in patients with successful percutaneous transluminal coronary angioplasty (PTCA). Methods: Sixty patients (10 females and 50 males), (Age 54.18 +/- 11.71 years) were analyzed. MPI was performed before PTCA, and then 3-6 months after the procedure. In all patients repeated coronary angiography was done at least once after PTCA. Before PTCA myocardial perfusion defects were observed in all patients. Statistical analysis of the number of segments with various degrees of perfusion (normal, transient ischemia, irreversible ischemia), before and after PTCA, was performed for three groups separately. Statistical analyses were performed using the paired T test and also ANOVA test. Results: Improvement as a decrease in the number of transiently or irreversibly ischemic segments, was observed in 13 out of 16 patients in 6-10 days, 18 out of 21 cases 1-3 months and 20 out of 23 patients 3-6 months following PTCA. The scans performed 3-6 months after PTCA as compared to 1-3 months MPI showed an increase in the number of transiently ischemic segments and a decrease of normal perfused segments, but it did not reach a statistical significance. Sensitivity and specificity of MPI using angiography as the gold standard calculated four times; before PTCA, 6-10 days,1-3 months and 3-6 months after PTCA were 80, 81; 100, 35 ; 90, 100 and 76, 100 percent, respectively. Conclusion: Our results confirm the necessity for an assessment of perfusion, both before and shortly after angioplasty, so that the longer term consequences can be followed accurately. In addition our study confirmed that MPI approximately 4 weeks after the intervention has a good correlation between stress-induced myocardial perfusion abnormalities and the presence or absence of stenosis, independent of clinical symptoms.
A study to assess changes in myocardial perfusion after treatment with spinal cord stimulation and percutaneous myocardial laser revascularisation; data from a randomised trial
Sadia N Khan, Duncan C McNab, Linda D Sharples, Carol J Freeman, Ian Hardy, David L Stone, Peter M Schofield
Trials , 2008, DOI: 10.1186/1745-6215-9-9
Abstract: Subjects with Canadian Cardiovascular Society class 3/4 angina and reversible perfusion defects as assessed by single-photon emission computed tomographic myocardial perfusion scintigraphy were randomised to SCS (34) or PMR (34). 28 subjects in each group underwent repeat myocardial perfusion imaging 12 months post intervention. Visual scoring of perfusion images was performed using a 20-segment model and a scale of 0 to 4.The mean (standard deviation) baseline summed rest score (SRS) and stress scores (SSS) were 4.6 (5.7) and 13.6 (9.0) in the PMR group and 6.1 (7.4) and 16.8 (11.6) in the SCS group. At 12 months, SRS was 5.5 (6.0) and SSS 15.3 (11.3) in the PMR group and 6.9 (8.2) and 15.1 (10.9) in the SCS group. There was no significant difference between the two treatment groups adjusted for baseline (p = 1.0 for SRS, p = 0.29 for SSS).There was no significant difference in myocardial perfusion one year post treatment with SCS or PMR.The SPiRiT trial is an open label, single-centre, parallel group randomised trial comparing percutaneous myocardial laser revascularisation (PMR) with spinal cord stimulation (SCS) in patients with refractory angina pectoris [1]. These techniques have been shown to improve symptom control [2-6] in this group, although there is debate as to the mechanisms underlying the clinical response [7-10]. In accordance with the previous studies on laser revascularisation carried out at this institution [2,3,11] and with the recommendations of the European Society of Cardiology Joint Study Group [12], the presence of a reversible perfusion defect was an inclusion criterion for this study. Perfusion imaging was repeated 12 months post intervention in order to determine whether SCS and PMR treatment lead to an improvement in perfusion, a possible mechanism of action of these therapeutic modalities, and whether such change correlated with change in angina score as measured by CCS class.The inclusion/exclusion criteria and methods of the SPiRiT tr
Clinical correlates of arterial lactate levels in patients with ST-segment elevation myocardial infarction at admission: a descriptive study
Robert P Vermeulen, Miriam Hoekstra, Maarten WN Nijsten, Iwan C van der Horst, L Joost van Pelt, Gillian A Jessurun, Tiny Jaarsma, Felix Zijlstra, Ad F van den Heuvel
Critical Care , 2010, DOI: 10.1186/cc9253
Abstract: To assess the relation of systemic arterial lactate levels in STEMI patients with clinical correlates at presentation in the catheterization laboratory, we measured arterial lactate levels with a rapid point-of-care technique, immediately following femoral sheath insertion. The study population (n= 1,176) was divided into tertiles with lactate levels ≤1.1 (n = 410), 1.2 to 1.7 (n = 398) and ≥1.8 mmol/l (n = 368). We compared both baseline characteristics and outcome measures of the three lactate groups.Factors independently associated with higher lactate levels were hypotension, heart rate, thrombolysis in myocardial infarction (TIMI) flow 0 to 1, diabetes and non-smoking. Mortality at 30 days in the three groups was 2.0%, 1.5% and 6.5%. The latter group also showed lower blush grades and greater enzymatic infarct sizes. An intra aortic balloon pump (IABP) was used more frequently in patients with higher lactate levels (4.2%, 7.6% and 14.7%).In STEMI patients, impaired hemodynamics, worse TIMI flow and non-smoking were related to increased arterial lactate levels. Higher lactate levels were independently related with 30-day mortality and an overall worse response to percutaneous coronary intervention (PCI). In particular, acute mortality was related to admission lactates ≥1.8 mmol/L. Point-of-care measurement of arterial lactate at admission in patients with STEMI has the potential to improve acute risk stratification.The clinical value of circulating lactate has been extensively demonstrated in critical care medicine [1]. Blood lactate measurements can be used as an indicator of hemodynamic impairment and as a predictor of outcome in various forms of shock. In patients with cardiogenic shock, several studies document marked elevations in circulating lactate [2-9]. One of the most frequent causes of circulatory shock is acute myocardial infarction. When tissue perfusion is impaired during acute myocardial infarction, decreased oxygen delivery can induce muscle cells
Incidencia y significado clínico del grado de perfusión miocárdica durante la angioplastia primaria en el paciente con inf arto agudo del miocardio
Hamdan,Nabil; Hurtado,édgar; Castro,Pablo; Calderón,Luis; Gómez,Germán; Estrada,Gilberto;
Revista Colombiana de Cardiología , 2006,
Abstract: introduction and objectives: a variable percentage of patients with myocardial infarction treated with primary percutaneous coronary intervention have myocardial perfusion involvement, in spite of reestablishing the epicardium coronary flow. in this study, the relation between the grade of myocardial perfusion and the probability of clinical events such as angina, cardiac failure or the re-admission due to cardiac causes and intra-hospitalary death and that occurred after six months, are evaluated. materials and methods: in 86 patients with acute myocardial infarction treated with primary percutaneous coronary intervention, the angiographic and clinical results were compared according to the grade of myocardial perfusion. in all of them, during the hospitalization, the cardiac enzymes? levels were evaluated, an electrocardiogram in the first two hours after the percutaneous coronary intervention was performed, and the ventricular function was observed through echocardiography. six months clinical follow-up was realized in 80 patients (93%) and clinical events such as angina, heart failure, re-admission due to cardiac causes and death were evaluated. results: no angina was observed in the different groups treated with primary percutaneous coronary intervention during the hospitalization. heart failure occurred in 3 patients (23.1%) from the 0-1 grade group of myocardial perfusion and in none from the grade 3 group of myocardial perfusion (p<0.01). there were 2 deaths (13.3%) in the group with 0-1 grade of myocardial perfusion and none in the group with grade 3 of myocardial perfusion (p=0.01). seven patients (63.9%) from the group with degree 0-1 of myocardial perfusion and 2 patients (5%) from the group with myocardial perfusion grade 3 (p=0.01) developed heart failure. 7 patients (41.2) were re-hospitalized due to cardiac causes, with myocardial perfusion grade 0-1 and 2 patients (6.9%) with myocardial perfusion grade 3 (p < 0.01). death occurred in 3 patients (27.
Relationship between TIMI frame count and admission glucose values in acute ST elevation myocardial infarction patients who underwent successful primary percutaneous intervention  [cached]
Meltem Ege,ümit Güray,Ye?im Güray,Mehmet Birhan Y?lmaz
Anadolu Kardiyoloji Dergisi , 2011,
Abstract: Objective: Admission hyperglycemia is associated with poor prognosis in patients with acute myocardial infarction. Final Thrombolysis in Myocardial Infarction (TIMI) frame counts of culprit coronary arteries may show significant variability despite successful coronary reperfusion after primary percutaneous coronary intervention (PCI). In this prospective observational study, relationship between final TIMI frame counts of the culprit coronary artery and admission glucose values was investigated in patients who underwent successful primary PCI due to acute ST-elevation myocardial infarction (STEMI). Methods: During a 6- month period of time, 73 non-diabetic patients presented with acute STEMI who have undergone primary PCI with final TIMI 3 flow were consecutively included in the study. Patients were divided into two groups according to final TIMI frame counts. Group 1 (n=53) consisted of patients with final TIMI frame counts of the culprit coronary artery within the two standard deviation of predefined values and Group 2 (n=20) consisted of those with higher TIMI frame counts. Statistical analysis was performed using Chi-square, Mann-Whitney U tests and multiple linear regression analysis. Results: Despite similar fasting glucose values, admission glucose levels were significantly higher in Group 2 as compared to Group 1 (138 [114-165] vs. 123 [97-143] mg/dl, p=0.03). In whole group, admission glucose values were significantly correlated with corrected TIMI frame counts of culprit coronary arteries (r=0.30, p=0.01). In addition, there were significant association between admission glucose values and peak creatine kinase-MB (r=0.36, p=0.007) values as well as left ventricular ejection fraction (r=-0.43, p=0.009). In multiple linear regression analysis, only admission glucose value was found to be significantly related to the final TIMI frame count of the culprit artery (β=0.04, 95% CI: 0.02-0.085, p=0.04).Conclusion: High admission glucose values were significantly associated with impaired coronary flow even after successful primary PCI in non-diabetic patients with STEMI.
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