Epicardial Flow Research Articles

To evaluate coronary microvascular obstruction by myocardial contrast echocardiography and its influence on prognosis in patients with ST-segment elevation myocardial infarction

Abstract Background The goal of primary PCI (pPCI) is not only to restore epicardial coronary blood flow quickly but also to provide continuous myocardial tissue level reperfusion through coronary microcirculation. However, the incidence of coronary microvascular obstruction (MVO) after pPCI is as high as 50%-60%, which is closely related to the occurrence of heart failure and increased mortality of patients. Myocardial contrast echocardiography (MCE) is a new noninvasive technique for real-time observation of myocardial microcirculation perfusion in a specific imaging mode. At present, there are few studies on the application of MCE in the evaluation of coronary MVO in STEMI patients in China. Purpose To evaluate coronary MVO by MCE and its influencing factors and prognosis value after pPCI in patients with STEMI. Methods Patients with STEMI who received pPCI from October 2020 to June 2023 in the CCU were enrolled. MCE examination was performed on the 5th to 7th day after pPCI. The patients were divided into the MVO group and Non-MVO group. Major adverse cardiovascular events (MACE) were observed by 6-month follow-up after STEMI onset. Multiple Logistic regression analysis was used to analyze the risk factors for MVO, Multiple Cox regression analysis of the risk factors for MACE and Kaplan-Meier survival curve to compare the cumulative event-free survival of the two groups. Results A total of 98 patients were included in the analysis. The age was 59.88±11.71 years old, and 76(77.55%) were male. MCE examination showed 52 cases in the MVO group and 46 cases in the Non-MVO group. The incidence of MVO was 53.1% (52/98). There were 15 patients with MACE during follow-up. The results of stepwise Multivariate Logistic regression analysis showed that the peak value of cardiac troponin T (cTnT) (OR=1.354,95%CI 1.103-1.661, P=0.004) and without thrombus aspiration (TA) were independent risk factors for MVO (OR=5.588,95%CI 1.915-16.308, P=0.002). Multivariate Cox regression analysis indicated that female (HR=2.891, 95%CI 1.027-8.135, P=0.044), left ventricular ejection fraction (LVEF) <40% (HR=9.960, 95%CI 3.370-29.435, P<0.001) and MVO (HR=5.759,95%CI 1.279-25.935, P=0.023) were independent risk factors for MACE. Kaplan-Meier survival curve showed that the cumulative event-free survival rate in the Non-MVO group was higher than that in the MVO group, and the difference was statistically significant (P=0.0047). Conclusion The incidence of coronary MVO was higher in STEMI patients after pPCI, the peak value of cTnT and without TA were independent risk factors of MVO. The independent risk factors for MACE were female, LVEF < 40%, and MVO.

Assessment of coronary microvascular function with absolute coronary fl ow measurements

Abstract Background Reliable assessment of microvascular function is essential, both in research setting and clinical practice. New techniques, such as continuous coronary thermodilution, are very promising and could revolutionize the field. However, there is a need for proper validation before widespread use is possible. Purpose The goals of this study were: 1. to validate the potential of saline infusion to generate maximum hyperemia in vivo. 2. to validate absolute blood flow (ABF) measured with continuous coronary thermodilution at higher (40-50 ml/min) infusion speeds 3. To assess the safety of higher infusion speeds. Methods Fourteen closed-chest sheep underwent ABF measurements with increasing saline infusion speeds with and without adenosine. Another seven open-chest sheep underwent these measurements with epicardial doppler flow probes on both the left anterior descending artery and left circumflex coronary artery. Maximal hyperemia was defined as maximal flow after 45 seconds of proximal occlusion. The principles of laboratory animal care and all national regulations were followed. Results 20 ml/min of saline infusion induced lower hyperemic coronary flow (140 vs 191 ml/min, p=0.0165) and lower coronary flow reserve (CFR) (1.82 vs 3.21, p= <0.0001) than coronary occlusion. In contrast, 30 ml/min resulted in flow (196 vs 192 ml/min, p=0.8292) and CFR (2.77 vs 3.21, p=0.1107) that were not different from post-occlusion. There was a significant flow overestimation bias (Bland-Altman: Bias ± SD: -73.09 ± 30.52, 95% Limits of agreement: -132.9 to -13.27) with 40-50ml/min of saline. Occasionally, higher saline infusion rates resulted in ischemic ECG-changes and ventricular fibrillation (9.5% at 50 ml/min). Conclusions Continuous saline infusion of 30ml/min, but not 20 ml/min, induced maximal hyperemia. ABF measured with saline infusion speeds of 40-50 ml/min was not accurate nor safe, and should therefore be avoided.

Hypoperfused myocardium and systolic function in patients with AMI undergoing complete revascularization

Abstract Background and Aim Coronary revascularization is the standard treatment for acute myocardial infarction (AMI), while the restoration of epicardial flow is non-parallel to myocardial reperfusion. This study sought to investigate the dynamic of myocardial perfusion and its association with left ventricular (LV) systolic function in AMI patients undergoing complete revascularization. Methods AMI patients who underwent complete revascularization were prospectively enrolled, and hybrid positron emission tomography/magnetic resonance (PET/MR) was performed at 2 months and 1 year. Hypoperfused myocardium was defined as myocardium with reduced perfusion and normal metabolism. Results Forty-five patients (59.80 ± 10.68 years, 80.0% male) were enrolled, and hypoperfused myocardium (median: 12% of LV) was detected in 21 (46.7%) patients 2 months post-AMI. Patients with hypoperfused myocardium (Group A) had significantly higher hypersensitive C-reactive protein (hs-CRP) (p = 0.016) and lower T2 value (p = 0.010) than those without (Group B). In the follow-up PET/MR at 1 year, significant LV ejection fraction improvement was observed in Group A (56.39 ± 9.76% vs. 54.58 ± 10.39%, p = 0.016) but not in Group B (51.63 ± 13.09% vs. 50.79 ± 16.95%, p = 0.615). Six (31.6%) patients in Group A showed recovery of perfusion, of which there were more females (p = 0.025), fewer diabetics (p = 0.044), or overweight (p = 0.035), with better global longitudinal strain (GLS) (p = 0.005). Conclusions Myocardial hypoperfusion is not rare and evolves over time in AMI patients undergoing complete revascularization, of which the reversal is probably associated with improved LV systolic function.Structured Graphical AbstractRepresentative PET/MR image of 2 separat

Mechanism of Coronary Microcirculation Obstruction after Acute Myocardial Infarction and Cardioprotective Strategies.

ST-segment elevation myocardial infarction patients are best treated with emergency percutaneous coronary intervention (PCI), while coronary microvascular dysfunction and obstruction (CMVO) are indicated by the absence or slowing of antegrade epicardial flow on angiography, resulting in suboptimal myocardial perfusion despite the lack of mechanical vascular obstruction. CMVO occurs in up to half of patients who undergo PCI for the first time and is associated with poor outcomes. This review summarizes the complex mechanisms leading to CMVO and elaborates on the changes observed at the organism, tissue, organ, cellular, and molecular levels. It also describes the current diagnostic methods and comprehensive treatment methods for CMVO.

Analysis of Energy and Pressure in the Sinus with Different Blood Pressures after Bioprosthetic Aortic Valve Replacement.

To investigate the effect of changing systolic and diastolic blood pressures (SBP and DBP, respectively) on sinus flow andvalvular and epicardial coronary flow dynamics after TAVR and SAVR. SAPIEN 3 and Magna valves were deployed in an idealized aortic root model as part of a pulse duplicating left heart flow loop simulator. Different combinations of SBP and DBP were applied to the test setup and the resulting change in total coronary flow from baseline (120/60mmHg), effective orifice area (EOA), and left ventricular (LV) workload, with each combination, was assessed. In addition, particle image velocimetry was used to assess the Laplacian of pressure ( ) in the sinus, coronary and main flow velocities, the energy dissipation rate (EDR) in the sinus and the LV workload. This study shows that under an elevated SBP, there is an increase in the total coronary flow, EOA, LV workload, peak velocities downstream of the valve, , and EDR. With an elevated DBP, there was an increase in the total coronary flow and . However, EOA and LV workload decreased with an increase in DBP, and EDR increased with a decrease in DBP. Blood pressure alters the hemodynamics in the sinus and downstream flow following aortic valve replacement, potentially influencing outcomes in some patients.

The value of viscoelastic platelet function measurements with Sonoclot in patients with acute coronary syndrome undergoing percutaneous coronary intervention

PurposePlatelets play an important role in the pathogenesis of acute coronary syndrome (ACS), and adequate platelet inhibition is a cornerstone during invasive management with percutaneous coronary intervention (PCI). Despite this, pivotal role routine measurement of platelet function is not done. We aimed at using the using the Sonoclot device for measuring platelet activity and predicting outcome in patients with ACS undergoing PCI.MethodsThis was a cohort longitudinal study involving 50 patients who were admitted with ACS and undergoing emergent PCI in the critical care department at Cairo University from November 2020 to July 2021. Three parameters will be obtained: platelet function, ACT, and coagulation rate.ResultsAccording to the 1st parameter (platelet function), adequate platelet inhibition was achieved in 54% of our cases. To study the impact of this analysis, our population was classified into 2 groups (well-inhibited platelets vs. poorly inhibited platelets). The 2nd and 3rd parameters (ACT, CR) could separate our patients into 2 groups according to whether patients were well anticoagulated or not. Classification 1, well vs. poorly inhibited platelets, both groups were comparable. However, epicardial coronary flow (TIMI flow) and myocardial blush grade post-stenting were better in the well-inhibited platelets group. Classification 2, well vs. poor anticoagulation, there were no significant differences between the 2 groups.ConclusionAdequate platelet inhibition as measured by Sonoclot device can predict better outcomes in patients with ACS undergoing PCI.

Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis

BackgroundDespite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic...

Incidence and Prognostic Value of Single Lead QRS Fragmentation in Successfully Revascularized Inferior STEMI Patients

Abstract Background the main therapeutic strategy for acute ST segment elevation myocardial infarction (STEMI) is the rapid restoration of epicardial blood flow in the infarcted related artery (IRA). Primary percutaneous coronary intervention (pPCI) is the most effective and recommended therapeutic intervention for the reperfusion strategy. Aim of the Work to investigate the incidence of QRS fragmentation among successfully revascularized inferior STEMI patients including single lead fragmentation (sl-fQRS) and classic QRS fragmentation (fQRS) and the prognostic importance of (sl-QRS) in patients with inferior STEMI who achieved TIMI 3 flow by primary PCI and its relation to results of angiography, poor prognosis prediction including in hospital mortality and Major Adverse Cardiac Events (MACE). Patients and Methods this prospective cohort study was carried out on 150 patients with successfully revascularized inferior STEMI patients by primary PCI, Patients were recruited postoperative from cardiology department, Ain Shams University Hospitals after undergoing Coronary Angiography for myocardial infarction which is the standard of care for such patients for follow-up during the study period (6 months). All patients were given informed consent. The study protocol was approved by the ethical committee, Faculty of Medicine, Ain Shams University. Results 150 patients with acute myocardial infarction, who were referred to the cardiology department for primary PCI, were eligible to participate in the study. Their mean age was 54.45 ± 11.11 years old. Most of them were males (78.7% of patients, 118 patients). 95 patients (63.3% of patients) had history of smoking wether current or ex-smokers. Nearly, one third of patients (34.7% of patients, 52 patients) were diabetic. Similarly, 34.7% of patients (52 patients) were dyslipidemic. 43.3% of patients (65 patients) were hypertensive. Their mean BMI was 26.69 ± 2.65 kg/m2. Most of patients (76.7% of patients, 115 patients) had positive family history. Conclusion The concept of at least two derivations is mentioned for the classical definition of fQRS, and only one lead with fQRS has not been accepted for the presence of fQRS. However, we showed that sl-fQRS is associated with MACE and higher risk. Therefore, instead of the concept of at least two derivations, the presence of fQRS in only one lead and/or ≥1 leads with fQRS may also be enough when describing the patients under high cardiac risk.

Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction.

The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were classified according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Epicardial blood flow was assessed using the TIMI grading system after reperfusion. A total of 935 patients were included; 85.6% were males and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

Peculiarities of the ST-segment elevation myocardial infarction morphogenesis after mechanical restoration of epicardial blood flow without ECG signs of reperfusion

The aim of the study was to investigate the peculiarities of STEMI morphogenesis after mechanical restoration of epicardial blood flow without ECG signs of reperfusion. The autopsy data of 44 patients with STEMI who died at different times after PCI performed within the first 12 hours (27 cases), or 12–24 hours (17 cases), without ECG signs of reperfusion after the intervention, were analyzed. The comparison group consisted of 85 deceased without reperfusion therapy (RT). Histological examination of the myocardium was performed at following time: within 12 hours, at 13–24 hours, 2–4 days, 5–8 days, 9–15 and 16–22 days. The most common cause of death was acute left ventricular failure (ALVF) both in the group of blood flow restoration without ECG signs of reperfusion, and in the group without RT: 85 % and 79 %, respectively. In each of the two groups the number of deaths occurred in the first 12 hours exceeded one third, half of the patients died in the subsequent 12 hours, two thirds of the deaths occurred within further 2–3 days. The rates of risk factors: older age, anterior and recurrent myocardial infarction, three-vessel lesion of the coronary artery, and a large infarction area were similar in the two groups. From the first hours after PCI, the infarction zone was characterized by hemorrhagic imbibition, numerous injuries of the microcirculatory bed, by the signs of blood flow restoration in damaged vessels appeared from days 2–4, early manifestations of repair from days 5–7. In the MI group without PCI, the hemorrhagic demarcation started on days from 3–4, coagulation necrosis prevailed in the microvascular bed, signs of repair appeared at a later date. Multiple spasms and thromboses in the microvasculature may have been a response to a blood pressure drop that accompanies an acute decrease in the left ventricle contractile function caused by a large infarction area and/or unresolved complications arising during the interventions per se. This mechanism explains the rapid progression of left ventricular failure, the most common cause of death after the interventions with achieving the epicardial blood flow without ECG signs of reperfusion. The revealed microcirculation disorders reflect the absence of myocardial reperfusion, which is more prognostically significant than the restoration of epicardial blood flow.

Optimization of Absolute Coronary Blood Flow Measurements to Assess Microvascular Function: In Vivo Validation of Hyperemia and Higher Infusion Speeds.

Reliable assessment of coronary microvascular function is essential. Techniques to measure absolute coronary blood flow are promising but need validation. The objectives of this study were: first, to validate the potential of saline infusion to generate maximum hyperemia in vivo. Second, to validate absolute coronary blood flow measured with continuous coronary thermodilution at high (40-50 mL/min) infusion speeds and asses its safety. Fourteen closed-chest sheep underwent absolute coronary blood flow measurements with increasing saline infusion speeds at different dosages under general anesthesia. An additional 7 open-chest sheep underwent these measurements with epicardial Doppler flow probes. Coronary flows were compared with reactive hyperemia after 45 s of coronary occlusion. Twenty milliliters per minute of saline infusion induced a significantly lower hyperemic coronary flow (140 versus 191 mL/min; P=0.0165), lower coronary flow reserve (1.82 versus 3.21; P≤0.0001), and higher coronary resistance (655 versus 422 woods units; P=0.0053) than coronary occlusion. On the other hand, 30 mL/min of saline infusion resulted in hyperemic coronary flow (196 versus 192 mL/min; P=0.8292), coronary flow reserve (2.77 versus 3.21; P=0.1107), and coronary resistance (415 versus 422 woods units; P=0.9181) that were not different from coronary occlusion. Hyperemic coronary flow was 40.7% with 5 mL/min, 40.8% with 10 mL/min, 73.1% with 20 mL/min, 102.3% with 30 mL/min, 99.0% with 40 mL/min, and 98.0% with 50 mL/min of saline infusion when compared with postocclusive hyperemic flow. There was a significant bias toward flow overestimation (Bland-Altman: bias±SD, -73.09±30.52; 95% limits of agreement, -132.9 to -13.27) with 40 to 50 mL/min of saline. Occasionally, ischemic changes resulted in ventricular fibrillation (9.5% with 50 mL/min) at higher infusion rates. Continuous saline infusion of 30 mL/min but not 20 mL/min induced maximal hyperemia. Absolute coronary blood flow measured with saline infusion speeds of 40 to 50 mL/min was not accurate and not safe.

The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice.

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

Coronary Slow-Flow Phenomenon in Takotsubo Syndrome: The Prevalence, Clinical Determinants, and Long-Term Prognostic Impact.

Patients with takotsubo syndrome (TTS) may present coronary slow flow (CSF) in angiography performed in the acute myocardial infarction (MI). However, the detailed clinical relevance and its long-term impact remain poorly understood. Among 7771 MI patients hospitalized between 2012 and 2019, TTS was identified in 82 (1.1%) subjects. The epicardial blood flow was assessed with thrombolysis in myocardial infarction (TIMI) scale and corrected TIMI frame count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). CSF was defined as TIMI-2 or corrected TFC > 27 frames in at least one epicardial vessel. CSF was identified in 33 (40.2%) TTS patients. In the CSF-TTS versus normal-flow-TTS group, lower values of left ventricular ejection fraction on admission (33.5 (25-40) vs. 40 (35-45)%, p = 0.019), more frequent midventricular TTS (27.3 vs. 8.2%, p = 0.020) and the coexistence of both physical and emotional triggers (9.1 vs. 0%, p = 0.032) were noted. Within a median observation of 55 months, higher all-cause mortality was found in CSF-TTS compared with normal-flow TTS (30.3 vs. 10.2%, p = 0.024). CSF was identified as an independent predictor of long-term mortality (hazard ratio 10.09, 95% confidence interval 2.12-48.00, p = 0.004). CSF identified in two-fifths of TTS patients was associated with unfavorable long-term outcomes.

Differential Impact of Blood Pressure Control Targets on Epicardial Coronary Flow After Transcatheter Aortic Valve Replacement

BackgroundThe cause for the association between increased cardiovascular mortality rates and lower blood pressure (BP) after aortic valve replacement (AVR) is unclear. This study aims to assess how the epicardial coronary flow (ECF) after AVR varies as BP levels are changed in the presence of a right coronary lesion. MethodsThe hemodynamics of a 3D printed aortic root model with a SAPIEN 3 26 deployed were evaluated in an in vitro left heart simulator under a range of varying systolic blood pressure (SBP) and diastolic blood pressure (DBP). ECF and the flow ratio index were calculated. Flow index value <0.8 was considered a threshold for ischemia. ResultsAs SBP decreased, the average ECF decreased below the physiological coronary minimum at 120 mmHg. As DBP decreased, the average ECF was still maintained above the physiological minimum. The flow ratio index was >0.9 for SBP ≥130 mmHg. However, at an SBP of 120 mmHg, the flow ratio was 0.63 (p ≤ 0.0055). With decreasing DBP, no BP condition yielded a flow ratio index that was less than 0.91. ConclusionsReducing BP to the current recommended levels assigned for the general population after AVR in the presence of coronary artery disease may require reconsideration of levels and treatment priority. Additional studies are needed to fully understand the changes in ECF dynamics after AVR in the presence and absence of coronary artery disease.

In vivo validation of intra-coronary absolute flow measurements and comparison of reliability between different microvascular indices and the microvascular resistance reserve

Abstract Background Coronary microvascular dysfunction plays a major role in patients with cardiac ischemia without flow limiting epicardial coronary stenosis, takotsubo cardiomyopathy, aortic valve stenosis and heart failure with preserved ejection fraction. In clinical practice, the index of microvascular resistance (IMR) and coronary flow reserve (CFR), and more recently the absolute coronary blood flow (ABF), absolute coronary resistance (ACR) and the microvascular resistance reserve (MRR) are used as parameters to measure resistance and flow using continuous coronary thermodilution. Purpose Firstly, to validate ABF measured with continuous coronary thermodilution in vivo against epicardial doppler-measured flow. Secondly, to assess reliability and reproducibility in-vivo of different microvascular indices. Methods For the purpose of this study coronary measurements were conducted in two large animal models and in patients, all with the appropriate ethical committee approval. For the first part of the study, fourteen sheep underwent repeated paired measurements of ABF and ACR (with use of continuous thermodilution) with different saline infusion speeds, as well as IMR, CFR and MRR in multiple coronary vessels. Seven additional sheep underwent these measurements while having simultaneous measurements with epicardial coronary flow probes (gold standard) in an open-chest model. The epicardial flow probes were placed on the proximal left anterior descending and circumflex artery. Maximal hyperemia was induced with adenosine (CFR and IMR) or infusion of saline at a rate of 30ml/min (ABF, ACR and MRR). For the second part of the study, in 41 patients receiving routine microvascular assessment, IMR and CFR measurements were duplicated by a single operator, after re-calibration, to assess the reproducibility of the measurement. The combined animal and human data resulted in the analysis of 408 coronary measurements made in 88 coronary vessels during 65 heart catheterizations. Results In sheep, ABF measured with continuous thermodilution (with saline infusion speeds from 5ml/min to 30ml/min) was accurate when compared with epicardial flow measurements. (Table 1, Fig 1A) Notably, the continuous thermodilution measurement had the tendency to slightly overestimate ABF. (Table 1, Fig 1B) The two methods were equivalent within 15% (Two one-sided test: mean difference: -8.73%; 95% CI: -14.40 to -3.06%, p= 0.016). When comparing test-retest reproducibility between the indices, CFR performed the worst while ACR and MRR performed the best. MRR had a significantly better reproducibility than the IMR. (Table 1, Fig 1C). Conclusion ABF can accurately be determined by continuous coronary thermodilution. MRR and ACR have a significantly superior reliability and reproducibility compared to IMR and CFR. Unlike ACR, MRR is not vessel or territory-size dependent and is therefore the index of choice for future research and clinical assessment of the microcirculation.

Point-of-care biomarkers of thrombotic status predict spontaneous reperfusion in ST-segment elevation MI and clinical outcomes

Abstract Background Spontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery (IRA), with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. Purpose We aimed to assess whether the thrombotic profile of patients with and without spontaneous reperfusion differed significantly, and whether such patients had better outcomes. Methods We performed a prospective, observational study in consecutive patients presenting with STEMI. Blood samples were taken from a 6 Fr arterial sheath immediately before emergency angiography, before PPCI, after dual antiplatelet therapy loading, but before the administration of heparin or other anticoagulant. Blood samples were tested using a point-of-care global test of thrombotic status, measuring occlusion (OT) and endogenous fibrinolysis (LT) times. Spontaneous reperfusion was defined as IRA TIMI III flow pre-PCI. Patients were followed for major cardiovascular events (MACE; death, myocardial infarction, stroke). Results Spontaneous reperfusion was associated with longer OT (435s vs. 366s, p&amp;lt;0.001) and shorter LT (1257s vs. 1616s, p&amp;lt;0.001), lower troponin and better LV function. LT was superior to OT for predicting spontaneous reperfusion (AUC for LT: 0.707, 95% CI 0.661-0.753; AUC for OT: 0.629, 95% CI 0.581-0.677). Amongst patients with spontaneous reperfusion, those with complete, versus partial ST-segment resolution, had longer OT (p=0.002) and shorter LT (p&amp;lt;0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4-years, patients with spontaneous reperfusion experienced fewer MACE than those without (4.1% vs. 10.6%, p=0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs. 10.1%, p=0.029). Conclusions We demonstrate a novel haematological signature in STEMI patients with spontaneous reperfusion, namely reduced platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This indicates a role for modulating thrombotic status early following STEMI-onset, to facilitate spontaneous reperfusion and improve outcomes.Visual abstractThrombotic profile predicts outcome

Soluble ST2 in predicting an adverse outcome of revascularization and the development of heart failure in patients with acute myocardial infarction with ST segment elevation

Abstract Funding Acknowledgements Type of funding sources: None. Objective to study the relationship between the sST2 level and the degree of epicardial blood flow recovery and with the heart failure (HF) development or exacerbation in 6 month follow-up in patients with STEMI after PCI. Materials and methods The study involved 61 patients with STEMI — 51 (83.6%) males and 10 (16.4%) females, with average age of 59.85 ± 10.01 years. Standard clinical and biochemical parameters were determined, as well as sST2 level was measured by enzyme immunoassay using a reagent kit «Presage ST2 analysis, Critical Diagnosis» (USA) in all patients, on the first day of the disease. Patients were divided into two groups depending on the degree of blood flow recovery in a culprit artery (TIMI) The first group (n = 12) included patients with TIMI 0, I, II, the second group (n = 49) with TIMI III. Results The sST2 level was significantly higher in the first hours of the disease in the group with unrepaired or decreased epicardial blood flow (TIMI 0-II) after PCI (p = 0.003). ROC analysis showed that sST2 levels above 34.2 ng / ml, detected in the first hours of the disease, is an independent predictor of adverse revascularization (TIMI 0-II) in patients with STEMI with a sensitivity of 92.3% and a specificity of 62.5%; the area under curve (the AUC) is 0.8 (95% CI = 0.651 - 0.873; p = 0.001). When conducting a univariate (χ2 = 17.741; p = 0.04) and multivariate (χ2= 9.293; p = 0.004) logistic analyzes, sST2 was a significant predictor of the unfavorable outcome of epicardial vascular revascularization (TIMI 0-ІІ). Conclusions sST2 is highly associated with the degree of epicardial blood flow recovery in patients with STEMI and is of great clinical importance as prognostic marker.

Зв’язок ST2 з результатом реваскуляризації та розвитком серцевої недостатності у хворих з гострим інфарктом міокарда з елевацією сегмента ST

The aim – to study the relationship between the sST2 level and the degree of epicardial blood flow recovery and with the heart failure (HF) development in 6 month follow-up in patients with STEMI after PCI.Materials and methods. The study involved 61 patients with STEMI – 51 (83.6 %) males and 10 (16.4 %) females, with average age of 59.85±10.01 years. Standard clinical and biochemical parameters were determined, as well as sST2 level was measured by enzyme immunoassay using a reagent kit «Presage ST2 analysis, Critical Diagnosis» (USA) in all patients, on the first day of the disease. Patients were divided into two groups depending on the degree of blood flow recovery in a culprit artery (TIMI) The first group (n=12) included patients with TIMI 0, I, II, the second group (n=49) with TIMI III.Results and discussion. The sST2 level was significantly higher in the first hours of the disease in the group with unrepaired or decreased epicardial blood flow (TIMI 0–II) after PCI (p=0.003). ROC analysis showed that sST2 levels above 34.2 ng/ml, detected in the first hours of the disease, is an independent marker of adverse revascularization (TIMI 0–I) in patients with STEMI with a sensitivity of 92.3 % and a specificity of 62.5 %; the area under curve (the AUC) is 0.8 (95 % CI=0.651–0.873; p=0.001). When conducting a univariate (χ2=17.741; p=0.04) and multivariate (χ2=9.293; p=0.004) logistic analyzes, sST2 was a significant influencer of the unfavorable outcome of epicardial vascular revascularization (TIMI 0–ІІ).Conclusions. sST2 is highly associated with the degree of epicardial blood flow recovery in patients with STEMI and is of great clinical importance as diagnostic marker.

Biomarkers of Thrombotic Status Predict Spontaneous Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction

BackgroundSpontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery, with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. ObjectivesThe authors sought to relate spontaneous reperfusion to the thrombotic profile. MethodsIn a prospective study, blood from STEMI patients (n = 801) was tested pre-PCI to assess in vitro, point-of-care, occlusion times (OT) and endogenous lysis times (LT). Spontaneous reperfusion was defined as infarct-related artery Thrombolysis In Myocardial Infarction flow grade 3 before PCI. Patients were followed for major cardiovascular events (death, myocardial infarction, or stroke). ResultsSpontaneous reperfusion was associated with a longer OT (435 seconds vs 366 seconds; P < 0.001) and a shorter LT (1,257 seconds vs 1,616 seconds; P < 0.001), lower troponin, and better left ventricular function. LT was superior to OT for predicting spontaneous reperfusion (area under the curve for LT: 0.707; 95% CI: 0.661-0.753; area under the curve for OT: 0.629; 95% CI: 0.581-0.677). Among patients with spontaneous reperfusion, those with complete, vs partial ST-segment resolution, had a longer OT (P = 0.002) and a shorter LT (P < 0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4 years, patients with spontaneous reperfusion experienced fewer major adverse cardiovascular events than those without (4.1% vs 10.6%; P = 0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs 10.1%; P = 0.029). ConclusionsWe demonstrate a novel hematological signature in STEMI patients with spontaneous reperfusion, namely, decreased platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This finding indicates a role for modulating thrombotic status early after STEMI onset, to facilitate spontaneous reperfusion and improve outcomes.

Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging.

Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral.