Myocardial Tissue Reperfusion Research Articles

Culprit Lesion Vessel Size and Risk of Reperfusion Injury in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study.

Microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) are well-established imaging biomarkers of failed myocardial tissue reperfusion in patients with ST-segment elevation-myocardial infarction treated with percutaneous coronary intervention. MVO and IMH are associated with an increased risk of adverse outcome independent of infarct size, but whether the size of the culprit lesion vessel plays a role in the occurrence and severity of reperfusion injury is currently unknown. This study aimed to evaluate the association between culprit lesion vessel size and the occurrence and severity of reperfusion injury as determined by cardiac magnetic resonance imaging. Patients (n=516) with first-time ST-segment-elevation myocardial infarction underwent evaluation with cardiac magnetic resonance at 4 (3-5) days after infarction. MVO was assessed with late gadolinium enhancement imaging and IMH with T2* mapping. Vessel dimensions were determined using catheter-based reference. Median culprit lesion vessel size was 3.1 (2.7-3.6) mm. MVO and IMH were found in 299 (58%) and 182 (35%) patients. Culprit lesion vessel size was associated with body surface area, diabetes, total ischemic time, postinterventional thrombolysis in myocardial infarction flow, and infarct size. There was no association between vessel size and MVO or IMH in univariable and multivariable analysis (P>0.05). These findings were consistent across patient subgroups with left anterior descending artery and non-left anterior descending artery infarctions and those with thrombolysis in myocardial infarction 3 flow post-percutaneous coronary intervention. Comprehensive characterization of myocardial tissue reperfusion injury by cardiac magnetic resonance revealed no association between culprit lesion vessel size and the occurrence of MVO and IMH in patients treated with primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction.

A High De Ritis Ratio Predicts Poor Myocardial Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction.

Successful reperfusion of myocardial tissue is the goal of primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the association between the De Ritis ratio (AST/ALT) and myocardial reperfusion in patients with STEMI who underwent pPCI. We retrospectively investigated 1236 consecutive patients who were hospitalized for STEMI and underwent pPCI. ST-segment resolution (STR) was defined as the return of the deviated ST-segment to baseline; poor myocardial reperfusion was defined as <70% STR. Patients were divided into 2 groups according to the median De Ritis ratio (.921); 618 patients (50%) were assigned to the De Ritis low group while 618 patients (50%) were assigned to the De Ritis high group. Stent size, neutrophil-to lymphocyte ratio (NLR), and the De Ritis ratio found to be associated with poor myocardial reperfusion (Odds ratio (OR) 1.45, 95% CI 1.07-1.98, P = .01, OR 1.22, 95% CI 1.01-1.48, P = .03 and OR 10.9, 95% CI 7.9-15, P < .001, respectively). A high De Ritis ratio was associated with poor myocardial reperfusion in STEMI patients who underwent pPCI. As an easily obtainable test in clinical practice, the De Ritis ratio may help identify patients at major risk for impaired myocardial perfusion.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction.

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet. Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value. Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively). Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction

Abstract Background Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear. Objectives To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients. Methods This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI. Results HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c &amp;lt;5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p&amp;lt;0.001). Conclusions In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c &amp;lt;5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)

TGFβ-Neurotrophin Interactions in Heart, Retina, and Brain.

Ischemic insults to the heart and brain, i.e., myocardial and cerebral infarction, respectively, are amongst the leading causes of death worldwide. While there are therapeutic options to allow reperfusion of ischemic myocardial and brain tissue by reopening obstructed vessels, mitigating primary tissue damage, post-infarction inflammation and tissue remodeling can lead to secondary tissue damage. Similarly, ischemia in retinal tissue is the driving force in the progression of neovascular eye diseases such as diabetic retinopathy (DR) and age-related macular degeneration (AMD), which eventually lead to functional blindness, if left untreated. Intriguingly, the easily observable retinal blood vessels can be used as a window to the heart and brain to allow judgement of microvascular damages in diseases such as diabetes or hypertension. The complex neuronal and endocrine interactions between heart, retina and brain have also been appreciated in myocardial infarction, ischemic stroke, and retinal diseases. To describe the intimate relationship between the individual tissues, we use the terms heart-brain and brain-retina axis in this review and focus on the role of transforming growth factor β (TGFβ) and neurotrophins in regulation of these axes under physiologic and pathologic conditions. Moreover, we particularly discuss their roles in inflammation and repair following ischemic/neovascular insults. As there is evidence that TGFβ signaling has the potential to regulate expression of neurotrophins, it is tempting to speculate, and is discussed here, that cross-talk between TGFβ and neurotrophin signaling protects cells from harmful and/or damaging events in the heart, retina, and brain.

Comparison of myocardial tissue-reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet. Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value. Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively). Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

No-reflow: update on diagnosis, pathophysiology and therapeutic strategies

Primary percutaneous coronary intervention (PCI) represents the reperfusion strategy of choice for patients presenting with ST-segment elevation myocardial infarction. However, despite the restoration of epicardial flow, primary PCI may not determine an effective reperfusion of myocardial tissue due to the occurrence of microvascular obstruction. This phenomenon also known as "no-reflow" may occur in 30-60% of patients treated with primary PCI. Of importance, no-reflow attenuates the benefit of reperfusion therapy and is associated with a poor clinical outcome in terms of adverse ventricular remodeling, heart failure and mortality. The pathophysiology of no-reflow is complex and multiple players may be involved. Indeed, distal embolization, ischemia-reperfusion injury and an individual predisposition to microvascular dysfunction synergically interact to determine the occurrence of no-reflow. In this review, we will analyze the pathophysiological mechanisms, the diagnostic tools and the main therapeutic targets of no-reflow, with particular attention to the most recent acquisitions in this field.

Delayed vs. immediate stenting in STEMI with ahigh thrombus burden : Asystematic review and meta-analysis.

The results of several large-scale randomized controlled trials are controversial regarding the advantages of delayed stenting (DS) compared with immediate stenting (IS). We sought to determine whether DS has benefits for patients with ST-segment elevation myocardial infarction (STEMI) with ahigh thrombus burden compared with IS. We systematically searched fourelectronic databases. Thrombolysis in Myocardial Infarction (TIMI) grade3 flow, TIMI myocardial blush grade (TMBG), complete ST-segment resolution (>70%), major adverse cardiac events (MACE), and major bleeding complications were studied as outcomes. Data analysis was performed using arandom-effects model utilizing the Review Manager5.3 software. Our meta-analysis included eightstudies involving 744patients. DS showed greater benefits than IS in terms of TIMI grade3 flow (odds ratio [OR]: 5.09, 95% confidence interval [CI]: 1.98-13.02, p < 0.001), TMBG (OR:4.17, 95% CI: 1.87-9.31, p < 0.001), complete ST-segment resolution (OR:2.16, 95% CI: 1.36-3.43, p = 0.001), and MACE (OR:0.48, 95% CI: 0.25-0.94, p = 0.03). No significant difference was observed regarding major bleeding events (OR:1.76, 95% CI: 0.40-7.66, p = 0.45). DS yielded satisfactory outcomes regarding myocardial tissue reperfusion, demonstrated by the improved TIMI flow grade, TMBG, complete ST-segment resolution, and decreased MACEs without increasing major bleeding events in patients with STEMI and ahigh thrombus burden. DS may be preferred to IS for treating patients with this characteristic presentation.

Higher admission glycaemia independently of diagnosed or unrecognised diabetes mellitus is a risk factor for failed myocardial tissue reperfusion and higher mortality after primary angioplasty.

Admission hyperglycaemia worsens reperfusion in ST-segment elevation myocardial infarction (STEMI). ST-segment elevation resolution parallels myocardial tissue reperfusion and predicts the outcome of primary percutaneous coronary intervention (pPCI). We investigated whether higher glycaemia on admission impairs tissue-level reperfusion after pPCI for STEMI, as-sessed with the single-lead Schröder method of ST-segment resolution analysis (maxSTE). Among 323 patients (60.4 ± 11.5 years, 27.8% female), 13.4% of nondiabetic subjects and 58.2% of those with known diabetic history (17%) were admitted with glycaemia > 11.1 mmol/L. Failed tissue reperfusion, recognised if high-risk maxSTE criteria were fulfilled, was present among 25% of patients. The overall 180-day mortality rate was 6.8% (n = 22). Admission glycaemia ≥ 8.75 mmol/L appeared as the single risk factor for failed tissue reperfusion (ROC area = 0.638, standard error = 0.038, p < 0.001). Even after adjustment for diabetes history, patients with admission glycaemia ≥ 8.75 mmol/L (44.5%) had 2.36-fold higher risk (95% confidence interval [CI] 1.25-4.46, p = 0.008) of failed tissue reperfusion. After exclusion of patients with known diabetes and those with acute blood glucose level > 11.1 mmol/L (28%), admission glycaemia remained an independent predictor of failed tissue reperfusion (odds ratio [OR] 1.32, 95% CI 1.03-1.69, p = 0.028). Admission glycae-mia and failed tissue reperfusion (high- vs. low-risk maxSTE category) were the independent predictors of 180-day mortality (OR 1.18, 95% CI 1.05-1.32, p = 0.004 and OR 3.84, 95% CI 1.12-13.21, p = 0.033, respectively). Higher admission glycaemia in patients treated with pPCI for STEMI predicts failed myocardial tissue reperfusion and 180-day mortality, independently of prior or acute diabetic status.

Intralesional versus intracoronary administration of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention in patients with acute coronary syndromes: A meta-analysis of randomized controlled trials.

Background:Glycoprotein IIb/IIIa inhibitors (GPIs) have been regarded as an adjuvant regimen to deal with no-reflow. However, whether intralesional (IL) administration of GPIs improves myocardial reperfusion without increasing bleeding in patients with acute coronary syndrome (ACS) compared with intracoronary (IC) administration has not been well addressed. Our meta-analysis aimed to evaluate the efficacy and safety of IL versus IC administration of GPIs for patients with ACS during percutaneous coronary intervention.Methods:We systematically searched Medline, Embase, the Cochrane Central Register of Controlled Trials, and Cambridge Scientific s from January 2007 to May 2017. Thrombolysis in Myocardial Infarction (TIMI) 3 flow, corrected TIMI frame count (CTFC), and complete ST-segment resolution (>70%) were selected as the primary outcomes. Major adverse cardiac events (MACEs) were the secondary outcome, and major bleeding complications were the safety outcome. Data analysis was conducted using the Review Manager 5.3 software.Results:Six randomized controlled trials were included in our meta-analysis. Compared with IC, IL obtained better results in terms of TIMI grade 3 flow [odds ratio (OR) 2.29; 95% confidence intervals (CIs) 1.31–4.01; P = .004], CTFC [weighted mean difference (WMD) -4.63; 95% CI -8.82 to -0.43; P = .03], and complete ST-segment resolution (OR 1.55; 95% CI 1.12–2.14; P = .008). There was a trend toward decreased MACE in the IL administration groups, which was not of statistical significance (OR 0.63; 95% CI 0.30–1.31; P = .22). No significant difference was found between the two groups in terms of in-hospital major bleeding events (OR 2.52; 95% CI .66 to 9.62; P = .18).Conclusion:IL administration yielded favorable outcomes in terms of myocardial tissue reperfusion as evidenced by the improved TIMI flow grade, CTFC, complete ST-segment resolution, and decreased MACE without increasing in-hospital major bleeding events. The IL administration of GPIs can be recommended as the preferred regimen to guard against no-reflow.

RELATIONSHIP OF SMOKING WITH MYOCARDIAL INJURY AND CLINICAL OUTCOME IN PATIENTS UNDERGOING MECHANICAL REPERFUSION FOR ST-ELEVATION MYOCARDIAL INFARCTION

There is evidence suggesting a positive effect of cigarette smoking on myocardial tissue reperfusion and clinical outcomes in patients with myocardial infarction (“smoker's paradox”). We aimed to evaluate the relationship of smoking with cardiac magnetic resonance (CMR)-determined myocardial

Abstract 19136: Association of Smoking With Myocardial Injury and Clinical Outcome in Patients Undergoing Mechanical Reperfusion for ST-Elevation Myocardial Infarction: Insights From Cardiovascular Magnetic Resonance Imaging

Introduction: There is evidence suggesting a positive effect of cigarette smoking on myocardial tissue reperfusion and clinical outcomes in patients with myocardial infarction (“smoker’s paradox”). Hypothesis/Aim: We aimed to evaluate the relationship of smoking status with cardiac magnetic resonance (CMR)-determined myocardial salvage and damage as well as clinical outcome in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). Methods: This multicenter study included 727 consecutive STEMI patients reperfused within 12 hours after symptom onset. CMR imaging parameters (area-at-risk [AAR], infarct size [IS], myocardial salvage index [MSI], and microvascular obstruction [MVO]) were compared according to admission smoking status. Major adverse cardiac events (MACE) rates at 12 months after infarction were compared between groups. Results: In our study cohort 339 (46.6%) patients were current smokers. There was no difference in the extent of AAR (35[24-47] vs. 37[27-49] %LV, p=0.10), IS (16[8-25] vs. 17[10-26] %LV, p=0.21), MSI (53[29-70] vs. 52[34-71], p=0.47) or MVO (0[0-1.7] vs. 0[0-1.6] %LV, p=0.91) between smokers and non-smokers. Smokers had lower MACE (3.8% vs. 8.2%, p=0.01) and mortality (0.9% vs. 3.9%, p=0.01) rates. However, after adjustment for differences in baseline risk factors, smoking was no longer associated with MACE (HR=0.72, 95% CI 0.37 to 1.41, p=0.34) or mortality (HR=0.49, 95% CI 0.14 to 1.76, p=0.27). Conclusion: Smoking is not associated with PPCI efficacy (myocardial salvage) or irreversible myocardial damage in patients with acute STEMI. The lower MACE and mortality rates of smokers were entirely explained by differences in baseline risk characteristics, thus challenging the existence of a “smoker’s paradox”.

Thrombus aspiration in acute myocardial infarction: Rationale and indication.

Reperfusion of myocardial tissue is the main goal of primary percutaneous coronary intervention (PPCI) with stent implantation in the treatment of acute ST-segment elevation myocardial infarction (STEMI). Although PPCI has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients. Several mechanisms may contribute to myocardial reperfusion failure, in particular distal embolization of the thrombus and plaque fragments. In fact, this is a possible complication during PPCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of PPCI in patients with STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy during PPCI has been proposed to prevent embolization in order to improve these outcomes. In fact, the most recent guidelines suggest the routine use of manual aspiration thrombectomy during PPCI (class IIa) to reduce the risk of distal embolization. Even though numerous international studies have been reported, there are conflicting results on the clinical impact of aspiration thrombectomy during PPCI. In particular, data on long-term clinical outcomes are still inconsistent. In this review, we have carefully analyzed literature data on thrombectomy during PPCI, taking into account the most recent studies and meta-analyses.

Upośledzona funkcja nerek u chorych z zawałem serca leczonych pierwotną angioplastyką wieńcową a ryzyko nieskutecznej reperfuzji tkankowej i rokowanie odległe

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Karwowski D, Kalińczuk Ł, Majewski K, et al. Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2012;8(1):18-24. doi:10.5114/pwki.2012.27921. APA Karwowski, D., Kalińczuk, Ł., Majewski, K., Łada, M., Noll, D., & Radecki, P. et al. (2012). Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 8(1), 18-24. https://doi.org/10.5114/pwki.2012.27921 Chicago Karwowski, Dariusz, Łukasz Kalińczuk, Krzysztof Majewski, Mariusz Łada, Dariusz Noll, Paweł Radecki, and Wojciech Suchcicki et al. 2012. "Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 8 (1): 18-24. doi:10.5114/pwki.2012.27921. Harvard Karwowski, D., Kalińczuk, Ł., Majewski, K., Łada, M., Noll, D., Radecki, P., Suchcicki, W., Tyszka, A., and Demkow, M. (2012). Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 8(1), pp.18-24. https://doi.org/10.5114/pwki.2012.27921 MLA Karwowski, Dariusz et al. "Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 8, no. 1, 2012, pp. 18-24. doi:10.5114/pwki.2012.27921. Vancouver Karwowski D, Kalińczuk Ł, Majewski K, Łada M, Noll D, Radecki P et al. Impaired renal function in patients with myocardial infarction treated with primary angioplasty and the risk for failed myocardial tissue reperfusion and thus worse long-term outcomes. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2012;8(1):18-24. doi:10.5114/pwki.2012.27921.

The no-reflow phenomenon associated with percutaneous coronary intervention: its mechanisms and treatment

In patients with acute coronary syndrome (ACS), the immediate therapeutic goal is to establish patency of the infarct-related artery and to achieve optimal myocardial tissue reperfusion. Coronary microvasculatures, however, are often damaged irreversibly due to myocardial ischemia and reperfusion, and flow to the previously ischemic myocardium is markedly reduced, a phenomenon known as the "no-reflow phenomenon". In clinical settings, percutaneous coronary intervention (PCI) may accelerate embolization of plaque gruels and microthrombi to the microvessels, which further reduces tissue perfusion. The microvascular dysfunction attenuates the beneficial impact of PCI. The extent of the no-reflow phenomenon correlates with infarct size, and it has additional prognostic information. Patients with the no-reflow phenomenon have poor functional and clinical outcomes. Recent advances in imaging modalities have enabled diagnosis of the no-reflow phenomenon and assessment of the mechanisms of the microvascular dysfunction in patients. Use of pharmacological interventions and catheter-based devices to retrieve embolic materials have been proposed, and some of them are associated with improvement in clinical outcomes. Thus, we should keep in mind that only the achievement of successful myocardial perfusion is associated with better functional and clinical outcomes in patients with ACS.

E0632 A randomised comparison study of recombinant staphylokinase vs recombinant tissue-type tissue plasminogen activator for safety and coronary artery patency in patients with acute myocardial infarction

ObjectiveTo evaluate the efficacy and safety of r-SAK (recombinant staphylokinase) for acute ST-segment elevation myocardial infarction (STEMI).MethodsA total of 48 patients with acute STEMI randomised into r-SAK group and r-tPA...

Tirofiban: A Review of its Use in Patients with ST and Non ST Elevation Myocardial Infarction

Acute coronary syndrome is one of the major health problems worldwide and accounts for a great number of cardiac hospitalizations in the Western world. Atherosclerotic plaque rupture or erosion followed by platelet activation and total occlusion of a coronary artery is involved in the pathogenesis of acute coronary syndrome and myocardial infarction. The glycoprotein IIb/IIIa receptor, a platelet surface integrin, plays a key role in platelet aggregation once it has been activated. In order to improve myocardial tissue reperfusion, platelet inhibition with glycoprotein IIb/IIIa inhibitors (in combination with aspirin, clopidogrel, and heparin) has been shown as beneficial adjuvant therapy in patients with acute myocardial infarction. Tirofiban is a glycoprotein IIb/IIIa inhibitor. This article reviews the data concerning its use in patients with ST elevation myocardial infarction, the pharmacokinetic profile, contraindications, an adjuvant anticoagulation therapy and the surveillance.

Impact of Thrombus Aspiration on Myocardial Tissue Reperfusion and Left Ventricular Functional Recovery and Remodeling After Primary Angioplasty

Failure to achieve myocardial reperfusion often occurs during percutaneous coronary intervention (PCI) in patients with myocardial infarction with ST-segment elevation. We hypothesized that manual thrombus aspiration during primary PCI would favorably influence tissue-level myocardial perfusion and left ventricular (LV) functional recovery and remodeling. We prospectively randomized 111 patients with ST-segment elevation myocardial infarction to either standard or thrombus-aspiration PCI. Primary end point of the study was postprocedural incidence of ST-segment resolution >or=70%. Secondary end points included Thrombolysis in Myocardial Infarction (TIMI) myocardial perfusion grade >or=2, the combination of TIMI myocardial perfusion grade >or=2 and ST-segment resolution >or=70%, post-PCI TIMI grade 3 flow, corrected TIMI frame count, myocardial contrast echocardiography score index, the absence of persistent ST-segment deviation, and time course of wall-motion score index, LV ejection fraction, and LV volume in the 2 groups. The incidence of ST-segment resolution >or=70% was 71% and 39% in the thrombus-aspiration and standard PCI groups, respectively (odds ratio, 3.7; 95% CI, 1.7 to 8.3; P=0.001). TIMI myocardial perfusion grade >or=2 was attained in 93% in the thrombus-aspiration group compared with 71% in the standard PCI group (P=0.006). The percentage of patients with ST-segment resolution >or=70% and TIMI myocardial perfusion grade >or=2 was significantly greater in the thrombus-aspiration group compared with the standard PCI group (69% versus 36%, P=0.0006). Myocardial contrast echocardiography score index was significantly higher in the thrombus-aspiration group compared with the standard PCI group (0.86+/-0.20 versus 0.65+/-0.31; P<0.0001). A significantly greater improvement in LV ejection fraction and in wall-motion score index from baseline to 6-month follow-up was observed in the thrombus-aspiration group compared with the standard PCI group (LV ejection fraction from 48+/-6% to 55+/-6% versus 48.7+/-7% to 49+/-8%, P<0.0001; wall-motion score index from 1.59+/-0.13 to 1.31+/-0.19 versus 1.64+/-0.20 to 1.51+/-0.26, P=0.008). Twelve patients (11%) developed LV remodeling at 6 months, 2 (4%) in the thrombus-aspiration group and 10 (18%) in the standard PCI group (P=0.02). Manual thrombus aspiration in the setting of primary PCI improves myocardial tissue-level perfusion as well as LV functional recovery and remodeling.

Adjunctive use of the Rinspiration system for fluidic thrombectomy during primary angioplasty: The Rinspiration international registry

Atherothrombotic embolization during primary percutaneous coronary intervention (PCI) induces microvascular obstruction and reduces myocardial tissue reperfusion. A variety of thrombectomy devices have been evaluated as an adjunct to primary PCI in patients with ST-elevation myocardial infarction (STEMI) to reduce distal embolization. Results have been inconsistent and difficult to predict. The aim of this study was to investigate the safety and efficacy of an innovative thrombectomy device, the Rinspiration System, which simultaneously "rinses" the vessel with turbulent flow and aspirates thrombus. We prospectively enrolled 109 patients at six academic institutions in three countries referred for primary or rescue PCI for STEMI presenting within 12 hr of symptom onset. The primary endpoint was >or=50% ST-segment elevation resolution (STR) measured 60 min after PCI by continuous electrocardiographic recording, Secondary end points included STR > 70% at 60 min, final TIMI flow, myocardial blush score, and 30-day major adverse cardiac events (MACE). Mean symptom-to-PCI time was 4.7 +/- 2.7 hr. Rinspiration was successfully delivered in 98% of cases. Final TIMI three flow was achieved in 89% of patients and myocardial blush >or=2 in 78%. Rates of STR >or= 50% and >70% at 60 min were 97 and 80%, respectively. No device-related complications were observed. Thirty-day MACE rate was 4.6%. This international multicenter registry demonstrates that the adjunctive use of Rinspiration during primary PCI is safe and feasible. The excellent STR data compare favorably with results of previous trials using different devices for thrombus management, indicating a potential clinical benefit.

Comparison of Different Methods of ST Segment Resolution Analysis for Prediction of 1‐Year Mortality after Primary Angioplasty for Acute Myocardial Infarction

Resolution of ST segment elevation corresponds with myocardial tissue reperfusion and correlates with clinical outcome after ST elevation myocardial infarction. Simpler method evaluating the extent of maximal deviation persisting in a single ECG lead was an even stronger mortality predictor. Our aim was to evaluate and compare prognostic accuracy of different methods of ST segment elevation resolution analysis after primary percutaneous coronary intervention (PCI) in a real-life setting. Paired 12-lead ECGs were analyzed in 324 consecutive and unselected patients treated routinely with primary PCI in a single high-volume center. ST segment resolution was quantified and categorized into complete, partial, or none, upon the (1) sum of multilead ST elevations (sumSTE) and (2) sum of ST elevations plus reciprocal depressions (sumSTE+D); or into the low-, medium-, and high-risk groups by (3) the single-lead extent of maximal postprocedural ST deviation (maxSTE). Complete, partial, and nonresolution groups by sumSTE constituted 39%, 40%, and 21% of patients, respective groups by sumSTE+D comprised 40%, 39%, and 21%. The low-, medium-, and high-risk groups constituted 43%, 32%, and 25%. One-year mortality rates for rising risk groups by sumSTE were 4.7%, 10.2%, and 14.5% (P = 0.049), for sumSTE+D 3.8%, 9.6%, and 17.6% (P = 0.004) and for maxSTE 5.1%, 6.7%, and 18.5% (P = 0.001), respectively. After adjustment for multiple covariates only maxSTE (high vs low-risk, odds ratio [OR] 3.10; 95% confidence interval [CI] 1.11-8.63; P = 0.030) and age (OR 1.07; 95% CI 1.02-1.11; P = 0.002) remained independent predictors of mortality. In unselected population risk stratifications based on the postprocedural ST resolution analysis correlate with 1-year mortality after primary PCI. However, only the single-lead ST deviation analysis allows an independent mortality prediction.