Improvement In Regional Wall Motion Research Articles

Impact of Impella protected-percutaneous coronary intervention on left ventricle function recovery of patients with extensive coronary disease and poor left ventricular function

BackgroundThe use of Impella support is increasingly adopted to “protect” patients with severe coronary artery disease (CAD) and left ventricle (LV) dysfunction undergoing percutaneous coronary intervention (PCI). AimsTo evaluate the impact of Impella-protected (Abiomed, Danvers, Massachusetts, USA) PCIs on myocardial function recovery. MethodsPatients with significant LV dysfunction undergoing multi-vessel PCIs with pre-intervention Impella implantation were evaluated by echocardiography before PCI and at median follow up of 6 months: global and segmental LV contractile function were assessed by LV ejection fraction (LVEF) and wall motion score index (WMSI), respectively. Extent of revascularization was graded using the British Cardiovascular Intervention Society Jeopardy score (BCIS-JS). Study endpoints were LVEF and WMSI improvement, and its correlation with revascularization. ResultsA total of 48 high surgical risk (mean EuroSCORE II 8) patients with median LVEF value of 30%, extensive wall motion abnormalities (median WMSI 2.16), and severe multi-vessel CAD (mean SYNTAX score 35) were included. PCIs brought a significant reduction of ischemic myocardium burden with BCIS-JS decrease from mean value of 12 to 4 (p < 0.001). At follow-up, WMSI reduced from 2.2 to 2.0 (p = 0.004) and LVEF increased from 30% to 35% (p = 0.016). WMSI improvement was proportional to the baseline impairment (R − 0.50, p < 0.001), and confined to revascularized segments (from 2.1 to 1.9, p < 0.001). ConclusionsIn patients with extensive CAD and severe LV dysfunction, multi-vessel Impella-protected PCI was associated to an appreciable contractile recovery, mainly determined by regional wall motion improvement in revascularized segments.

945 TRANSIENT LEFT VENTRICULAR THROMBOSIS TAKOTSUBO-RELATED

Abstract Background Takotsubo syndrome (TTS) is an increasingly widespread syndrome characterized by an acute and usually transient left ventricular (LV) dysfunction. Despite its transient nature, the acute phase can be characterized by serious complications such as LV thrombosis, as occurred in this case. Case description A 93-year-old woman was admitted to our emergency department due to a recent and self-limiting episode of acute chest pain. The ECG showed ST-elevation in leads V2, V3 and V4 (Fig.1), with cardiac biomarkers elevation. Transthoracic echocardiography (TTE) revealed apical akinesia and hypokinesia of the other LV segments with a severely reduced ejection fraction (EF 35%). Emergency coronary angiography showed normal epicardial coronary vessels. So, Takotsubo cardiomyopathy was hypothesized as diagnosis. A mass suspect for a thrombus was detected into the apex on day 3, despite a mild improvement of the other segments contraction (EF 40%), and clearly confirmed with the contrast echocardiography on day 5 (Fig.2). Unexpectedly, any LV thrombus was identified with cardiac MRI study performed on day 7 (Fig.3). Meanwhile, the patient never showed neurological disorders or other signs of thromboembolic complications. Echocardiography performed on day 11, before discharge, showed a great improvement of regional wall motion with residual LV apical hypokinesia (EF 55%) and no apical masses. Discussion This case emphasizes the need of frequent echocardiographic follow up in stress-induced cardiomyopathy, not only during the akinetic phase but also during the period of wall motion recovery, in order to diagnose and treat as soon as possible a LV apical thrombosis avoiding thromboembolic complications. We hypothesized that the early anticoagulation therapy combined with the initial improvement in LV wall motion facilitated the process of thrombosis resolution. Cardiac MRI played a relevant role in the comprehensive assessment of the functional and structural LV changes; the absence of late gadolinium enhancement (LGE) can be considered as a positive prognostic factor, indicating a complete resolution without residual fibrosis. Conclusion A multimodality imaging approach, based on a frequent echocardiographic follow up combined with cardiac MRI, is fundamental for an early diagnosis and a rapid treatment of LV thrombosis Takotsubo-related.

Predictive Value of Two-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Ventricular Restoration

ObjectivesParameters of left ventricular (LV) mechanics, obtained from speckle-tracking echocardiography (STE), were found to be of prognostic value in patients with heart failure and those who underwent cardiac surgery. This study aimed to assess the value of STE in patients scheduled to undergo surgical ventricular restoration (SVR).MethodsA total of 158 consecutive patients with baseline STE who underwent SVR due to an LV anteroapical aneurysm were included in the analysis. Preoperative longitudinal STE parameters were evaluated for their association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The echocardiographic follow-up to assess the change in the regional function of the segments remote from the aneurysm was performed in 43 patients at a median of 10 months [interquartile range (IQR): 6–12.7 months] after SVR.ResultsDuring a median follow-up of 5.1 years (IQR: 1.6–8.7 years), events occurred in 68 patients (48%). Less impaired mean basal end-systolic longitudinal strain (BLS) with a cutoff value ≤ −10.1 % demonstrated a strong association with event-free survival, also in patients with an LV shape corresponding to an intermediate shape between aneurysmal and globally akinetic. Initially hypo- or akinetic basal segments with preoperative end-systolic strain ≤ −7.8% showed a greater improvement in wall motion at the short-term follow up.ConclusionPatients with less impaired preoperative BLS exhibited a better event-free survival after SVR, also those with severe LV remodeling. The preserved preoperative segmental longitudinal strain was associated with a greater improvement in regional wall motion after SVR. BLS assessment may play a predictive role in patients with an LV anteroapical aneurysm who are scheduled to undergo SVR.

Endothelial Cells Strengthening: Improving Functions in Management of Acute Coronary Syndrome (A Double Blind Randomized Interventional Control Trial)

Objective: Endothelial dysfunction/injury is the main reason for Acute Coronary Syndrome (ACS). Current therapy includes antiplatelet, lipid lowering and thrombus removal by drugs/ intervention. Endothelial strengthening in management of ACS is less narrated in literature. This study describes endothelial strengthening and clinical outcome in ACS with Triphala powder, a mixture of Amla (Phyllanthus emblica), Harad (Terminalia chebula), and Behda (Terminalia bellirica). Methods: This is a double blind randomized interventional control trial. 80 cases coming to the emergency department were selected for study, divided into two groups. Group 1 (n=40, control), group 2 (n=40, study). Further subdivided into subgroup 1A and 2A ST-Elevation Myocardial Infarction (STEMI) and subgroup 1B and 2B Unstable Angina (UA). All subgroups were given clopidogrel, aspirin and atorvastatin and subjected to thrombolysis or Coronary Angiography (CAG) according to requirement. In addition study group was given Triphala powder 10 grams in a cup of water. Outcome was observed for relief in chest pain, ECG, Echocardiography changes at 50 minutes; (SSR) Sympathetic Skin Response was done initially. Statistical analysis was done by SPSS 20 software. Results: In intervention subgroups 2A and 2B there was significant relief in chest pain, settling down of ECG changes, and improvement in regional wall motion in echocardiography (p&lt;0.001). There was increased sympathetic activity in all subgroups (spike response in SSR). Conclusion: Sudden mismatch in ATP (Adenosine Triphosphate) supply results in endothelial dysfunction. It occurs primarily due to increase in sympathetic discharge. Endothelial dysfunction results in UA/STEMI. Triphala increases ATP synthesis by increasing mitochondrial capacity to maximum; strengthens endothelium which behaves like normal endothelium and resolves symptoms and signs of ACS.

A Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion: The REVASC Trial

ObjectivesThe aim of this study was to investigate whether percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) improves left ventricular function. BackgroundThe benefit of PCI in CTOs is still controversial. MethodsPatients with CTOs who were candidates for PCI were eligible for the study and were randomized to PCI or no PCI of CTO. Relevant coexisting non-CTO lesions were treated as indicated. Patients underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary endpoint was the change in segmental wall thickening (SWT) in the CTO territory. Secondary endpoints were improvement of regional wall motion and changes in left ventricular volumes and ejection fraction. Furthermore, major adverse coronary events after 12 months were assessed. ResultsThe CTO PCI group comprised 101 patients and the no CTO PCI group 104 patients. The change in SWT did not differ between the CTO PCI (4.1% [interquartile range: 14.6 to 19.3]) and no CTO PCI (6.0% [interquartile range: 8.6 to 6.0]) groups (p = 0.57). Similar results were obtained for other indexes of regional and global left ventricular function. Subgroup analysis revealed that only in patients without major non-CTO lesions (basal SYNTAX [Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery] score ≤13) CTO PCI was associated with larger improvement in SWT than no CTO PCI (p for interaction = 0.002). Driven by repeat intervention, major adverse coronary event rates at 12 months were significantly lower in the CTO PCI group (16.3% vs. 5.9%; p = 0.02). ConclusionsNo benefit was seen for CTO PCI in terms of the primary endpoint, SWT, or other indexes of left ventricular function. CTO PCI resulted in clinical benefit over no CTO PCI, as evidenced by reduced major adverse coronary event rates at 12 months.

PET/MRI early after myocardial infarction: evaluation of viability with late gadolinium enhancement transmurality vs. 18F-FDG uptake.

F-18 fluorodeoxyglucose (FDG) myocardial PET imaging is since more than two decades considered to delineate glucose utilization in dysfunctional but viable cardiomyocytes. Late gadolinium enhancement (LGE) MRI was introduced more than a decade ago and identifies increased extravascular space in areas of infarction and scar. Although the physiological foundation differs, both approaches are valuable in the prediction of functional outcome of the left ventricle, but synergistic effects are yet unknown. We aimed to compare the improvement of LV function after 6 months based on the regional FDG uptake and the transmurality of scar by LGE in patients early after acute myocardial infarction (AMI). Twenty-eight patients with primary AMI underwent simultaneous PET/MRI for assessment of regional FDG uptake and degree of LGE transmurality 5-7 days after PCI. Follow-up by MRI was performed in 20 patients 6 months later. Myocardium was defined 'PET viable' based on the established threshold of ≥ 50% FDG uptake compared with remote myocardium or as 'MRI viable' when LGE transmurality of ≤ 50% was present. Regional wall motion was measured by MRI. Ninety-five dysfunctional segments were further analysed regarding regional wall motion recovery. There was a substantial intermethod agreement for segmental LGE transmurality and reduction of FDG uptake (κ = 0.65). 'PET viable' and 'MRI viable' segments showed a lower wall motion abnormality score (PET: initial: 1.4 ± 0.6 vs. 1.9 ± 0.8, P < 0.008; follow-up: 0.5 ± 0.7 vs. 1.5 ± 1.0, P < 0.0001; MRI: initial: 1.5 ± 0.6 vs. 2.0 ± 0.8, P < 0.002; follow-up: 0.7 ± 0.8 vs. 1.6 ± 1.0, P < 0.0001) and a better regional wall motion improvement (PET: -0.9 ± 0.7 vs. -0.4 ± 0.7, P < 0.0007; MRI: -0.8 ± 0.7 vs. -0.4 ± 0.7, P < 0.009) compared with 'PET non-viable' or 'MRI non-viable' segments, respectively. Eighteen per cent of the dysfunctional segments showed discrepant findings ('PET non-viable' but 'MRI viable'). At follow-up, the regional wall motion of these segments was inferior compared with 'PET viable/MRI viable' segments (1.1 ± 0.8 vs. 0.5 ± 0.7, P < 0.01), had an inferior functional recovery (-0.5 ± 0.6 vs. -0.9 ± 0.7, P < 0.03), but showed no difference compared with concordant 'PET non-viable/MRI non-viable' segments. The simultaneous assessment of LGE and FDG uptake using a hybrid PET/MRI system is feasible. The established PET and MRI 'viability' parameter prior to revascularization therapy also predicts accurately the regional outcome of wall motion after AMI. In a small proportion of segments with discrepant FDG PET and LGE MRI findings, FDG uptake was a better predictor for functional recovery.

Intravascular cell delivery device for therapeutic VEGF-induced angiogenesis in chronic vascular occlusion

Site specific targeting remains elusive for gene and stem cell therapies in the cardiovascular field. One promising option involves use of devices that deliver larger and more sustained cell/gene payloads to specific disease sites using the versatility of percutaneous vascular access technology. Smooth muscle cells (SMCs) engineered to deliver high local concentrations of an angiogenic molecule (VEGF) were placed in an intravascular cell delivery device (ICDD) in a porcine model of chronic total occlusion (CTO) involving ameroid placement on the proximal left circumflex (LCx) artery. Implanted SMC were retained within the ICDD and were competent for VEGF production in vitro and in vivo. Following implantation, micro-CT analyses revealed that ICDD-VEGF significantly enhanced vasa vasora microvessel density with a concomitant increase in tissue VEGF protein levels and formation of endothelial cell colonies suggesting increased angiogenic potential. ICDD-VEGF markedly enhanced regional blood flow determined by microsphere and contrast CT analysis translating to a functional improvement in regional wall motion and global left ventricular (LV) systolic and diastolic function. Our data indicate robust, clinically relevant angiogenesis can be achieved in a human scale porcine chronic vascular occlusion model following ICDD-VEGF-based delivery of angiogenic cells. This may have implications for percutaneous delivery of numerous therapeutic factors promoting creation of microvascular bypass networks in chronic vaso-occlusive diseases.

Improvement of myocardial function and perfusion after successful percutaneous revascularization in patients with chronic total coronary occlusion

BackgroundPercutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of a coronary artery can provide benefits in terms of myocardial function and survival but the procedure is complex and the success rate is relatively low. To assess these benefits, myocardial function, ischemia and viability should be clearly determined by means of a reliable diagnostic test. This study aimed to assess ventricular function and myocardial ischemia before and after PCI for CTO using cardiac magnetic resonance (CMR). NYHA functional class was also assessed before and after PCI. Methods and resultsCMR studies were performed in 43 consecutive patients (7 females; aged 64±9.6y.o.) with CTO scheduled for PCI and repeated 6months post-PCI. PCI was successful in 33 (77%) of them. In this group CMR had shown inducible perfusion defects in 26 (79%) before PCI, while they were observed in 10 (30%) post-PCI CMR study (p<0.001). The number of segments showing inducible perfusion defect (3.4±2 prevs. 2.9±4.5 post-PCI, p=0.002) was significantly reduced in this group. Regional contractile function of segments showing viability also improved significantly in the group with successful CTO PCI compared to the group with an unsuccessful procedure. NYHA functional class for angina also improved in patients with successful revascularization while it remained unchanged in the group with unsuccessful procedures. ConclusionsA successful CTO PCI leads to a reduction in inducible myocardial ischemia and to an improvement in regional wall motion, which results in clinical improvement.

Transplant of stunned donor hearts rescued by pharmacological stress echocardiography: a “proof of concept” report

BackgroundDue to the shortage of donor hearts, the criteria for acceptance have been considerably expanded. Hearts with regional or global left ventricular dysfunction are excluded from donation, but stress echo might be useful to identify patients with reversible wall motion abnormalities, potentially eligible for donation.MethodsSix marginal candidate donors (mean age, 40 ± 13 years; three men) were enrolled. Resting echocardiography showed in all subjects a LV ejection fraction ≥ 45% (mean 51 ± 5%), but multiple risk factors were present. All donors had either global or discrete wall motion abnormalities: Wall Motion Score Index (WMSI) rest = 1.33 ± 0.25. Stress echocardiography was performed with the dipyridamole high dose of 0.84 mg/kg given over 6 min.ResultsThe stress echo results were abnormal in three donors (WMSI rest = 1.51 ± 0.19 vs peak = 1.41 ± 0.30). These hearts were excluded from donation and cardiac pathology verification was available in two cases of confirmed LV myocardial fibrosis and/or severe coronary stenosis. The remaining three hearts improved during stress (WMSI rest = 1.15 ± 0.13 vs peak = 1.04 ± 0.06) and were transplanted uneventfully. Recipients (three males, mean age 53 ± 4 years) underwent post-TX coronary angiography, IVUS and endomyocardial biopsies. No recipient had primary graft failure, and all showed normal coronary angiography and normal LV function (EF = 57 ± 6%; WMSI = 1 ± 0) at 1-month post-TX. The recipients were alive at 12-month median follow-up.ConclusionsDipyridamole stress echo performed in brain-dead potential donors with LV resting global or discrete wall motion abnormalities identifies hearts with severe morphologic abnormalities excluded from donation (with fixed response during stress echo) from hearts eligible for donation, showing improvement in regional wall motion during stress (viability response) and normal function and coronary anatomy following transplantation.

Characterization of acute myocardial infarction by pre-contrast T1 mapping

Summary Novel CMR techniques are needed to assess reversible myocardial injury in acute MI. Our results show that pre-contrast T1 mapping CMR could be such a technique: increasingly higher T1 values are associated with larger extent of acute myocardial injury and with reduced functional recovery at 6 months. Background Cardiovascular magnetic resonance (CMR) techniques such as late gadolinium enhancement (LGE) and edema imaging (T2W) are used to delineate acute myocardial infarction (MI). However, the use of LGE and T2W to assess reversible injury acutely is challenged by the dynamic changes occurring in the myocardial tissue. T1mapping is a novel technique that provides voxel-wise quantitative information on the regional tissue state and therefore can characterize in detail the various components of ischemic injury. In acute MI patients, we sought to investigate whether pre-contrast T1-mapping11 (1) detects acute myocardial injury, (2) allows for quantification of the severity of damage when compared to standard techniques such as LGE and T2W, and (3) has the ability to predict long term functional recovery. Methods 3T CMR including T2W, T1 mapping and LGE was performed in patients with acute MI at 12-48 hour after chest pain onset and at 6 months. Patients with ST elevation MI (STEMI) underwent primary PCI prior to CMR. Assessment of acute regional wall motion abnormalities, acute segmental damaged fraction by T2W and LGE and mean segmental T1 values was performed on matching short axis slices. LGE and improvement in regional wall motion at 6M were also obtained.

Scintigraphic parameters with emphasis on perfusion appraisal in rest 99mTc-sestamibi SPECT in the recovery of myocardial function after thrombolytic therapy in patients with ST elevation myocardial infarction (STEMI)

This study was performed to determine the clinical application of rest 99mTc-sestamibi in the assessment of viability and functional improvement of the left ventricle (LV) myocardium in the post-thrombolytic therapy of acute myocardial infarction (AMI). In 37 patients with AMI who received thrombolytic therapy, 2-dimensional (2D) echocardiography, as well as the resting redistribution of 99mTc-sestamibi, was investigated, both within 1 week and 3-5 months after AMI. The predictive capacity of the perfusion percentage for myocardial function recovery was evaluated. Also, the capacities of the possible variables in the prediction of recovery of myocardial function resulting from a change in LV ejection fraction (EF) were evaluated using stepwise multiple regression analysis. Thirty-seven patients (30 men and 7 women; mean age: 58±14 years) with AMI were enrolled in the study. Redistribution was observed in 35 and 50 segments of the initial and follow-up scans, respectively. In addition, 146 segments with reverse redistribution (RR), both in the initial scan (118 segments) and the follow-up scan (86 segments), were also observed. An apparent difference in wall motion scores was seen between the initial and follow-up echocardiographs (p<0.001). Furthermore, using the optimal cut-off point of perfusion percentage in each image set, sensitivity as well as specificity and likelihood ratio (LR) for the improvement of regional wall motion after 3-5 months were defined. These data showed that redistribution and reverse redistribution of 99mTc-sestamibi post thrombolytic therapy can be used as a marker of viability to predict the recovery of segmental wall motion abnormality (stunning), as well as the improvement of segmental perfusion uptake. This study also demonstrates that the resting 99mTc-sestamibi SPECT can be used for an approximate assessment of LV function status and can predict the recovery of jeopardized myocardium function after thrombolytic therapy.

CRT in Patients with Heart Failure: Time Course of Perfusion and Wall Motion Changes

In patients treated with CRT no data relative to the relationship between regional wall motion and perfusion and reverse remodelling of the left ventricle at short and medium term followup were available. To this aim, 36 heart failure patients were studied by G-SPECT before (T0), within 2 months (T1) and 6 months (T2) after CRT. A clinical followup was completed for 36 months. In 30/36 patients there was an improvement of NYHA Class at T1 that persisted at T2. G-SPECT showed significant improvement of perfusion at T1 in 92% of patients without further changes at T2. A reduction of LV volumes, an increase of EF and an improvement of regional wall motion and thickening were observed at T1 versus baseline, with only minor changes at T2. Moreover, baseline extension of perfusion defects was scarcely correlated with improvement after CRT. Finally, end diastolic volume, perfusion defect and diabetes mellitus were independent predictors of survival. The main effects of CRT on regional myocardial perfusion and wall motion are obtained within 2 months. Volume overload modulates recovery of ventricular function independently of reperfusion and, with extension of perfusion abnormalities and diabetes were independent predictors of survival during followup.

Placing a Saline Bag Underneath the Displaced Heart Enhances Transgastric Transesophageal Echocardiographic Imaging During Off-Pump Coronary Artery Bypass Surgery

Placing a Saline Bag Underneath the Displaced Heart Enhances Transgastric Transesophageal Echocardiographic Imaging During Off-Pump Coronary Artery Bypass Surgery

Acute Myocardial Infarction With Hyperoxemic Therapy (AMIHOT): A Prospective, Randomized Trial of Intracoronary Hyperoxemic Reperfusion After Percutaneous Coronary Intervention

This study sought to determine whether hyperoxemic reperfusion with aqueous oxygen (AO) improves recovery of ventricular function after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Hyperbaric oxygen reduces myocardial injury and improves ventricular function when administered during ischemia-reperfusion. In a prospective, multicenter study, 269 patients with acute anterior or large inferior AMI undergoing primary or rescue PCI (<24 h from symptom onset) were randomly assigned after successful PCI to receive hyperoxemic reperfusion (treatment group) or normoxemic blood autoreperfusion (control group). Hyperoxemic reperfusion was performed for 90 min using intracoronary AO. The primary end points were final infarct size at 14 days, ST-segment resolution, and delta regional wall motion score index of the infarct zone at 3 months. At 30 days, the incidence of major adverse cardiac events was similar between the control and AO groups (5.2% vs. 6.7%, p = 0.62). There was no significant difference in the incidence of the primary end points between the study groups. In post-hoc analysis, anterior AMI patients reperfused <6 h who were treated with AO had a greater improvement in regional wall motion (delta wall motion score index = 0.54 in control group vs. 0.75 in AO group, p = 0.03), smaller infarct size (23% of left ventricle in control group vs. 9% of left ventricle in AO group, p = 0.04), and improved ST-segment resolution compared with normoxemic controls. Intracoronary hyperoxemic reperfusion was safe and well tolerated after PCI for AMI, but did not improve regional wall motion, ST-segment resolution, or final infarct size. A possible treatment effect was observed in anterior AMI patients reperfused <6 h of symptom onset.

Trimetazidine Administration Minimizes Myocardial Damage and Improves Left Ventricular Function after Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the administration of trimetazidine, a piperazine derivative, to patients before and after percutaneous coronary intervention (PCI) minimizes the PCI-induced myocardial damage and improves left ventricular function 1 and 3 months after the procedure. Fifty-two patients hospitalized for acute coronary syndromes (ACS) were included in this study. Patients were randomized into two groups: group A (trimetazidine group; n = 27) and group B (placebo group; n = 25). All patients received conventional antianginal therapy. In addition, group A patients received oral trimetazidine 20 mg every 8 hours, starting 15 days before PCI and continuing for 3 months after the procedure. For each patient, serum troponin I and creatinine kinase (CK)-MB levels were measured before PCI, then at 6, 24, and 48 hours after the procedure; a 2D cardiac echocardiogram was performed before PCI and at 1 and 3 months after the procedure. Twenty-four hours after PCI, troponin I levels were >1 ng/mL in 7 of 27 patients (26%) of group A and 11 of 25 patients (44%) in group B. Fourty-eight hours after revascularization troponin levels remained elevated in 15% of patients in group A and in 32% of patients in group B. Twenty-two percent of patients in group A had CK-MB levels >5 ng/mL, 24 hours after PCI, compared with 40% of patients in group B; four patients of group A had high CK-MB levels prior to PCI procedure. Echocardiographic measurements before revascularization revealed that 11 of 27 patients (40%) in group A had an ejection fraction <50% versus 8 of 24 patients (33%) in group B . The number of patients with an ejection fraction <50% was significantly reduced in group A compared with group B at 1 and 3 months after PCI, i.e. 11% versus 16% (p = 0.046) at 1 month and 4% versus 16% (p = 0.017) at 3 months.A significant improvement in regional wall motion was noted after treatment with trimetazidine compared with placebo. One month after PCI, inferior left ventricular (LV) wall hypokinesia had improved in 4 of 6 trimetazidine recipients and in 4 of 14 placebo recipients (p = 0.014, group A vs group B). After 3 months inferior wall hypokinesia improved in four patients in group A versus six patients in group (p = 0.05). Similarly, anterior LV wall motion improved in 3 of 11 patients in group A and in 1 of 6 patients in group B at 1 month. After 3 months anterior wall hypokinesia had improved in eight patients in group A and in two patients in group B (p = 0.04, group A vs group B). The metabolic agent trimetazidine appears to minimize myocardial reperfusion injury during PCI and improves global and regional wall motion at 1 and 3 months after PCI. This study was limited by small patient numbers and further studies are necessary to evaluate exact mechanisms of action and clinical implications of using trimetazidine in conjunction with PCI.

Tissue velocity imaging during dobutamine stimulation for assessment of myocardial viability: Segmental analysis in patients after myocardial infarction

Background Dobutamine stress echocardiography (DSE) is an established method for the detection of viable myocardium, but evaluation of this method is subjective. Tissue velocity Imaging (TVI) allows quantitative analysis of regional myocardial wall motion by assessment of systolic myocardial velocities. The aim of this study was to evaluate the diagnostic value of DSE and TVI for detection of viable myocardium. Methods In 56 patients (58 ± 12 years) with previous myocardial infarction (130 ± 42 days, mean ejection fraction 42 ± 15%) low-dose DSE was combined with analysis of peak systolic myocardial velocities ( V peak) by TVI for assessment of myocardial viability. As reference served a follow-up echocardiography after successful revascularization (mean 91 ± 3 days). Results Of a total of 896 segments 200 showed abnormal wall motion (31 mildly hypokinetic, 50 severely hypokinetic, 115 akinetic, 4 dyskinetic). In 125 of these 200 segments regional improvement of regional wall motion was observed (62.5% viable). An increase of V peak > 1 cm/s during dobutamine stimulation allowed the identification of viable myocardium with a sensitivity of 82% and a specificity 82% (DSE: 77% and 80%). By receiver operating characteristic (ROC) curve analysis, a cut-off value of 1.0 cm/s was the best parameter to differ viable from nonviable myocardium (area under the curve 0.85; p < 0.01; 95% CI 0.79 to 0.90). Improvement of global ejection fraction after revascularization (47 ± 13%, p = 0.11) corresponded with three TVI viable segments with a sensitivity of 92% and a specificity of 89% ( p = 0.012). Conclusions TVI allows the identification of viable myocardium during dobutamine stimulation and enables a quantitative interpretation of DSE.

Late improvement of regional wall motion after the subacute phase of myocardial infarction treated by acute PTCA in a 6-month follow-up.

The aim of this follow-up study was to investigate the late effects of acute coronary angioplasty (PTCA) on regional wall motion after the subacute phase of myocardial infarction (MI). Seventeen patients were investigated initially at a median of 11 days and again at 6 months after acute PTCA for myocardial infarction (< 8 hours after onset of symptoms) by cardiac magnetic resonance imaging. Corresponding short-axis slices encompassing the left ventricle (LV) were acquired using a standard cine MR for regional wall motion analysis and using delayed contrast enhanced magnetic resonance imaging (ceMRI) for infarct size quantification. The infarct size was similar in the subacute phase and the 6 month follow-up (20.8 and 21.9%, respectively; n.s.). Regional wall motion improved significantly in the area of hyperenhancement [percentage wall thickening (PWT) 21.9% and 37.9%, p < 0.05] in contrast to remote normal myocardium (46.4% and 38.4%; n.s.). Regional wall motion was significantly poorer in transmural compared with nontransmural MI in the subacute stage, and a late improvement could only be observed in transmural MI. Transmural areas of hyperenhancement displayed significant late long-term improvement of regional wall motion after acute PTCA, possibly related to prolonged stunning compared with nontransmural areas.

Milrinone echocardiographic viability test: A pilot study

We assessed the utility of milrinone to predict recovery of function after surgical myocardial revascularization in patients with severe baseline left ventricular systolic dysfunction caused by coronary artery disease (CAD). Prediction of viable myocardial segments that will regain function after revascularization may help in the selection of patients who will benefit from coronary artery bypass graft surgery (CABG) as well as aid in the choice of target sites for coronary revascularization. We investigated 20 consecutive patients with CAD and left ventricular ejection fraction ≤40% who had evidence of myocardial viability by either thallium scan or dobutamine viability test and were candidates for elective CABG. Left ventricular regional wall motion and global ejection fraction were assessed by transesophageal echocardiography in the operating room. Measurements were done before and 10 minutes after milrinone infusion, and immediately after CABG. Left ventricular wall motion score was derived by means of a 12-segment model. Functional improvement for each segment was defined as a wall motion change >1. Baseline ejection fraction was 27% ± 5% (mean ± SD). Ejection fraction increased to 35% ± 5% after milrinone infusion ( P < .0001) and to 36% ± 6% after CABG ( P < .0001). Post-CABG ejection fraction was significantly correlated with postmilrinone ejection fraction ( r = 0.65, P < .0001). Milrinone infusion resulted in augmentation of contraction in 98 of the 209 abnormal segments (wall motion score ≥2); 91 (92.9%) of these improved after CABG. One hundred nine of the 111 segments that showed no improvement with milrinone did not improve after revascularization (98.2%). Seventy-three segments were akinetic or dyskinetic at baseline; 46 (63.0%) of these improved with milrinone. Improvement in regional wall motion after revascularization was detected in 84.8% of the segments that improved with milrinone versus only 3.7% of the segments that did not improve with milrinone. In patients with ischemic cardiomyopathy, improvement in left ventricular function (segmental wall motion and global ejection fraction) during milrinone infusion is highly predictive of improvement after CABG. (J Am Soc Echocardiogr 2001;14:668-75.)

Myocardial viability assessment by endocardial electroanatomic mapping: comparison with metabolic imaging and functional recovery after coronary revascularization

OBJECTIVESThe objective of this study was to compare electroanatomic mapping for the assessment of myocardial viability with nuclear metabolic imaging using positron emission computed tomography (PET) and with data on functional recovery after successful myocardial revascularization.BACKGROUNDAnimal experiments and first clinical studies suggested that electroanatomic endocardial mapping identifies the presence and absence of myocardial viability.METHODSForty-six patients with prior (≥2 weeks) myocardial infarction underwent fluorine-18 fluorodeoxyglucose (FDG) PET and Tc-99m sestamibi single-photon emission computed tomography (SPECT) before mapping and percutaneous coronary revascularization. The left ventricular endocardium was mapped and divided into 12 regions, which were assigned to corresponding nuclear regions. Functional recovery using the centerline method was assessed in 25 patients with a follow-up angiography.RESULTSRegional unipolar electrogram amplitude was 11.0 mV ± 3.6 mV in regions with normal perfusion, 9.0 mV ± 2.8 mV in regions with reduced perfusion and preserved FDG-uptake and 6.5 mV ± 2.6 mV in scar regions (p < 0.001 for all comparisons). At a threshold amplitude of 7.5 mV, the sensitivity and specificity for detecting viable (by PET/SPECT) myocardium were 77% and 75%, respectively. In infarct areas with electrogram amplitudes >7.5 mV, improvement of regional wall motion (RWM) from −2.4 SD/chord ± 1.0 SD/chord to −1.5 SD/chord ± 1.1 SD/chord (p < 0.01) was observed, whereas, in infarct areas with amplitudes <7.5 mV, RWM remained unchanged at follow-up (−2.3 SD/chord ± 0.7 SD/chord to −2.4 SD/chord ± 0.7 SD/chord).CONCLUSIONSThese data suggest that the regional unipolar electrogram amplitude is a marker for myocardial viability and that electroanatomic mapping can be used for viability assessment in the catheterization laboratory.

Assessing Myocardial Viability Using the Coronary Flow Response to Intravenous Dobutamine Infusion in Recent Myocardial Infarction

Coronary flow response to low-dose (5 and 10 micrograms/kg/min) dobutamine infusion was used to assess myocardial viability at the time of cardiac catheterization in 13 patients (age, 60 +/- 11 years) with recent myocardial infarction. Echocardiographic improvement in regional wall motion performed 4 to 6 weeks after discharge was used as the marker for viability. Viable patients demonstrated a 2-fold increase in flow from baseline (p < 0.001) during intravenous infusion. In contrast, patients without viability demonstrated no increase in flow. The coronary flow response to dobutamine measured at the time of catheterization shows promise in identifying viable myocardium in postinfarction patients.