Regional Wall Motion Index Research Articles

Abstract 10445: Detection of Viability and Clinical Implications Using Pet/Mri in Patients With Acute Myocardial Infarction

Background: The purpose of this study is to evaluate the role of viability on PET-MRI to predict improvement of echocardiographic findings such as regional wall motion index and left ventricular ejection fraction after successful percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI). Method: A total of 154 patients with AMI who was performed cardiac PET/MRI within 7 days after PCI were enrolled were enrolled. We performed TTE twice before and after in We performed TTE twice before and after PCI in 103 patients. We categorized these patients according to presence of viability on PET-MRI: group A (N=53, patients with viability on PET-MRI) and group B (N=50, patients without viability on PET-MRI) and compared. The primary end point is improvement of regional wall motion abnormality (RWMA) on TTE. Results: Clinical and angiographic findings were similar between the two groups during follow-up of 11months. Among 53 patients in group A, 30 patients (56.6%) showed the result of slight improvement of RWMA on TTE and among them 13 patients (24.5%) showed result of disappeared RWMA on TTE. In contrast, among 50 patients in group B, 22 patients (44%) showed the result of slight improvement and among them, only 4 patients (8%) showed result of disappeared RWMA on TTE. The proportion of patients who showed slight improvement of RWMA between two groups are not statistically significant (p=0.201). But, the proportion of patients who showed disappeared RWMA between two groups are statistically significant (p=0.024). Conclusions: PET/MRI is useful tool to detect viability in patients with AMI. It seems to be predictable to improve cardiac function for the patients with viability on PET-MRI.

Admission blood glucose and echocardiography to predict major adverse cardiac events in acute coronary syndrome: a review

A life-threatening presentation of coronary artery disease is acute coronary syndrome (ACS). The major adverse cardiac events (MACE) after acute coronary syndrome include life threatening arrhythmias, cardiac failure, cardiogenic shock, recurrent ischemia and sudden death. Patients with severe and moderate LV dysfunction are more likely to have triple vessel disease. Regional wall motion abnormality assessed by regional wall motion index using 2D-echocardiography correlates with infarct size which in turn predicts the occurrence of major adverse cardiac events (MACE) in patients with acute coronary syndrome. The cause for cardiogenic shock is left ventricular pump failure due to extensive damage to the myocardium and infarct related mechanical complications. In patients admitted with acute coronary syndrome, 5% develop ventricular tachycardia or ventricular fibrillation especially after 48 hours after hospital admission. Hyperglycemia causes stronger sympathetic activation in patients with severe illness and hence increased glucose levels. Insulin resistance not only causes hyperglycemia but can also lead to reduced energy production in the heart and lower tolerance to hypoperfusion and acts as an indicator of systemic and organ specific metabolic dysregulation and also stress hyperglycemia is implicated in the activation of pathological processes that causes cellular and tissue injury like increasing free radical formation and oxidative stress, inducing prothrombotic stress and worsening endothelial function. Hence higher levels of admission time blood glucose, hypoglycaemia during hospital stay, persistent hyperglycemia are considered as poor prognostic markers in patients with acute coronary syndrome.

Correlation of Admission Time Blood Glucose, Left Ventricular Function and Regional Wall Motion Index with Occurrence of In-hospital Major Adverse Cardiac Events in Acute Coronary Syndrome

Correlation of Admission Time Blood Glucose, Left Ventricular Function and Regional Wall Motion Index with Occurrence of In-hospital Major Adverse Cardiac Events in Acute Coronary Syndrome

Wall motion changes in myocardial infarction in relation to the time elapsed from symptoms until revascularization.

ObjectiveWall motion abnormalities during acute ST-segment elevation myocardial infarction (STEMI) and the improvement after recanalization depend on the conditions of the coronary occlusion.MethodsFifty-seven patients with first-ever STEMI due to one-artery occlusion, treated with primary PCI, were evaluated. Area at risk and left ventricular wall motion abnormalities were localized with coronary angiography and echocardiography and then compared in relation to the time elapsed from the onset of symptoms at the time of infarction and at 3 months. Left ventricular diameters and ejection fractions were evaluated in relation to the ischemic time.ResultsThree hundred forty-one affected left ventricular segments were detected with angiography, while echocardiography showed 206 segments with motion abnormality. No correlation was found between the regional wall motion index in the area at risk and the time elapsed from the beginning of symptoms. However, the improvement in wall motion abnormalities at the follow-up was dependent on the ischemic time (r=-0.29, p<0.03). The early subgroup showed significant improvement in left ventricular ejection fraction at follow-up (p=0.03), whereas in the late subgroup, a significant increase in left ventricle diameters was observed.ConclusionOur results first demonstrate in humans that in the early hours from the occlusion of the coronary artery, the extent and severity of the wall motion abnormalities inside the area at risk show large variability without relation to the elapsed time since the onset of symptoms. On the other hand, the results of follow-up echocardiography proved that the wall motion improvement was highly dependent on the ischemic time.

531 IMPACT-CABG trial: Implantation of CD133+ stem cells in patients undergoing coronary bypass surgery, analysis of security, feasibility and efficacy for the first five open-labeled patients

Cellular transplantation is a novel strategy to improve ischemic myocardium healing. Bone marrow CD133+ cells are distinct early progenitor group of hematopoietic stem cells that possess high engraftment, pluripotent and angiogenic capacity and appear valuable for cardiac repair by promoting neovascularization, cardiomyogenesis and inhibition of apoptosis. The aim is to report the feasibility, security and beneficial effects of intramyocardial injection of CD133+ stem cells. We report herein the 6 month follow-up on the first 5 patients treated in an open labeled fashion in the IMPACT-CABG study. This is a randomized-controlled phase II clinical trial aiming to assess the safety and effects of intramyocardial injections of autologous CD 133+ selected stem cells in coronary artery bypass grafting (CABG) patients with chronic ischemic cardiomyopathy (left ventricular ejection fraction (LVEF) below 45%). Cardiac function and myocardial viability was assessed by stress echocardiography and magnetic resonance imaging (MRI) before and 6 months after surgery. Bone marrow aspiration and cell selection, using the CliniMACS system, are performed the morning of the surgical procedure and cells are injected intramyocardially after completion of the distal anastomosis before weaning from cardiopulmonary bypass. Five males, mean age 65 ± 10 years, underwent CABG for 3 ± 1 bypasses. A total of 10 millions CD133+ cells were injected in 15 sites (total cell suspension volume 2.0 ml). Post-operative course was uneventful for each patient. There was no peri-operative complication related to this protocol, and no Major Adverse Cardiac Event (MACE) defined as cardiac death, myocardial infarction, repeated coronary revascularization or sustained ventricular arrhythmias. Pre- and 6 months post-operative LVEF were 34.0 ± 2.2 and 39.0 ± 11.9 respectively (P = ns). Moreover, MRI studies suggested that LV end-diastolic and end-systolic volumes decreased after cell implantation compared to baseline. Echocardiographic regional wall motion index for all patients in the ischemic stem cell-injected territories improve at 6 months of follow-up in all patients compared to baseline. The NYHA functional class improved for every patient from class III to class I. This work represents the first Canadian experience with CD133+ stem cells for the treatment of chronic ischemic cardiomyopathy and relies on state-of-the-art methods for assessing myocardial functional recovery and viability. These encouraging results support the safety and feasibility of intramyocardial injections of CD 133+ cells in addition to CABG. IMPACT-CABG trial with further double-blind randomization between CD 133+ cells vs. placebo will test the beneficial impact of this approach.

453. Injectionof Different Adult Cell Types into Mouse Myocardium Three Days after Myocardial Infarction Using a Novel Echo-Guided Technique Improves Cardiac Function

Objective: Myocardial regeneration based on stem cell transplantation has emerged as a potential therapeutic approach toward replacing myocardial scar with functioning contractile tissue after myocardial infarction (MI). Considerable interest has focused on bone marrow cells (BMCs) and endothelial progenitor cells (EPCs) because they appear successful in attenuating remodeling following acute MI. However, preclinical experiments toward this goal have been limited to treatment within hours of an MI, in contrast to human trials, in which cell treatment has been performed several days later after patient stabilization and autologous cell harvesting. We sought to compare the therapeutic effects of different types of putative stem and progenitor cells in a mouse model of MI using a novel closed-chest echo-guided injection approach to deliver cells 3 days after infarction.

The Clinical Significance of Serum-Hydroxyproline in Acute Coronary Syndrome

Background and Objectives:The serum hydroxyproline level (SHL) has been regarded as evidence of collagen breakdown or extra-cellular matrix reorganization. The role of SHL as a diagnostic parameter in acute coronary syndrome, and the SHL changes depending on the left ventricular remodeling after acute myocardial infarction, was evaluated. Subjects and Methods:Venous blood samples were obtained from 122 patients with AMI at the time of admission, and on days 7, 21 and 90, and once from 15 patients with stable angina, 15 with unstable angina and 12 healthy subjects. The SHL was measured using the amino acid analysis system (HPLC). The regional wall motion index (RWMI), LVEF and LV dimensions were determined in the early ( 0.05). However, there was a significant elevation in the SHL 14 day after AMI in the patients of the non-reperfusion group (4.36±1.46, 7.63±2.69 μg/L, p=0.032). After 2 week, there was no significant difference in the SHL. There was a significant relationship between the late left ventricular ejection fraction and the SHL (r=-0.414, p=0.037), but no significant relationship between the other factors and the SHL (p>0.05). Conclusion:The serum hydroxyproline levels were significantly increased in patients with acute coronary syndrome, which reflect the early change in left ventricular remodeling in acute myocardial infarction. (Korean Circulation J

Comparison of developmental endothelial locus-1 angiogenic factor with vascular endothelial growth factor in a porcine model of cardiac ischemia

Background This study compared the angiogenic effects of developmental endothelial locus-1 (DEL-1), vascular endothelial growth factor (VEGF), as well as the negative control, β-galactosidase (β-gal), in a porcine model of cardiac ischemia. Methods Twenty pigs underwent left circumflex artery occlusions. After 3 weeks, the animals received myocardial injections of adenovirus expressing β-gal (n=6), DEL-1 (n=7), or VEGF (n=7). At 7 weeks, animals were assessed for both function and coronary flow and compared with baseline measurements. Results Regional wall motion index and global ejection fraction showed deterioration in function in the β-gal group and no change in the VEGF and DEL-1 groups between the treatment and harvest time points. Preload recruitable stroke work suggested functional improvement in the VEGF group (35.8 ± 8.6 vs 56.4 ± 17.8, p = 0.033). The increase in the DEL-1 group was not statistically significant (27.3 ± 9.8 vs, 40.2 ± 19.4, p = 0.067). The β-gal group exhibited minimal change (30.7 ± 14.8 vs 35.9 ± 12.1, p = 0.96). Regional blood flow as assessed by fluorescent microspheres was improved under stress conditions in the VEGF group (1.00 ± 0.15 vs 1.15 ±0.22, p = 0.03). Conclusions Treatment with VEGF led to a modest improvement in regional blood flow and cardiac function in previously ischemic myocardial tissue.

Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study.

Functional mitral regurgitation (FMR) occurs with a structurally normal valve as a complication of systolic left ventricular dysfunction (LVD). Determinants of degree of FMR are poorly defined; thus, mechanistic therapeutic approaches to FMR are hindered. In a prospective study of 21 control subjects and 128 patients with LVD (defined as ejection fraction <50%, mean 31+/-9%) in sinus rhythm, we quantified simultaneously by echocardiography the effective regurgitant orifice (ERO) of FMR by using 2 methods: mitral deformation (valve and annulus) and left ventricular (LV) global (volumes, stress, function, and sphericity) and local (papillary muscle displacements and regional wall motion index) remodeling. A wide range of ERO (15+/-14 mm(2), 0 to 87 mm(2)) was observed, unrelated to ejection fraction (P:=0.32). The major determinant of ERO was mitral deformation, ie, systolic valvular tenting and annular contraction in univariate (r=0.74 and r=-0.61, respectively; both P:<0.0001) and multivariate (both P:<0. 0001) analyses, independent of global LV remodeling. Systolic valvular tenting was strongly determined by local LV alterations, particularly apical (r=0.75) and posterior (r=0.70) displacement of papillary muscle, with confirmation in multivariate analysis (both P:<0.0001), independent of LV volumes, function, and sphericity. The presence and degree of FMR complicating LVD are unrelated to the severity of LVD. Local LV remodeling (apical and posterior displacement of papillary muscles) leads to excess valvular tenting independent of global LV remodeling. In turn, excess tenting and loss of systolic annular contraction are associated with larger EROs. These determinants of FMR warrant consideration for specific approaches to the treatment of FMR complicating LVD.

Evidence for the delayed effect in human ischemic preconditioning: Prospective multicenter study for preconditioning in acute myocardial infarction

OBJECTIVESThis study aimed to investigate prospectively the protective effect of a first preinfarction angina attack against acute myocardial infarction (AMI) in human hearts without significant collaterals.BACKGROUNDSeveral retrospective studies and the prospective studies have demonstrated the existence of the preconditioning (PC) effect in humans. However, collaterals were not examined in the prospective studies. In animal models, the PC effect on myocardial infarct size appears soon after PC reperfusion (classic) but disappears within 1 to 2 h. It then reappears 24 to 48 h after reperfusion (the delayed PC effect). Meanwhile, the PC effect on stunning appears 12 h after PC reperfusion (the delayed PC effect). The concept of the classic and delayed PC effects has not been investigated in human AMI studies. If the above concept is also correct in humans, the infarct size and/or impairment of the left ventricular function should be inversely correlated with the time interval between the first preinfarction angina attack and the onset of AMI when that time interval is limited to between 2 and 48 h.METHODSThe subjects were 25 patients with first AMI of the proximal left anterior descending artery who underwent successful direct percutaneous transluminal coronary angioplasty (PTCA) 2 to 6 h after the onset and with no (or poor) collateral circulation (grade 0 or 1). They were divided into two groups: preinfarction angina (PA)(+) group: 11 patients with new onset preinfarction angina from 2 to 48 h before the onset, PA(−) group: 14 patients without angina before infarction. Peak creatine kinase (CK) and cumulative CK were examined, and the left ventricular ejection fraction (LVEF) and the regional wall motion (RWM) were determined from the left ventriculograms during the acute (immediately after the coronary reperfusion) and chronic (four weeks after the onset of AMI) phases. The RWM index (RWMI) was then calculated as the mean motion of chords (standard deviation [SD]/chord) lying in the area of chords of RWM ≤ −2 SD in the acute phase (ischemic risk area).RESULTSThe increase in the RWMI between the acute and chronic phases was significantly larger in the PA(+) group than in the PA(−) group (1.55 ± 1.32 and 0.69 ± 0.75, p < 0.05, respectively) although no significant difference in the enzymatic infarct size was seen between the two groups. The increases in the LVEF and the RWMI were significantly correlated with the time interval from the first preinfarction angina attack to the onset of AMI (r = 0.622, p < 0.05 and r = 0.646, p < 0.05, respectively), but the enzymatic infarct size was not.CONCLUSIONSThe beneficial effect of preinfarction angina on left ventricular wall motion, independently of collateral flows, indicates the existence of the PC effect in humans. The greater protective effect of a longer time interval between angina pectoris and AMI suggests that the protection is due to a delayed PC effect.

Beneficial effects of mechanical reperfusion therapy on left ventricular remodeling and late outcome following myocardial infarction.

The long-term relative benefits of thrombolysis and mechanical reperfusion therapy following acute myocardial infarction (AMI) have not been established. The purpose of this study was to compare left ventricular function, left ventricular remodeling and late outcome after AMI for different reperfusion therapies. Thirty consecutive patients suffering their first anterior wall myocardial infarction with coronary stenoses limited to the left anterior descending coronary artery were studied. They included 10 patients who underwent intracoronary thrombolysis (ICT), 10 who underwent PTCA and 10 who underwent noninterventional medical treatment. All patients underwent coronary angiography (CAG) during the acute phase of AMI and also during the follow-up period, and left ventriculography during the follow-up period and clinical follow-up was performed (mean clinical follow-up period: 53 +/- 31 months). No significant difference in global ejection fraction was noted among the groups, although the end-diastolic volume index (EDVI) in the PTCA group (79.4 +/- 17.5 ml/m2) was significantly smaller than in the noninterventional (106.1 +/- 25.1 ml/m2) and ICT (107.9 +/- 28.3 ml/m2) group (p < 0.05). The regional wall motion index (RWMI) for the anterior region in the PTCA group (-2.7 +/- 0.8) was greater (p < 0.05) than in the noninterventional (-3.4 +/- 0.6) and ICT (-3.3 +/- 0.6) groups. A significant linear correlation was found between EDVI and % diameter stenosis and also between RWMI and % diameter stenosis following reperfusion (p = 0.01). There was no difference in the incidence of cardiac death, nonfatal reinfarction, bypass surgery or congestive heart failure among the groups. Disturbed left ventricular regional wall motion and remodeling benefit most from angioplasty because of prompt restoration of adequate blood flow. However, there was no difference in late outcomes following AMI among the three groups.

Effect of delayed percutaneous transluminal coronary angioplasty of occluded coronary arteries after acute myocardial infarction

Whether angioplasty of occluded vessels after myocardial infarction may have beneficial effects on left ventricular function remains unknown. Patients with a first myocardial infarction and thrombolytic therapy who had an occluded infarct-related vessel at delayed coronary angiography were referred systematically for an elective coronary angioplasty performed between 3 and 4 weeks after the myocardial infarction. All patients underwent stress-redistribution-reinjection thallium-201 single-photon emission computed tomography for myocardial viability assessment. Prior angioplasty, a quantitative evaluation of global and regional left ventricular function, was performed. The study group consisted of 38 patients (aged 57 ± 10 years); 18 had anterior wall infarctions and 20 inferior wall infarctions, but before angioplasty 3 had a patent artery and were excluded. Angioplasty was successful in 30 patients. At follow-up 13 patients (43%) had an occluded coronary artery. In contrast with patients with an occluded coronary artery at follow-up, those with a patent coronary artery had no left ventricular enlargement and had an improvement in both left ventricular ejection fraction (from 48 ± 9% to 52 ± 9.8%, p = 0.002) and regional wall motion index (Δ = +0.95 SD, p < 0.01). In patients with a patent vessel at follow-up, there was a positive correlation between the number of myocardial viable segments and improvement of the infarct zone wall motion (r = 0.52; p = 0.035), and the number of necrotic segments at baseline was positively correlated to the 4-month changes in end-diastolic volume indexes (r = 0.6; p = 0.04). Thus, elective revascularization of occluded coronary arteries with viable myocardium after myocardial infarction improves left ventricular function and lessens remodeling if the artery remains patent during follow-up.

Streptokinase

Streptokinase has been administered to many thousands of elderly patients with acute myocardial infarction. Results of large, randomised trials provide convincing evidence that intravenous streptokinase confers a distinct survival benefit in this population subgroup following myocardial infarction. The placebo-controlled ISIS-2 study demonstrated a 5-week absolute mortality reduction of 38 per 1000 patients aged 60 to 69 years administered streptokinase, compared with only 16 per 1000 for patients aged less than 60 years. Combining streptokinase with aspirin further reduces mortality, as shown by a 5-week absolute mortality reduction of 70 per 1000 patients aged 60 to 69 years administered this regimen in the ISIS-2 trial. While ideally patients should receive streptokinase as soon as possible after symptom onset, late benefit has been observed in patients presenting up to 12 hours after pain onset, as is often the case with the elderly. Indeed, in patients treated > 6 hours after infarct in the GUSTO trial, streptokinase produced lower mortality results than accelerated recombinant tissue plasminogen activator (rt-PA). However, in contrast to the similar effects of streptokinase and conventionally administered rt-PA on overall survival demonstrated in previous large trials, the GUSTO study showed a lower mortality rate for accelerated rt-PA than for streptokinase in the elderly and in the total patient population. The most frequent adverse effects associated with streptokinase therapy are haemorrhagic complications, with an incidence of 0.4% for major bleeding (requiring transfusion) and 3.6% for minor bleeding among the total population in the GISSI-1 and ISIS-2 trials. An excess of stroke, particularly haemorrhagic stroke, occurring with rt-PA in GUSTO and other major mortality trials affirms the use of streptokinase as a suitable option in the elderly who are at increased risk of this complication. Significantly reduced values of end-systolic volume and regional wall motion index have been observed in elderly patients following streptokinase therapy. Overall, streptokinase and rt-PA seem to cause similar improvements in left ventricular function in this age group. Patency of occluded coronary arteries appears to be achieved in a high percentage of elderly patients following streptokinase therapy, based on a small sample. Thus, in view of the extensive clinical experience that now exists, intravenous streptokinase represents an appropriate alternative in elderly patients with acute myocardial infarction, and may be considered a first-line therapy in selected individuals, such as those with multiple risk factors for stroke or who present later than 6 hours after infarct.(ABSTRACT TRUNCATED AT 400 WORDS)

New Noninvasive Assessment of Regional Left Ventricular Function by Digital Subtraction Angiography without the Use of Contrast Medium.

We have developed a new noninvasive method to evaluate regional left ventricular (LV) function by digital subtraction angiography (DSA) without the use of contrast medium. DSA images of the left ventricle with and without contrast medium were obtained from 35 patients with anterior myocardial infarction (MI) and from 35 control subjects. Using an image-processing computer, regional LV time-density curves were constructed for one cardiac cycle. Regional LV time-density curves obtained from DSA without the use of contrast medium presented a pattern similar to those from intravenous DSA. The amplitude of regional LV time-density curves in patients with MI decreased along with increasing severity of regional wall motion abnormality assessed by conventional left ventriculography. In attempting semi-quantitative evaluation by DSA without the use of contrast medium, the regional wall motion index (RWI) in the 6 segments of the left ventricle was calculated by normalizing segmental density changes to the maximal segmental density changes. When compared with control subjects, patients with MI have significantly lower RWIs in the anterolateral and apical regions. RWI showed a good correlation with the regional ejection fraction (REF) obtained from intravenous contrast DSA (r = 0.83). RWI decreased with increasing severity of regional wall motion abnormality by qualitative analysis in conventional left ventriculography, being consistent with REF. The diagnostic accuracy of RWI therefore seemed to be comparable to that of REF derived from intravenous contrast DSA. These results indicate that computerized analysis of DSA without the use of contrast medium is a valuable noninvasive method for semi-quantitative assessment of regional LV function.

Effect of streptokinase on left ventricular modeling and function after myocardial infarction: The GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico) trial

It has been shown that streptokinase administration at the time of acute myocardial infarction reduces mortality significantly, and that this reduction in mortality should be related to salvage of jeopardized myocardium and preservation of left ventricular function. To better define the relation between thrombolytic therapy and left ventricular modeling and function after acute myocardial infarction, 331 consecutive patients enrolled in the Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico trial were studied by two-dimensional echocardiography just before discharge from the hospital. A 6 month follow-up examination was also available in 232 of these patients. Ventricular volumes were computed from an apical four chamber view, according to a previously published algorithm. An infarct size index was also semiquantitatively assessed, according to the number of akinetic and dyskinetic segments in an 11 segment left ventricular model.At predischarge examination, the 161 patients assigned to streptokinase treatment showed smaller ventricular volumes (end-diastolic volume 119.3 ± 49.7 versus 134.5 ± 57.8 ml [p = 0.011]; end-systolic volume 65.4 ± 36.4 versus 74.9 ± 45.7 ml [p = 0.036]) and smaller regional wall motion index (2.2 ± 1.9 versus 2.7 ± 1.9 segments; p = 0.019) compared with values in the 170 patients assigned to standard care; there was no difference in ejection fraction (46.6 ± 14.1 versus 45.9 ± 14.9%; p = 0.64). For both groups of patients, there was a significant relation between end-systolic volume and regional wall motion index (p < 0.001); for large and similar extents of infarct size, ventricular volume was smaller in patients assigned to thrombolytic treatment than in patients assigned to standard care.At 6 months' follow-up, the differences in volume and regional dysfunction detected at the early examination persisted: 110.8 ± 47.6 versus 127.9 ± 53.8 ml for enddiastolic volume (p = 0.001), 56.3 ± 33.6 versus 69.4 ± 42.1 ml for end-systolic volume (p = 0.001) and 1.8 ± 1.8 versus 2.3 ± 1.8 segments for regional wall motion index (p = 0.001). Again, for comparable extents of infarct size, end-systolic volume was smaller in patients who received streptokinase (n = 110) than in those assigned to conventional treatment (n = 122).It is concluded that streptokinase improves left ventricular modeling and function in patients with myocardial infarction, reducing the extent of regional wall motion abnormalities and lessening postinfarction ventricular dilation. The beneficial effects persist up to 6 months.

Regional Wall Motion Index for Infarct and Noninfarct Regions after Reperfusion in Acute Myocardial Infarction: Comparison With Global Wall Motion Index

A regional wall motion index has been derived from two-dimensional echocardiograms by use of a 16-segment model that was subdivided into anterior (nine segments) and infero-postero-lateral (seven segments) regions. This new method is compared with the use of a previously described global wall motion index for the analysis of serial echocardiograms after reperfusion in 23 patients who had acute myocardial infarction. Mean global index improved from 1.84 ± 0.46 to 1.56 ± 0.37 at 24 hours (p < 0.01) and to 1.50 ± 0.29 after 3 days to 7 days (p < 0.02), whereas mean regional index for infarct regions improved from 2.28 ± 0.73 to 1.82 ± 0.58 at 24 hours (p < 0.01) and to 1.70 ± 0.42 after 3 to 7 days (p < 0.01), with no significant change in the noninfarct index (1.34 ± 0.32 initially and 1.28 ± 0.36 after 3 to 7 days). Although both global and regional indexes effectively demonstrate early recovery of left ventricular function, (within 24 hours in many patients), the regional index for infarct regions is higher than the global index and effectively distinguishes between infarct and noninfarct segments. An overlap index in which an additional apical segment is included in the anterior region (10 segments) for anterior infarctions and in the infero-postero-lateral region (eight segments) for inferior infarctions results in a greater differentiation between infarct and noninfarct regions, with the mean initial noninfarct overlap index (1.17 ± 0.33) significantly less than the nonoverlap index. For infarct regions, however, there is no significant difference between overlap and nonoverlap indexes, and the nonoverlap method has the advantages of simplicity and wider applicability in the absence of known coronary anatomy or other clinical information. This new method of regional wall motion analysis appears to be a usefinl addition to previous methods for the assessment of left ventricular function after myocardial infarction.

Comparison of Regional and Global Left Ventricular Function by Serial Echocardiograms After Reperfusion in Acute Myocardial Infarction

Fifty patients undergoing successful reperfusion therapy (percutaneous transluminal coronary angioplasty 20, thrombolysis 10, combined 20) for acute myocardial infarction were evaluated with serial two-dimensional echocardiograms performed early (less than 24 hours, mean 8 hours) and late (greater than 3 days, mean 6 days) after presentation. Treatment occurred within 12 hours of the onset of symptoms with most patients achieving reperfusion in less than 6 hours (mean 4.7 hours) from the onset of pain. Reperfusion was demonstrated short-term by angiography in 42 of 50 patients (84%). Four patients had clinical signs of reperfusion and subsequent angiographic confirmation. An additional four patients with "stuttering" infarct courses were treated late by percutaneous transluminal coronary angioplasty. Echocardiograms were analyzed for global performance by calculation of fractional area change at the papillary muscle level and ejection fraction (biplane Simpson's rule) in 18 patients in whom this analysis could be performed. Measurements of regional function included fractional shortening at the base (n = 37), regional wall motion index (n = 50) and percent of normal functioning myocardium (n = 50). Overall there was a significant improvement in regional wall scores and percent of functioning myocardium (regional wall motion index 1.73 to 1.43, p less than 0.001 and percent of functioning myocardium 0.61 to 0.70, p less than 0.001) but only a trend toward improvement when global function was assessed by ejection fraction (0.42 to 0.48, p less than 0.14).(ABSTRACT TRUNCATED AT 250 WORDS)

The acute effects of intravenous nisoldipine on left ventricular function 24 to 72 hours after uncomplicated acute myocardial infarction.

The acute effects on left ventricular function of nisoldipine were studied in six patients 56 +/- 12 hours (range 44 to 72 hours) after the onset of uncomplicated acute myocardial infarction. Nisoldipine was administered as a 4.5 micrograms/kg intravenous bolus over 3 minutes followed by an infusion of 0.2 microgram/kg during 60 minutes. Radionuclide angiography and two-dimensional echocardiography were performed before and during infusion with nisoldipine. The left ventricular ejection fraction increased significantly from 38% +/- 10% to 49% +/- 10% (P = 0.028) during nisoldipine infusion. Regional wall motion index was determined both by radionuclide and by two-dimensional echocardiography and showed a significant change during nisoldipine infusion from 1.9 +/- 0.3 to 1.5 +/- 0.3 (p = 0.028, radionuclide angiography) and from 0.7 +/- 0.2 to 0.3 +/- 0.2 (p = 0.043, two dimensional echocardiography). Heart rate increased significantly from 78 +/- 12 min-1 to 92 +/- 13 min-1 (p = 0.028), but mean double product did not change significantly during nisoldipine infusion. It is concluded that nisoldipine significantly improves global and regional left ventricular function in patients shortly after acute myocardial infarction. This beneficial effect may, however, be partially offset by an increase in heart rate. Since mean double product did not change, it is suggested that nisoldipine may improve coronary blood flow in patients with acute myocardial infarction.