Salvage Index Research Articles

Vascular Trauma in the Extremities: Factors Associated with the Outcome and Assessment of Amputation Indexes.

Traumatic vascular injury in the extremities may be associated with a low mortality rate but can lead to limb loss that seriously affects patients' functionality. Multiple scoring systems have been designed to evaluate the prognosis, but none are 100% predictive. The management of traumatic vascular injury remains challenging and depends mostly on the surgeon's experience. We identified the risks associated with limb loss and further investigated the utility of current amputation indexes. We retrospectively reviewed 53 cases of traumatic vascular injury in the extremities at a tertiary referral medical center over the past ten years (January 2011-December 2020). The mangled extremity severity score (MESS), limb salvage index (LSI), and predictive salvage index (PSI) were used to assess the traumatized limbs. The injury characteristics and outcomes were evaluated using regression analysis. The incidence of limb loss was 20.8% (n = 11), and open fractures were the most related factor. Extensive involvement of soft tissue, vascular injury combined with tibia or fibula fractures, initial shock status, and the amount of transfusion were associated with limb loss. Our study identified the risk factors and clinical utility of MESS, PSI, and LSI. While both LSI and PSI had acceptable diagnostic accuracy, amputation should be decided based on a variety of criteria and clinical features. Salvaging any limb that has not become apparently futile seems logical, yet the presence of certain factors may suggest a worse outcome.

Efficacy of comprehensive remote ischemic conditioning in elderly patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention.

BACKGROUNDRemote ischemic conditioning (RIC) is used to protect against myocardial injury. However, there is no adequate evidence for comprehensive RIC in elderly patients with ST-segment elevation myocardial infarction (STEMI). This study aimed to test whether comprehensive RIC, started pre-primary percutaneous coronary intervention (PPCI) and repeated daily on 1–30 days post-PPCI, can improve myocardial salvage index (SI), left ventricular ejection fraction (LVEF), Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS) and 6-min walk test distance (6MWD) in elderly patients with acute STEMI during 12 months follow-up.METHODS328 consenting elderly patients were randomized to receive standard PPCI plus comprehensive RIC (the treatment group) or standard PPCI (the control group). SI at 5–7 days after PPCI, LVEF, left ventricular end-diastolic volume index (LVEDVI), left ventricular end-systolic volume index (LVESVI), KCCQ-CSS, 6MWD and adverse events rates were measured and assessed.RESULTSSI was significantly higher in the treatment group [interquartile range (IQR): 0.38–0.66, P = 0.037]. There were no significant differences in major adverse events at 12 months. Although the differences of LVEDVI, LVESVI and LVEF between the treatment group and the control group did not reach statistical significance at 6 months and 12 months, LVEF tended to be higher, LVEDVI tended to be lower in the treatment group. The KCCQ-CSS was significantly higher in the treatment group at 1 month (IQR: 46.5–87, P = 0.001) and 12 months (IQR: 55–93, P = 0.008). There was significant difference in 6MWD between the treatment group and the control group (IQR: 258–360 vs. IQR: 250–345, P = 0.002) at 1 month and (IQR: 360–445 vs. IQR: 345–432, P = 0.035) at 12 months. A modest correlation was found between SI and LVEF (r = 0.452, P < 0.01), KCCQ-CSS ( r = 0.440, P < 0.01) and 6MWD ( r = 0.384, P < 0.01) respectively at 12 months. CONCLUSIONSThe comprehensive RIC can improve SI, KCCQ-CSS and 6MWD. It may be an adjunctive therapy to PPCI in elderly patients with STEMI.

Impact of intracoronary reteplase during primary percutaneous coronary intervention on infarct size in large anterior myocardial infarction: rationale and design of the RECOVER II trial

Thrombus embolization and microvascular obstruction during percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) is commonly detected, which causes inadequate myocardial perfusion and elevated infarct size. An approach with low-dose intracoronary fibrinolytic treatment for reducing distal embolization and improving myocardial reperfusion in high-risk STEMI cases remains controversial. The RECOVER II study represents a multicenter, randomized, double-blind, parallel-group trial assessing low-dose adjunctive intracoronary reteplase during primary PCI in individuals with large anterior myocardial infarction and thrombus determined by angiography. The trial will enroll 306 cases who present within 12 h following STEMI for proximal or mid left anterior descending artery occlusion undergoing primary PCI. Cases will be randomized to receive a bolus intracoronary reteplase at 9 mg or 18 mg vs. placebo. The drug will be delivered over 2 minutes proximal to culprit lesions with an intracoronary catheter early after wire-crossing and before thrombus aspiration or balloon dilation. The primary outcome will be infarct size assessed by late gadolinium-enhanced magnetic resonance imaging (MRI) (% of left ventricular mass) on day 7 after enrollment. Secondary outcomes will include the amount of microvascular obstruction and myocardial salvage index examined via MRI on day 7, angiographic measures of reperfusion [Thrombolysis in Myocardial Infarction (TIMI) coronary flow grade, TIMI frames count and myocardial blush grade], incidence of complete ST-segment resolution at 2 hours after reperfusion, area under the curve for troponin T, and rates of major adverse cardiovascular events at 30 days. RECOVER II will determine whether the addition of low-dose intracoronary reteplase early after wire-crossing as an adjunct to reperfusion treatment reduces infarct size in individuals with large anterior myocardial infarction. ClinicalTrials.gov Identifier: NCT04571580.

Índice de resistencia microcirculatoria y obstrucción microvascular en la resonancia magnética cardiaca tras un IAMCEST

Introduction and objectivesThe index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). MethodsThe current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. ResultsAmong the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). ConclusionsAngio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR.This trial was registered at ClnicalTrialsgov (Identifier: NCT04828681).

Limb salvage vs amputation in crush injury due to high energy injury: A case report

Limb injury possesses significant problems, both for the treating physician and patient. Numerous problems ranging from disability, limb amputation or even death can occur to the patient. However, the definitive therapy is still debated. A 50 years old man came to the emergency room with a chief complaint of an open wound of his right leg because of a traffic accident. Subsequently, the repair, secondary closure, and skeletal traction were done following the exploration and debridement. During the next follow up, the surrounding tissues seemed to be non-viable. Therefore, the surgeon decided to do an operation with a urologist to perform hip disarticulation and scrotum necrotomy. The patient undergoes repeated debridement in operating theatre and also using negative pressure wound therapy (NPWT). After three months from the first admission, the patient's condition started to deteriorate, and unfortunately, the patient died. There are several scoring systems that can be used to help determine the management of high energy lower extremity injuries. The most used is Mangled Extremity Severity Score (MESS), Limb Salvage Index (LSI) and Predictive Salvage Index (PSI) scores. Hospital type will surely determine the facility and personnel availability. If the facility and personnel are sufficient, limb reconstruction should be attempted first. However, in the end, the family's consent after considering the risk of the surgery will determine the chosen surgery to perform. The surgeon in charge should consider the decision with high vigilance regarding the patient's clinical condition. The decision between limb salvage and amputation should consider the long-term effect which influences the patient's quality of life.

Functional angiography-derived index of microcirculatory resistance validated with microvascular obstruction in cardiac magnetic resonance after STEMI

Introduction and objectivesThe index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). MethodsThe current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. ResultsAmong the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). ConclusionsAngio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR.This trial was registered at ClnicalTrialsgov (Identifier: NCT04828681).

Five-year follow-up of intracoronary autologous cell therapy in acute myocardial infarction: the REGENERATE-AMI trial.

AimsThe long‐term outcomes of the intracoronary delivery of autologous bone marrow‐derived cells (BMCs) after acute myocardial infarction are not well established. Following the promising 1 year results of the REGENERATE‐AMI trial (despite it not achieving its primary endpoint), this paper presents the analysis of the 5 year clinical outcomes of these acute myocardial infarction patients who were treated with an early intracoronary autologous BMC infusion or placebo.Methods and resultsA 5 year follow‐up of major adverse cardiac events (defined as the composite of all‐cause death, recurrent myocardial infarction, and all coronary revascularization) and of rehospitalization for heart failure was completed in 85 patients (BMC n = 46 and placebo n = 39). The incidence of major adverse cardiac events was similar between the BMC‐treated patients and the placebo group (26.1% vs. 18.0%, P = 0.41). There were no cases of cardiac death in either group, but an increase in non‐cardiac death was seen in the BMC group (6.5% vs. 0%, P = 0.11). The rates of recurrent myocardial infarction and repeat revascularization were similar between the two groups. There were no cases of rehospitalization for heart failure in either group.ConclusionThis 5 year follow‐up analysis of the REGENERATE‐AMI trial did not show an improvement in clinical outcomes for patients treated with cell therapy. This contrasts with the 1 year results which showed improvements in the surrogate outcome measures of ejection fraction and myocardial salvage index.

Prognostic value of the SYNTAX score on myocardial injury and salvage in STEMI patients after primary percutaneous coronary intervention: a single-center retrospective observational study

BackgroundSYNTAX score (SS) was shown to positively correlate with postprocedural myocardial injury in patients after elective coronary artery intervention, but evidence about the association of SS with myocardial salvage in ST-segment elevation myocardial infarction (STEMI) patients is still needed. This study aimed to evaluate the prognostic value of SS for myocardial injury and salvage assessed by cardiac magnetic resonance (CMR) after primary percutaneous coronary intervention (PCI) in STEMI patients.MethodsThis single-center retrospective study consecutively enrolled STEMI patients who had undergone primary PCI within 12 h from symptom onset. Both angiography and CMR were performed during hospitalization, and patients were divided into low SS (SS ≤ 22), mediate-high SS (SS > 22) groups. Correlation and multivariable analyses were performed.ResultsA total of 149 STEMI patients (96 low SS, 53 mediate-high SS) were included. In terms of myocardial injury parameters, there was a positive correlation (p < 0.001, Spearman r = 0.292) between SS and infarct size (IS), and a negative correlation (p < 0.001, Spearman r = − 0.314) between SS and myocardial salvage index (MSI). In the multivariable model, SS (> 22 as categorical variable, OR = 2.245, 95% CI [1.002–5.053], p = 0.048; as continuous variable, OR = 1.053, 95% CI [1.014–1.095], p = 0.008) was significantly associated with high IS (≥ mean 35.43). The areas under the receiver operating characteristic (ROC) curves of SS for high IS and low MSI (≤ median 28.01) were 0.664 and 0.610.ConclusionsIn STEMI patients undergoing primary PCI, SYNTAX score positively correlated with infarct size and negatively with myocardial salvage, indicating an independent predictive value of the myocardial injury.

Abstract 12366: Intracoronary Delivery of E06 Antibody Directed to Oxidized Phospholipids Decreases Infarct Size in a Porcine Model of Ischemia/Reperfusion Injury

Introduction: Myocardial ischemia/reperfusion injury (IRI) results in additional myocardial cell loss post reperfusion. Oxidized phosphocholine(PC)-containing phospholipids (OxPL) have been shown to result in cardiomyocyte cell death during IRI. E06 is a natural murine monoclonal IgM antibody which binds to the PC headgroup of OxPL. Transgenic mice expressing a single-chain Fv E06 fragment have recently been shown to have smaller infarct sizes post myocardial IRI. The objective of this study was to determine if directly infused E06 IgM reduced IRI in a porcine model of reperfusion injury that more closely reflects human physiology. Methods: Male pigs, 45 to 50 kg, were randomized equally to IRI in two groups: 1) control with saline coronary infusion (n=7). 2) IgM E06 coronary infusion over 1 hour (n=7). The left anterior descending (LAD) artery was occluded distal to the second diagonal branch for 60 minutes using an angioplasty balloon. Following balloon deflation, saline or IgM E06 was infused over 60 min through a microcatheter. Following 120 min of total reperfusion, the area at risk (AAR) and infarct size (IS) were determined by triphenyltetrazolium chloride staining technique (TTC), and myocardial salvage index determined. Results: All animals survived post reperfusion and no differences were present in hemodynamics at the baseline and 2 h post reperfusion between groups. A 51.3% reduction in infarct size was noted in animals receiving intracoronary E06 compared to controls (IS/AAR 21.7% ± 3.4 vs 42.3% ± 3.7 p&lt;0.0005). IS/LV size (7.7 ± 3.2 vs 11.9 ± 1.2 p&lt;0.004) and myocardial salvage index (82.6% vs 57.6% in controls) were significantly improved in animals receiving E06 compared to controls. Conclusion: Intracoronary delivery of E06 antibody at the time of reperfusion leads to a significant reduction in infarct size, suggesting that generation of OxPL during reperfusion leads to cardiomyocyte cell death. Translation of this approach using humanized anti-OxPL antibodies may allow a novel approach to treat myocardial IRI in humans.

A Retrospective Cohort Study of Treatment Outcomes of Adult Patients with Relapsed or Refractory Low-Grade Follicular Lymphoma (ReCORD-FL)

A Retrospective Cohort Study of Treatment Outcomes of Adult Patients with Relapsed or Refractory Low-Grade Follicular Lymphoma (ReCORD-FL)

Role of glucagon-like peptide-1 agonist in patients undergoing percutaneous coronary intervention or coronary artery bypass grafting: A meta-analysis

ImportanceGlucagon-like peptide-1 (GLP-1) protects against ischemia-reperfusion injury in patients with acute myocardial infarction (AMI). Controversy exists on the effects of GLP-1 on AMI patients undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery. Study objectiveWe aimed to investigate the cardioprotective effects of GLP-1 in AMI patients after PCI and CABG. DesignWe searched PubMed, Web of Science, EBSCO, Scopus, and the Cochrane Library for relevant randomized controlled trials (RCTs) up to June 2021, with no restriction on publication date. The following search terms are used: “percutaneous coronary intervention” or “coronary artery bypass grafting” or “myocardial infarction” and “glucagon-like peptide 1” or “exenatide” or “liraglutide”. Study selectionArticles were independently assessed by 2 reviewers. We included RCTs only that compared GLP-1 with control in AMI patients. Data extraction and synthesisContinuous data were pooled as mean differences (MDs), while dichotomous variables were pooled as odds ratios (ORs), with 95% confidence interval (CI), using R software (meta package) for windows. Subgroup analysis according to the intervention type and GLP-agents were conducted. We assessed the heterogeneity among RCTs using the Q statistic and I2 statistic. We also tested publication bias by funnel plot–based methods. The quality of each study was assessed with the Cochrane risk of bias tool. Main outcomes and measuresPrimary outcomes were changes of left ventricular ejection fraction (LVEF), myocardial infarct characteristics, salvage index. Secondary outcomes included major adverse cardiac events (MACE), gastrointestinal events, and hypoglycemia. ResultsNine RCTs (14 reports) including 1216 patients were included in this meta-analysis. At 3 months follow up, GLP-1 was associated with improved LVEF (MD = 2.81, 95% CI [0.69, 4.94]), infarct size in grams (MD = −5.71, 95% CI [−10.24, −1.18]), and salvage index (MD = 0.09, 95% CI [0.05, 0.14]). While, GLP-1 had less MACE rate than control (RR = 0.64, 95% CI [0.41, 0.99]), and higher gastrointestinal side effects (RR = 4.21, 95% CI [2.39, 7.41]). Conclusions and relevanceThis meta-analysis illustrated that GLP-1 was associated with better LVEF and reduced infarct size in patients with AMI undergoing PCI and CABG surgery, although the mechanism on how this agent provide this benefit is not clear. Key pointsQuestion: What is the effectiveness of Glucagon-like peptide-1 (GLP-1) agonist in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery.Findings: This systematic review and meta-analysis illustrated that GLP-1 was associated with better left ventricular ejection fraction and reduced infarct size in patients with AMI undergoing PCI and CABG surgery, probably by reducing reperfusion injury.Meaning: GLP-1 could improve systolic and diastolic function, lowering the cardiovascular risk of morbidity and mortality in AMI patients.

Protective Effect of Shexiang Baoxin Pill on Myocardial Ischemia/Reperfusion Injury in Patients With STEMI.

Background: There is no definite effect in the treatment of myocardial ischemia/reperfusion (I/R) injury in patients with acute ST-segment elevation myocardial infarction (STEMI). We evaluated the protective effect of Shexiang Baoxin Pill (SBP) on I/R injury in STEMI patients.Methods: STEMI patients were randomly divided into a primary percutaneous coronary intervention (PPCI) group (n = 52) and a PPCI + SBP group (n = 51). The area at risk of infarction (AAR) and final infarct size (FIS) were examined by single-photon emission computed tomography (SPECT). I/R injury was assessed using myocardial salvage (MS) and salvage index (SI) calculated from AAR and FIS.Results: The ST-segment resolution (STR) in the PPCI + SBP group was significantly higher than that in the PPCI group (p = 0.036), and the peak value of high-sensitivity troponin T (hsTNT) was lower than that in the PPCI group (p = 0.048). FIS in the PPCI + SBP group was smaller than that in the PPCI group (p = 0.047). MS (p = 0.023) and SI (p = 0.006) in the PPCI + SBP group were larger than those in the PPCI group. The left ventricular ejection fraction (LVEF) in the PPCI + SBP group was higher than that in the PPCI group (p = 0.049), and N-terminal pro-B type natriuretic peptide (NT-proBNP) level in the PPCI + SBP group was lower than that in the PPCI group (p = 0.048).Conclusions: SBP can alleviate I/R injury (MS and SI), decrease myocardial infarction area (peak value of hsTNT and FIS), and improve myocardial reperfusion (MBG and STR) and cardiac function (LVEF and NT-proBNP).

Myocardial salvage after ST-segment-elevation myocardial infarction: comparison between prasugrel and clopidogrel in the presence or absence of high-residual platelet reactivity

BackgroundThe effect of prasugrel over clopidogrel on myocardial salvage in ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) is not fully elucidated. MethodsAmong 854 consecutive STEMI patients who underwent p-PCI, 446 patients were evaluated by two-phase (7 days and 3 months) single-photo emission computed tomography (SPECT). Patients were divided into two groups based on the loading P2Y12 inhibitor. The clopidogrel group was further divided based on the result of platelet function testing. Thus, the prasugrel group included 227 patients; the clopidogrel without high-residual platelet reactivity (HRPR) group, 109 patients; and the clopidogrel with HRPR group, 107 patients. The primary endpoint was the Myocardial Salvage Index (MSI), determined by SPECT. ResultsThe incidence of final TIMI 0/1 and TIMI myocardial perfusion grade 0/1 was higher in the clopidogrel with HRPR group (0.9%, 1.8%, and 7.5%, P = .002; 19.8%, 29.4%, and 41.1%, P = .0002, in the prasugrel, clopidogrel without HRPR, and clopidogrel with HRPR groups, respectively). The MSI was significantly lower in the clopidogrel with HRPR group (48% [27-66], 44% [30-72], and 36% [15-55], P = .006, respectively). ConclusionsPrasugrel in STEMI patients was associated with an increased MSI compared with clopidogrel in the presence of HRPR.

Combined protocol for remote ischemic conditioning as the method of cardioprotection in patients with acute ST-segment elevation myocardial infarction

Background. There is currently no commonly accepted strategy for limiting the reperfusion injury that occurs after revascularization in patients with myocardial infarction. This study aimed to investigate the efficacy of a promising cardioprotective method.Material and Methods. Patients with acute anterior ST-segment elevation myocardial infarction (STEMI) (n = 87) were included in an open-label prospective randomized controlled trial. Control group comprised patients with STEMI who underwent only primary percutaneous coronary intervention (PPCI) (n = 44). Patients of intervention group (n = 43) underwent PPCI and remote ischemic perconditioning combined with postconditioning (RIC). The efficacy of RIC was assessed based on cardiac magnetic resonance (CMR) imaging data.Results. The medians of left ventricular (LV) infarct size were significantly higher in patients of control group: 44.8 (33.6; 55.5) versus 52.7 (35.5; 73.9) mL (p = 0.039) at day 10 after STEMI and 34.0 (25.8; 39.8) mL versus 46.0 (32.8; 55.0) mL six months after STEMI in control and intervention groups, respectively (p = 0.004). The groups of patients did not differ in the sizes of area at risk relative to the total LV myocardial volume: 40 (35; 45) and 43 (34; 49)% in control and intervention groups, respectively (р = 0.232). The groups significantly differed in the ratios of infarct size to area at risk: 70.3 (65.1; 86.6)% in control group versus 63.5 (52.7; 72.0)% in intervention group (р = 0.014) as well as in the myocardial salvage indexes: 29.7 (13.5; 34.9)% in control group versus 36.5 (28.0; 47.3)% in intervention group (р = 0.014). The study showed the tendency to greater LV myocardial salvage in intervention group versus control group at six-months follow-up (р = 0.073). The groups significantly differed in the medians of microvascular obstruction volume: 1.9 (1.4; 2.9) mL in intervention group versus 2.5 (1.8; 8.1) mL in control group (p = 0.049) as well as in the proportions of microvascular obstruction in the LV myocardium: 0.94 (0.79; 1.37)% in intervention group versus 1.50 (0.89; 3.66)% in control group (р = 0.046).Conclusion. The RIC method combined with PPCI contributed to the limitation of infarct and microvascular obstruction sizes and was associated with an increase in the myocardial salvage index in STEMI patients.

Efficacy and Safety of Early Intravenous Landiolol on Myocardial Salvage in Patients with ST-segment Elevation Myocardial Infarction before Primary Percutaneous Coronary Intervention: A Randomized Study.

Early treatment with an oral β-blocker is recommended in patients with a ST-segment-elevation myocardial infarction (STEMI). In this multicenter study, we evaluated the effects of a continuous administration of landiolol, an ultrashort-acting β-blocker, before primary percutaneous coronary intervention (PCI) on myocardial salvage and its safety in STEMI patients. A total of 47 Japanese patients with anterior or lateral STEMI undergoing a primary PCI within 12 h of symptom onset were randomized to receive intravenous landiolol (started at 3 μg/min/kg dose and continued to a total of 50 mg; n=23) or not (control; n=24). Patients with Killip class III or more were excluded. The primary outcome was the myocardial salvage index on cardiac magnetic resonance imaging (MRI) performed 5-7 days after the PCI. Cardiac MRI was performed in 35 patients (74%). The myocardial salvage index in the landiolol group was significantly greater than that in the control group (44.4±14.6% vs. 31.7±18.9%, respectively; p=0.04). There were no significant differences in adverse events at 24 h between the landiolol and control groups. A continuous administration of landiolol before a primary PCI may increase the degree of myocardial salvage without additional hemodynamic adverse effects within the first 24 h after STEMI.

The impact of epicardial adipose tissue in patients with acute myocardial infarction

AimsEpicardial adipose tissue (EAT) has been linked to impaired reperfusion success after percutaneous coronary intervention (PCI). Whether EAT predicts myocardial damage in the early phase after acute myocardial infarction (MI) is unclear. Therefore, we investigated whether EAT in patients with acute MI is associated with more microvascular obstruction (MVO), greater ST-deviation, larger infarct size and reduced myocardial salvage index (MSI).Methods and resultsThis retrospective analysis of a prospective observational study including patients with acute MI (n = 54) undergoing PCI and 12 healthy matched controls. EAT, infarct size and MSI were analyzed with cardiac magnetic resonance imaging, conducted 3–5 days and 12 weeks after MI. Patients with acute MI showed higher EAT volume than healthy controls (46 [25.;75. percentile: 37;59] vs. 24 [15;29] ml, p < 0.001). The high EAT group (above median) showed significantly more MVO (2.22 [0.00;5.38] vs. 0.0 [0.00;2.18] %, p = 0.004), greater ST-deviation (0.38 [0.22;0.55] vs. 0.15 [0.03;0.20] mV×10−1, p = 0.008), larger infarct size at 12 weeks (23 [17;29] vs. 10 [4;16] %, p < 0.001) and lower MSI (40 [37;54] vs. 66 [49;88] %, p < 0.001) after PCI than the low EAT group. After accounting for demographic characteristics, body-mass index, heart volume, infarct location, TIMI-flow grade as well as apnea–hypopnea index, EAT was associated with infarct size at 12 weeks (B = 0.38 [0.11;0.64], p = 0.006), but not with MSI.ConclusionsPatients with acute MI showed higher volume of EAT than healthy individuals. High EAT was linked to more MVO and greater ST-deviation. EAT was associated with infarct size, but not with MSI.Graphic abstract

Ischemia From Nonculprit Stenoses Is Not Associated With Reduced Culprit Infarct Size in Patients with ST-Segment-Elevation Myocardial Infarction.

In patients with ST-segment-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention, reperfusion injury accounts for a significant fraction of the final infarct size, which is directly related to patient prognosis. In animal studies, brief periods of ischemia in noninfarct-related (nonculprit) coronary arteries protect the culprit myocardium via remote ischemic preconditioning. Positive fractional flow reserve (FFR) documents functional significant coronary nonculprit stenosis, which may offer remote ischemic preconditioning of the culprit myocardium. The aim of the study was to investigate the association between functional significant, multivessel disease (MVD) and reduced culprit final infarct size or increased myocardial salvage (myocardial salvage index [MSI]) in a large contemporary cohort of STEMI patients. Cardiac magnetic resonance was performed in 610 patients with STEMI at day 1 and 3 months after primary percutaneous coronary intervention. Patients were stratified into 3 groups according to FFR measurements in nonculprit stenosis (if any): angiographic single vessel disease (SVD), FFR nonsignificant MVD (functional SVD), or FFR-significant, functional MVD. A total of 431 (71%) patients had SVD, 35 (6%) had functional SVD, and 144 (23%) had functional MVD. There was no difference in final infarct size (mean infarct size [%left ventricular mass] SVD, 9±3%; functional SVD, 9±3%; and functional MVD, 9±3% [P=0.82]) or in MSI between groups (mean MSI [%left] SVD, 66±23%; functional SVD, 68±19%; and functional MVD, 69±19% [P=0.62]). In multivariable analyses, functional MVD was not associated with larger MSI (P=0.56) or smaller infarct size (P=0.55). Functional MVD in nonculprit myocardium was not associated with reduced culprit final infarct size or increased MSI following STEMI. This is important knowledge for future studies examining a cardioprotective treatment in patients with STEMI, as a possible confounding effect of FFR-significant, functional MVD can be discarded. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01435408 (DANAMI 3-iPOST and DANAMI 3-DEFER) and NCT01960933 (DANAMI 3-PRIMULTI).

Randomized Trial of Interleukin-6 Receptor Inhibition in Patients With Acute ST-Segment Elevation Myocardial Infarction

BackgroundPrompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response. ObjectivesThis study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI. MethodsThe ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days. ResultsWe randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups. ConclusionsTocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703)

Remote ischemic conditioning: Feeling the squeeze

Key Points Adjunctive strategies to primary percutaneous coronary intervention (pPCI) that limit infarct size represent an unmet clinical need. The ability of remote ischemic conditioning to improve clinical outcomes in acute myocardial infarction treated with pPCI is not supported by clinical trials. The current study is consistent and found no improvement in myocardial salvage index by MRI at 6 months in patients with pPCI for anterior STEMI randomized to remote ischemic per‐postconditioning versus sham.

Effect of COMBinAtion therapy with remote ischemic conditioning and exenatide on the Myocardial Infarct size: a two-by-two factorial randomized trial (COMBAT-MI).

Remote ischemic conditioning (RIC) and the GLP-1 analog exenatide activate different cardioprotective pathways and may have additive effects on infarct size (IS). Here, we aimed to assess the efficacy of RIC as compared with sham procedure, and of exenatide, as compared with placebo, and the interaction between both, to reduce IS in humans. We designed a two-by-two factorial, randomized controlled, blinded, multicenter, clinical trial. Patients with ST-segment elevation myocardial infarction receiving primary percutaneous coronary intervention (PPCI) within 6h of symptoms were randomized to RIC or sham procedure and exenatide or matching placebo. The primary outcome was IS measured by late gadolinium enhancement in cardiac magnetic resonance performed 3-7days after PPCI. The secondary outcomes were myocardial salvage index, transmurality index, left ventricular ejection fraction and relative microvascular obstruction volume. A total of 378 patients were randomly allocated, and after applying exclusion criteria, 222 patients were available for analysis. There were no significant interactions between the two randomization factors on the primary or secondary outcomes. IS was similar between groups for the RIC (24 ± 11.8% in the RIC group vs 23.7 ± 10.9% in the sham group, P = 0.827) and the exenatide hypotheses (25.1 ± 11.5% in the exenatide group vs 22.5 ± 10.9% in the placebo group, P = 0.092). There were no effects with either RIC or exenatide on the secondary outcomes. Unexpected adverse events or side effects of RIC and exenatide were not observed. In conclusion, neither RIC nor exenatide, or its combination, were able to reduce IS in STEMI patients when administered as an adjunct to PPCI.