Assessment of no-reflow phenomenon after acute myocardial infarction with harmonic angiography and intravenous pump infusion with Levovist: Comparison with intracoronary contrast injection (original) (raw)
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Usefulness of Myocardial Contrast Echocardiography Early After Acute Myocardial Infarction
Echocardiography, 2006
Objectives: (1) Evaluate wall motion and perfusion abnormalities after reperfusion therapy of the culprit lesion, (2) delineate the ability of myocardial contrast echocardiography (MCE) to evaluate the microvasculature after reperfusion, in order to distinguish between stunning and necrosis in the risk area. Methods: We analyzed 446 segments from 28 patients, 10 normal controls (160 segments), and 18 with a first AMI (286 segments). MCE was obtained with Optison and a two-dimensional echocardiography was performed at 3 months post acute myocardial infarction (AMI). Results: In the group with AMI, we analyzed 286 segments, of which 107 had wall motion abnormalities (WMA) related to the culprit artery. Two subgroups were identified: Group I with WMA and normal perfusion (50 segments, 47%) and Group II with WMA and perfusion defects (57 segments, 53%). According to the 2D echocardiogram at 3 months, they were further subdivided into: Group IA: with wall motion improvement (stunning): 18 segments, 36%, Group IB: without wall motion improvement: 32 segments, 64%, Group IIA: with wall motion improvement: 12 segments, 21%, Group IIB: without wall motion improvement (necrosis): 45 segments, 79%. Conclusions: (1) The presence of myocardial perfusion in segments with WMA immediately after AMI reperfusion therapy predicts viability in most patients. Conversely, the lack of perfusion is not an absolute indicator of the presence of necrosis. (2) Perfusion defects allow to detect patients with thrombolysis in myocardial infarction (TIMI) 3 flow and "noreflow" phenomenon who will not show improved wall motion in the 2D echocardiogram. However, some patients with initial no-reflow could have microvascular stunning and their regional contractile function will normalize after a recovery period. (ECHOCARDIOGRAPHY, Volume 23, March 2006) myocardial contrast echocardiography, acute myocardial infarction, reperfusion, microcirculation, stunning
European Heart Journal, 1996
Myocardial contrast echocardiography is a technique used in experimental and clinical settings in order to visualize the pattern of intramyocardial perfusion. In the acute phase of myocardial infarction, regional absence of flow during myocardial contrast echocardiography delineates the area at risk of necrosis, while the definitive non-perfused area expresses infarct size. Reopening the infarct-related artery, which may be achieved spontaneously by thrombolysis or percutaneous transluminal coronary angioplasty, is not a reliable indicator of intramyocardial reperfusion. If myocardial ischaemia due to coronary occlusion has been sufficiently prolonged and severe, not only myocyte viability, but also microvascular integrity is lost. Myocardial contrast echocardiography, using intracoronary injection of sonicated contrast medium, gives information about microvascular integrity and the effective presence of intramyocardial reflow. Anatomical integrity of microvasculature does not necessarily imply preserved function, and thus the microvessel vasodilating reserve may also be impaired. Myocardial contrast echocardiography has the potential to assess alterations in microvascular function, showing, in the myocardial area with reduced coronary reserve, a relatively reduced increase in echocontrast signal intensity when an intravenous vasodilator agent is administered.
Revista Espanola De Cardiologia, 2004
We analyzed the safety and feasibility of myocardial echocardiography with intracoronary injection of contrast, its effect on left ventricular remodeling and systolic function, and its relationship with angiography and magnetic resonance imaging (MRI) for the evaluation of post-infarction coronary microcirculation.Thirty patients with a first ST-elevation myocardial infarction and a patent infarct-related artery were studied. Mean perfusion score of the infarcted area was analyzed with myocardial echocardiography. TIMI and Blush grades (angiography) were determined. Mean perfusion score (MRI-perfusion), end-diastolic volume index and ejection fraction were determined with MRI. At 6 months all studies were repeated in the first 17 patients.Forty-seven perfusion studies (30 in the first week and 17 after 6 months) were done without complications (6 [2] min per myocardial echocardiography study). Normal perfusion (myocardial echocardiography 0.75) was detected in 67% of the patients. Myocardial echocardiography was the best predictor of end-diastolic volume (r=-0.69; P = .002) and ejection fraction (r=0.72; P = .001) after 6 months. Normal perfusion was observed in 80% of the patients with TIMI grade 3, and in 14% of those with TIMI grade 2. Of the 40 studies in patients with TIMI grade 3, normal perfusion was seen in 85% of the patients with Blush grade 2-3 and in 50% of those with Blush 0-1. Perfusion was also normal in 90% of the patients with MRI-perfusion =1 and in 62% of those with MRI-perfusion <1.Myocardial echocardiography is a feasible and relatively rapid technique with no side effects. This technique provided the most reliable perfusion index for predicting late left ventricular remodeling and systolic function. To achieve normal perfusion, TIMI grade 3 is necessary but does not guarantee success. In patients with TIMI grade 3, a normal Blush score or a normal MRI-perfusion study suggests good reperfusion.Analizamos la aplicabilidad y seguridad de la ecografía miocárdica con inyección intracoronaria de contraste, su papel en la remodelación ventricular y en la función sistólica, así como su relación con la angiografía y la resonancia magnética para valorar la microcirculación coronaria postinfarto.Se estudió a 30 pacientes con un primer infarto de miocardio con elevación del segmento ST y arteria responsable abierta. Con inyección intracoronaria de contraste se determinó la puntuación media de perfusión en la zona infartada. Mediante angiografía se cuantificaron los grados TIMI y Blush. Se utilizó la resonancia magnética para determinar la puntuación media de perfusión (RM-perfusión), el índice de volumen telediastólico y la fracción de eyección. Al sexto mes se repitieron todas las exploraciones en los primeros 17 pacientes.Se realizaron 47 estudios de perfusión (30 en la primera semana y 17 en el sexto mes) sin complicaciones (6 ± 2 min por estudio de inyección intracoronaria de contraste). Se observó una perfusión normal (inyección intracoronaria de contraste > 0,75) en el 67% de los casos. La inyección intracoronaria de contraste fue el mejor predictor de volumen telediastólico (r = -0,69; p = 0,002) y de fracción de eyección (r = 0,72; p = 0,001) al sexto mes. Hubo perfusión normal en el 80% de los casos con TIMI 3 y en el 14% de los casos con TIMI 2. Entre los 40 estudios con TIMI 3 se observó una perfusión normal en el 85% de casos con un índice de Blush de 2-3 y en el 50% de aquellos con un índice de Blush de 0-1, así como en el 90% de casos con RM-perfusión = 1 y en el 62% con RM-perfusión < 1.La inyección intracoronaria de contraste es factible con un escaso consumo de tiempo y sin efectos secundarios; asimismo, fue el índice de perfusión más fiable para predecir la remodelación y la función sistólica tardía. Para lograr una perfusión normal es indispensable (aunque no una garantía) que el paciente se encuentre con flujo TIMI 3. En los casos con TIMI 3, la normalidad en el índice Blush o en el estudio de perfusión con resonancia magnética sugiere una buena reperfusión.
The American Journal of Cardiology, 2004
Clinical evaluation of arterial patency in acute ST-elevation myocardial infarction (STEMI) is unreliable. We sought to identify infarction and predict infarct-related artery patency measured by the Thrombolysis In Myocardial Infarction (TIMI) score with qualitative and quantitative intravenous myocardial contrast echocardiography (MCE). Thirty-four patients with suspected STEMI underwent MCE before emergency angiography and planned angioplasty. MCE was performed with harmonic imaging and variable triggering intervals during intravenous administration of Optison. Myocardial perfusion was quantified offline, fitting an exponential function to contrast intensity at various pulsing intervals. Plateau myocardial contrast intensity (A), rate of rise (), and myocardial flow (Q ؍ A ؋ ) were assessed in 6 segments. Qualitative assessment of perfusion defects was sensitive for the diagnosis of infarction (sensitivity 93%) and did not differ between anterior and inferior infarctions. However, qualitative assessment had only moderate specificity (50%), and perfusion defects were unrelated to TIMI flow. In patients with STEMI, quantitatively derived myocardial blood flow Q (A ؋ ) was significantly lower in territories subtended by an artery with impaired (TIMI 0 to 2) flow than those territories supplied by a reperfused artery with TIMI 3 flow (10.2 ؎ 9.1 vs 44.3 ؎ 50.4, p ؍ 0.03). Quantitative flow was also lower in segments with impaired flow in the subtending artery compared with "normal" patients with TIMI 3 flow (42.8 ؎ 36.6, p ؍ 0.006) and all segments with TIMI 3 flow (35.3 ؎ 32.9, p ؍ 0.018). An receiveroperator characteristic curve derived cut-off Q value of <11.3, representing impaired myocardial flow, was 73% sensitive and 67% specific for TIMI <3 flow at angiography. Thus, qualitative MCE identifies patients with STEMI but provides no information regarding infarct-related artery patency, whereas quantitative MCE can predict impaired flow in patients with acute STEMI. ᮊ2004 by Excerpta Medica, Inc.