485 Cost-effectiveness of second generation contrast agents in stress echocardiography (original) (raw)
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Myocardial contrast echocardiography in ST elevation myocardial infarction: ready for prime time?
European Heart Journal, 2008
Acute myocardial infarction (AMI) continues to be a significant public health problem in industrialized countries and an increasingly significant problem in developing countries. ST elevation myocardial infarctions (STEMI) constitute 40% of all AMIs with 670,000 cases yearly in the United States alone. The risk of further cardiac complications such as re-infarction, sudden death, and heart failure for those who survive AMI is substantial. Thus, early assessment and risk stratification during the acute phase of STEMI is important. Furthermore, it is essential to assess the efficacy early after any initial therapeutic intervention, not only to facilitate further management, but also to enable development of new treatment algorithms/approaches to further improve the outcome. The aim of reperfusion therapy in AMI is not only to rapidly restore epicardial coronary blood flow but also to restore perfusion at the microcirculatory level. Myocardial contrast echocardiography (MCE) which utilizes microbubbles can assess myocardial perfusion in real time. Its ability to assess myocardial perfusion and function in one examination allows it to ascertain the extent of myocardial reperfusion achieved in the risk area. Furthermore, in stable patients after AMI, MCE allows assessment of LV function, residual myocardial viability, and ischaemia which are all powerful prognostic markers of outcome. Its portability, rapid acquisition and interpretation of data, and the absence of radiation exposure make it an ideal bedside technique.
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
Journal of Nuclear Cardiology, 1997
We sought to compare myocardial contrast echocardiography with low dose dobutamine echocardiography for predicting 1-month recovery of ventricular function in acute myocardial infarction treated with primary coronary angioplasty. The relation between myocardial perfusion and contractile reserve in patients with acute myocardial infarction, in whom anterograde flow is fully restored without significant residual stenosis, is still unclear. Thirty patients with acute myocardial infarction treated successfully with primary coronary angioplasty underwent intracoronary contrast echocardiography before and after angioplasty and dobutamine echocardiography 3 days after the index infarction. One month later, two-dimensional echocardiography and coronary angiography were repeated in all patients and contrast echocardiography in 18 patients. After coronary recanalization, 26 patients showed myocardial reperfusion within the risk area, although 4 did not. At 1-month follow-up, all patients had a patient infarct-related artery without significant restenosis. Both left ventricular ejection fraction and wall motion score index within the risk area significantly improved in the patients with reperfusion ([mean +/- SD] 38 +/- 8% vs. 48 +/- 12%, p < 0.005; and 2.35 +/- 0.5 vs. 2 +/- 0.6, p < 0.001, respectively), but not in those with no reflow. Of the 72 nonperfused segments before angioplasty, 27 showed functional improvement at follow-up. Myocardial contrast echocardiography had a sensitivity and a negative predictive value similar to dobutamine echocardiography in predicting late functional recovery (96% vs. 89% and 89% vs. 93%, respectively), but a lower specificity (18% vs. 91%, p < 0.001), positive predictive value (41% vs. 86%, p < 0.001) and overall accuracy (47% vs. 90%, p < 0.001). Microvascular integrity is a prerequisite for myocardial viability after acute myocardial infarction. However, contrast enhancement shortly after recanalization does not necessarily imply a late functional improvement. Thus, contractile reserve elicited by low dose dobutamine is a more accurate predictor of regional functional recovery after reperfused acute myocardial infarction than microvascular integrity.
Assessment of myocardial perfusion by contrast echocardiography
Revista portuguesa de cardiologia : orgão oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology, 2001
Contrast echocardiography delineates myocardial perfusion and has the potential for quantitating coronary flow and assessing myocardial viability. These applications add important physiologic information to the anatomic information readily available from conventional echocardiography. Because it can be rapidly performed at the bedside, contrast echocardiography may be valuable tool for the use in acute myocardial ischemia. When contrast echocardiography has been used after recanalization of occluded coronary arteries, the assessment of myocardial salvage conveys information concerning reflow, stunning, and prognosis, and in the case of angioplasty it provides immediate information regarding the success of the procedure. Contrast echocardiography can also assess myocardial areas at risk of irreversible damage and the presence or absence of collateral flow. Myocardial contrast echocardiography is a rapidly changing field and with the continued development of newer contrast agents and ...
Heart, 2005
To assess the role of intravenous myocardial contrast echocardiography (MCE) in predicting functional recovery and regional or global left ventricular (LV) remodelling after acute myocardial infarction (AMI) compared with low dose dobutamine stress echocardiography (LDSE). Methods: 21 patients with anterior AMI and successful primary angioplasty underwent MCE and LDSE during the subacute stage (2-4 weeks after AMI). Myocardial perfusion and contractile reserve were assessed in each segment (12 segment model) with MCE and LDSE. The 118 dyssynergic segments in the subacute stage were classified as recovered, unchanged, or remodelled according to wall motion at six months' follow up. Percentage increase in LV end diastolic volume (%DEDV) was also calculated. Results: The presence of perfusion was less accurate than the presence of contractile reserve in predicting regional recovery (55% v 81%, p , 0.0001). However, the absence of perfusion was more accurate than the absence of contractile reserve in predicting regional remodelling (83% v 48%, p , 0.0001). The number of segments without perfusion was an independent predictor of %DEDV, whereas the number of segments without contractile reserve was not. The area under the receiver operating characteristic curve showed that the number of segments without perfusion predicted substantial LV dilatation (%DEDV. 20%) more accurately than did the number of segments without contractile reserve (0.88 v 0.72). Conclusion: In successfully revascularised patients with AMI, myocardial perfusion assessed by MCE is predictive of regional and global LV remodelling rather than of functional recovery, whereas contractile reserve assessed by LDSE is predictive of functional recovery rather than of LV remodelling.
Role of echocardiography in acute coronary syndromes
Heart, 2002
The term "acute coronary syndrome" covers a spectrum of presentations, from unstable angina through to ST segment elevation myocardial infarction. There have been remarkable changes in the management of these conditions in the past two decades. With increasing emphasis on early reperfusion and prevention of left ventricular remodelling, echocardiography is assuming a prominent role in this area. It is non-invasive and relatively cheap, and is an ideal portable imaging technique. Newer imaging modalities, including myocardial contrast echo for the assessment of perfusion, hold great promise.
2002
The aim of this study was to assess the role of intravenous myocardial contrast echocardiography (IMCE) in the prediction of left ventricular (LV) remodeling in patients with acute myocardial infarction (AMI). Sixty-three patients with AMI, who were successfully treated with acute coronary angioplasty, underwent IMCE and lowdose dobutamine echocardiography during hospital admission. IMCE was graded semiquantitatively on a score of 0 (no visible contrast effect), 0.5 (patchy myocardial contrast enhancement), and 1 (homogenous contrast effect). Patients were considered to have microvascular impairment if <50% of segments within the infarctrelated area had score of 1. A mean perfusion score index was calculated for each patient. Patients with a good perfusion at IMCE (IMCE؉) showed a lower creatine kinase peak (p ؍ 0.001) and lower creatine kinase-MB (p ؍ 0.01), and a better baseline regional contractile function compared with patients who had negative results at IMCE (IMCE؊)( p<0.0001) and a higher amount of myocardial viability at low-dose dobutamine echocardiography (p ؍ 0.03). At follow-up, a higher improvement in regional systolic function (p ؍ 0.0006) was observed in IMCE؉ patients, whereas IMCE؊ patients showed an evident increase in LV enddiastolic volume from baseline to 6-month follow-up (p <0.0001), implying LV remodeling, which has been associated with a higher incidence of adverse cardiac events (p ؍ 0.005). By stepwise multiple regression analysis, microvascular impairment at IMCE was a significant independent predictor of LV remodeling (p <0.0001). Thus, IMCE seems to be an important diagnostic tool, able to predict LV remodeling in patients with AMI. ᮊ2002 by Excerpta Medica, Inc.