Intra-Aortic Balloon Counter Pulsation After Primary Percutaneous Coronary Intervention and Suboptimal Coronary Flow: Higher Flow Predict Higher Left Ventricular Systolic Function (original) (raw)
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Intra-aortic balloon pumping: effects on left ventricular diastolic function
European Journal of Cardio-Thoracic Surgery, 2003
Objective: The intra-aortic balloon pump is the most widely used form of temporary cardiac assist and often utilised in patients before and after cardiac surgery. Several effects of balloon counter-pulsation have been reported previously, but its effect on left ventricular diastolic function has not been thoroughly investigated. The aim of this study is to examine the effect of the intra-aortic balloon pump on left ventricular wall motion and transmitral flow. Methods: We studied 20 patients in the intensive care unit, less than 36 h following cardiac surgery. We recorded left anterior descending coronary artery and transmitral E-wave flow velocities using transesophageal echocardiography pulsed Doppler. We also recorded left ventricular long axis free-wall movement using M-mode. The intra-aortic balloon pump was set to full augmentation and recordings were made at pumping cycles 1:1, 1:2, 1:3, and when the pump was on stand-by, leaving a minimum of 5 min between the pumping modes to allow the return to control conditions. In order to eliminate time effects, the sequence of recording was varied between patients using a 4 by 4 Latin-square. Results: The peak diastolic left anterior descending coronary artery and transmitral E-wave flow velocities, and left ventricular free-wall early diastolic lengthening velocity increased significantly with intra-aortic balloon pumping cycles 1:1, 1:2 and 1:3 compared to their value with the pump on stand-by, all P , 0:001. The increase in peak transmitral E-wave flow velocity correlated with the increase in peak left anterior descending coronary artery diastolic flow velocity (r ¼ 0:74, P ¼ 0:02), and with the increase in left ventricular free-wall early diastolic lengthening velocity (r ¼ 0:80, P , 0:001). Conclusion: Using the intra-aortic balloon pump post-cardiac surgery significantly increases peak diastolic left anterior descending coronary artery flow velocities and left ventricular free-wall early diastolic lengthening velocity, whose increase explains the increase in peak transmitral E-wave velocity. Although coronary flow is epicardial and mitral flow is intracardial, their close relationship suggests an improvement in left ventricular diastolic function with intra-aortic balloon pump. q
PloS one, 2015
Intraaortic balloon pump counterpulsation (IABP) is often used in patients with acute coronary syndrome for its favourable effects on left ventricular (LV) systolic function and coronary perfusion. However, the effects of IABP on LV diastolic function have not been comprehensively investigated. Acute diastolic dysfunction has been linked to increased morbidity and mortality. The aim of this study was to examine the influence of IABP on LV diastolic dysfunction using standard TEE derived parameters. Intraoperative TEE was performed in 10 patients (mean age 65 ± 11 yrs) undergoing urgent coronary artery bypass graft surgery (CABG), who had received an IABP preoperatively. TEE derived measures of diastolic dysfunction included early to late transmitral Doppler inflow velocity ratio (E/A), deceleration time (Dt), pulmonary venous systolic to diastolic Doppler velocity ratio (S/D), transmitral propagation velocity (Vp), and the ratio of early to late mitral annular tissue Doppler velocit...
Echocardiography, 2016
Background: Myocardial stunning is responsible for partially reversible left ventricular (LV) systolic dysfunction after successful primary percutaneous coronary intervention (PPCI) in patients with acute ST-elevation myocardial infarction (STEMI). Aim: To test the hypothesis that early coronary blood flow (CBF) to LV systolic function ratios, as an equivalent to LV stunning index (SI), predict recovery of LV systolic function after PPCI in patients with acute STEMI. Methods: Twenty-four patients with acute anterior STEMI who had successful PPCI were evaluated and compared to 96 control subjects. Transthoracic echocardiography with measurement of LV ejection fraction (EF), LV, and left anterior descending (LAD) coronary artery area wall-motion score index (WMSI) as well as Doppler sampling of LAD blood velocities, early after PPCI and 5 days later, were performed. SI was evaluated as the early ratio of CBF parameters in the LAD to LV systolic function parameters. Results: Early SI-LVEF well predicted late LVEF (r=.51, P<.01) and the change in LVEF (r=.48, P<.017). Early SI-LVMSI predicted well late LVEF (r=.56, P<.006) and the change in LVEF (r=.46, P<.028). Early SI-LADWMSI predicted late LVEF (r=.44, P<.028). Other SI indices measured as other LAD-CBF to LV systolic function parameters were not predictive of late LV systolic function. Conclusions: LV stunning indices measured as early LAD flow to LVEF, LVWMSI, and LADWMSI ratios well predicted late LVEF and the change in LVEF. Thus, greater early coronary artery flow to LV systolic function parameter ratios predict a better improvement in late LV systolic function after PPCI.
Journal of Evidence Based Medicine and Healthcare, 2020
BACKGROUND Although percutaneous coronary intervention (PCI) is an excellent therapy for coronary artery disease, the effects of PCI on left ventricular diastolic function have not been systematically investigated in patients of Acute ST Elevation Myocardial Infarction (STEMI) in our population. The aim of this study was to investigate the reversibility of these diastolic abnormalities and improvement in left ventricular diastolic function by using echocardiographic diastolic parameters in patients with Acute STEMI in the setting of PCI and thus determine the effects of improved myocardial perfusion on impaired left ventricular diastolic abnormalities. METHODS A total of 100 consecutive patients admitted to Intensive Coronary Care Unit (ICCU), was included in the study. Echocardiography was done before PCI and 48 hours after PCI, to evaluate the indices of LV diastolic function in these patients. RESULTS The mean age of the patients was 52.04 ± 9.49 years, and majority of patients were males (84%). All had mild to moderate degree of left ventricular diastolic dysfunction. Mitral E wave velocity (63.41 cm/s ± 19.93 before treatment versus 71.51 cm/s ± 9.56, 48 hours after treatment), the peak velocity of late filling due to atrial contraction (mitral A wave velocity) (75.93 cm/s ± 20.3 before treatment vs. 78.96 cm/s ± 24.18, 48 hours after treatment), E/A ratio (1.03 ± 0.3 before treatment vs. 0.98 ± 0.24, 48 hours after treatment) showed improvement after PCI. After PCI deceleration time (DT) decreased (210.15 msec ± 47.43 before treatment versus 201.64 msec ± 28.15, 48 hours after treatment), and the difference was statistically significant (p<0.001). It is notable that early diastolic mitral annular velocity (E') improved significantly 48 hours after PCI (5.81 cm/s ± 1.65 before treatment vs. 7.96 cm/s ± 1.95, 48 hours after treatment, p < 0.001). E/ E2 ratio showed significant change 48 hours after PCI; it was statistically significant (10.17 ± 2.26 before treatment vs. 8.83 ± 1.7, 48 hours after treatment p<0.001). CONCLUSIONS Improvement in some indices of left ventricular diastolic function after PCI suggests that PCI can be an effective modality of treatment for diastolic dysfunction caused by myocardial ischemia and revascularization can restore diastolic properties of the heart after the insult in STEMI patients and thus prevent their progression to HFPEF.
The American Journal of Cardiology, 2011
Measurement of left ventricular end-diastolic pressure (LVEDP) is readily obtainable in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, the prognostic utility of LVEDP during primary PCI has never been studied. LVEDP was measured in 2,797 patients during primary PCI in the Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial. Outcomes were assessed at 30 days and 2 years stratified by medians of LVEDP. Multivariable analysis was performed to determine whether LVEDP was an independent determinate of adverse outcomes. The median (interquartile range) for LVEDP was 18 mm Hg (12 to 24). For patients with LVEDP &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;18 mm Hg versus those with ≤18 mm Hg, hazard ratios (95% confidence intervals) for death and death or reinfarction at 30 days were 2.00 (1.20 to 3.33, p = 0.007) and 1.84 (1.24 to 2.73, p = 0.002), respectively, and at 2 years were 1.57 (1.12 to 2.21, p = 0.009) and 1.45 (1.14 to 1.85, p = 0.002), respectively. Patients in the highest quartile of LVEDP (≥24 mm Hg) were at the greatest risk of mortality. Only a weak correlation was present between LVEDP and left ventricular ejection fraction (LVEF; R(2) = 0.03, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). By multivariable analysis increased LVEDP was an independent predictor of death or reinfarction at 2 years (hazard ratio 1.20, 95% confidence interval 1.02 to 1.42, p = 0.03) even after adjustment for baseline LVEF. In conclusion, baseline increased LVEDP is an independent predictor of adverse outcomes in patients with STEMI undergoing primary PCI even after adjustment for baseline LVEF. Patients with LVEDP ≥24 mm Hg are at the greatest risk for early and late mortality.
Journal of the American Society of Echocardiography, 2005
Background : Isovolumic acceleration (IVA) obtained by tissue Doppler echocardiography (TDE) is a sensitive and relatively load-independent index for assessing systolic ventricular function. IVA also has the ability to describe the force-frequency relationship during incremental atrial pacing in vivo. Objective : We sought to assess the ability of IVA to detect global left ventricular (LV) dysfunction induced by coronary constriction. Methods : In 6 open-chest anesthetized pigs we examined right ventricular and LV long-axis function by TDE (4-chamber view) with simultaneous invasive measurements of intraventricular pressure, maximum dP/dt, minimum dP/dt, and by microtip catheter. A pneumatic cuff was placed around the proximal portion of left anterior descending coronary artery (LAD) and distal flow was monitored by transonic flow probe. Mean arterial pressures were monitored by indwelling cannula. Baseline studies assessed force-frequency relationships with TDE and invasive measurements during incremental pacing from 100 to 200/min (20/min increments every 10 minutes). The protocol was repeated 10 minutes after balloon inflation to reduce LAD blood flow by 50%. Results : Compared with baseline, LV pressure decreased significantly (P ؍ .03, 2-way analysis of variance) as did maximum dP/dt (P < .004) with LAD constriction. At the same time IVA and isovolumic velocity at the LV free wall were significantly reduced (P < .002 and P ؍ .04, respectively) and both IVA and isovolumic velocity were correlated with dP/dt (r ؍ 0.45, P < .002, and r ؍ 0.35, P < .02, respectively). TDE systolic indices were unchanged in the right ventricle. Conclusion : IVA detects changes in global LV systolic function during LAD constriction and may be a useful clinical tool to diagnose ischemia.
Journal of Cardiovascular Magnetic Resonance, 2009
Introduction: Prophylactic implantation of a cardioverter/ defibrillator (ICD) has been shown to reduce mortality in patients with chronic myocardial infarction (CMI) and an increased risk for life threatening ventricular arrhythmia (VA). The use of ICDs in this large patient population is still limited by high costs and possible adverse events including inappropriate discharges and progression of heart failure. VA is related to infarct size and seems to be related to infarct morphology. Contrast enhanced cardiovascular magnetic resonance imaging (ceCMR) can detect and quantify myocardial fibrosis in the setting of CMI and might therefore be a valuable tool for a more accurate risk stratification in this setting. Hypothesis: ceCMR can identify the subgroup developing VA in patients with prophylactic ICD implantation following MADIT criteria. Methods: We prospectively enrolled 52 patients (49 males, age 69 ± 10 years) with CMI and clinical indication for ICD therapy following MADIT criteria. Prior to implantation (36 ± 78 days) patients were investigated on a 1.5 T clinical scanner (Siemens Avanto © , Germany) to assess left ventricular function (LVEF), LV end-diastolic volume (LVEDV) and LV mass (sequence parameters: GRE SSFP, matrix 256 × 192, short axis stack; full LV coverage, no gap; slice thickness 6 mm). For quantitative assessment of infarct morphology late gadolinium enhancement (LGE) was performed including measurement of total and relative infarct mass (related to LV mass) and the degree of transmurality (DT) as defined by the percentage of transmurality in each scar. (sequence parameters: inversion recovery gradient echo; matrix 256 × 148, imaging 10 min after 0.2 μg/kg gadolinium DTPA; slice orientation equal to SSFP). MRI images were analysed using dedicated software (MASS © , Medis, Netherlands). LGE was defined as myocardial areas with signal intensity above the average plus 5 SD of the remote myocardium. After implantation, patients were followed up including ICD readout after 3 and than every 6 months for a mean of 945 ± 344 days. ICD data were evaluated by an experienced electrophysiologist. Primary endpoint was the occurrence of an appropriate discharge (DC), antitachycard pacing (ATP) or death from cardiac cause. Results: The endpoint occurred in 10 patients (3 DC, 6 ATP, 1 death). These patients had a higher relative infarct mass (28 ± 7% vs. 22 ± 11%, p = 0.03) as well as high degree of transmurality (64 ± 22% vs. 44 ± 25%, p = 0.05). Their LVEF (29 ± 8% vs. 30 ± 4%, p = 0.75), LV mass (148 ± 29 g vs. 154 ± 42 g, p = 0.60), LVEDV (270 ± 133 ml vs. 275 ± 83 ml, p = 0.90) or total infarct mass (43 ± 19 g vs. 37 ± 21 g, p = 0.43) were however not significant from the group with no events. In a cox proportional hazards regression model including LVEF, LVEDV, LV mass, DT and age, only degree of transmurality and relative infarct mass emerged as independent predictors of the primary end point (p = 0.009). Conclusion: In CMI-patients fulfilling MADIT criteria ceCMR could show that the extent and transmurality of myocardial scarring are independent predictors for life threatening ventricular arrhythmia or death. This additional information could lead to more precise risk stratification and might reduce adverse events and cost of ICD therapy in this patient population. Larger trials are needed to confirm this finding.
Global Heart, 2014
for diabetes. Its prognostic value compared to fasting blood glucose (BSL) in patients with ST-elevation myocardial infarction (STEMI) is unknown. Objectives: Compare HbA1c and fasting BSL for left ventricular (LV) diastolic function and filling pressures after STEMI. Methods: A total of 142 (61.8AE12.1 years, 74.6% male) first STEMI patients were prospectively recruited. LV diastolic function was defined as the mean septal and lateral early diastolic velocities (average e') by pulsed wave tissue Doppler, and filling pressure was the ratio of transmitral early diastolic velocity to average e' (average E/e'). Results: Mean HbA1c and fasting BSL were 6.5AE1.6% and 7.7AE2.8mmol/L respectively. Between diabetics and non-diabetics, there were no differences in the rates of coronary angioplasty (p¼0.50), bypass surgery (p¼0.39), LV end-diastolic volume (EDV, 116AE37 vs. 118AE43mL, p¼0.78), end-systolic volume (ESV, 69AE33 vs. 68AE35mL, p¼0.93), ejection fraction (EF, 42AE12 vs. 44AE11%, p¼0.49). On multivariable analyses, average e' was independently associated with age (b¼-0.283, r¼0.001), LVEF (b¼0.211, r¼0.013) and HbA1c (b¼-0.173, p¼0.034), but not BSL (p¼0.83). Similarly, average E/e' was independently associated with age (b¼0.290, p<0.001), LVEF (b¼-0.201, p¼0.018) and HbA1c (b¼0.240, p¼0.003), but not BSL (p¼0.07). ROC analysis showed that an optimal HbA1c cutoff of 6.4% (AUC¼0.68, p¼0.002) was associated with an elevated LV filling pressure (average E/e' !13). Conclusion: HbA1c, not fasting BSL is independently associated with impaired LV diastolic function and increased filling pressures after STEMI.
Artificial Organs, 2008
Our aim was to evaluate the effects of intraaortic balloon pumping (IABP) on the blood velocity waveform in the absence or presence of coronary artery stenosis. Using anesthetized open-chest dogs, the septal arterial blood flow velocities were measured with a 20 MHz 80-channel ultrasound pulsed Doppler velocimeter in the absence (n = 5) or presence (n = 3) of left main coronary artery stenosis. The blood velocity waveform was analyzed by calculating the systolic retrograde velocity integral (SR) and the diastolic antegrade velocity integral (DA). A slosh ratio was defined as SWDA. The left anterior descending arterial flow (CBF), aortic pres-