Background-We hypothesized that preserved microvascular integrity in the area at risk would favorably influence left ventricular (LV) remodeling and long-term outcome after acute myocardial infarction. Methods and Results-Before and after successful primary angioplasty (percutaneous transluminal coronary angioplasty[PTCA]), 124 patients with acute myocardial infarction underwent intracoronary myocardial contrast echo (MCE). An MCE score index (MCESI) was derived by averaging the single-segment score (0ϭnot visible, 1ϭpatchy, 2ϭhomo-geneous contrast effect) within the area at risk. An MCESI Ն1 was considered adequate reperfusion. Mean follow-up was 46Ϯ32 months. After PTCA, 100 patients showed adequate reperfusion (no microvascular dysfunction, NoMD), whereas 24 did not (MD

Background-We prospectively evaluated the prevalence, pattern, and prognostic impact of left ventricular (LV) remodeling after acute myocardial infarction (AMI) successfully treated with primary PTCA. The prevalence, course, and prognostic value of LV remodeling after primary PTCA are still to be clarified. Methods and Results-In 284 consecutive patients with AMI treated with primary PTCA, serial echocardiographic and angiographic studies, within 24 hours (T1), at 1 (T2) and 6 months (T3) after AMI were performed. Long-term (61Ϯ14 months) clinical follow-up data were collected for 98.6% patients enrolled in the study. Overall, 85 (30%) patients showed LV dilation (Ͼ20% end-diastolic volume increase) at T3 as compared with T1. Early (from T1 to T2), late (from T2 to T3), and progressive dilation patterns (from T1 to T2 to T3) were detected in 42 (15%), 41 (14%), and 36 (13%) patients, respectively. Cardiac death and combined events rate was significantly higher among patients with than among those without LV dilation (Pϭ0.005 and Pϭ0.025, respectively). The pattern of LV dilation during 6 months did not significantly affect survival. Cox survival analysis identified end-systolic volume at T1 and age as baseline predictors and end-systolic volume at T3 and age as 6-month predictors of cardiac death, respectively. Conclusions-LV remodeling after successful PTCA occurs despite sustained patency of the infarct-related artery and preservation of regional and global LV function. LV dilation at 6 months after AMI but not the specific pattern of LV dilation is clearly associated with worse long-term clinical outcome.

No abstract

This randomized trial compared rheolytic thrombectomy before direct infarct artery stenting with direct infarct artery stenting alone in 100 patients with a first acute myocardial infarction (AMI). The primary end point of the study was early ST-segment elevation resolution, and the secondary end points were corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, infarct size, and 1-month clinical outcome. The primary end point rates were 90% in the thrombectomy group and 72% in the placebo group (p ‫؍‬ 0.022). Randomization to thrombectomy was independently related to the primary end point (odds ratio 3.56, p ‫؍‬ 0.032). M acro-and microembolization during percutaneous coronary intervention (PCI) is frequent and may result in the obstruction of the microvessel coronary network. 1 In the setting of acute myocardial infarction (AMI), PCI-related embolization results in a decreased efficacy of mechanical reperfusion and myocardial salvage. Direct stenting without predilation may decrease embolization and the incidence of the no-reflow phenomenon. 2,3 More specific approaches to the problem of microvessel embolization during PCI include thrombectomy by different techniques and the use of anti-embolic protection devices. One randomized trial has reported rheolytic thrombectomy to be effective in decreasing embolization in patients who underwent PCI on venous grafts or native coronary vessel with massive thrombosis 4 ; however, few data exist on the effectiveness of rheolytic thrombectomy in the setting of AMI. 5,6 This randomized trial assessed the efficacy of rheolytic thrombectomy before direct infarct artery stent implantation in patients who underwent PCI for AMI.• • • Criteria for enrollment included chest pain persisting Ͼ30 minutes associated with an ST-segment elevation of Ն0.1 mV in Ն2 contiguous electrocardiographic leads. The exclusion criteria included (1) previous myocardial infarction, (2) administration of fibrinolytic therapy, (3) bundle branch block or ventricular pacing on the baseline electrocardiogram preventing analysis of the ST-segment changes, (4) infarct-related artery (IRA) diameter Ͻ2.5 mm on visual angiographic assessment, and (5) inability to obtain informed consent. Patients with cardiogenic shock due to predominant ventricular failure were included, as were patients with high-risk coronary anatomy. After coronary angiography, eligible patients were randomly assigned to direct IRA stenting alone or thrombectomy before stenting. Computer-generated sequences and assignments using a closed envelope system were used to perform randomization. Thrombectomy was accomplished with the second-generation rheolytic thrombectomy 4Fr catheter (AngioJet, Possis Medical, Minneapolis, Minnesota). Two types of stents were used: a tubular closed-cell carbon-coated stent (Techno, Sorin, Saluggia, Italy) and a tubular open-cell stent (Zeta, Guidant, Santa Clara, California). All patients received abciximab (ReoPro, Centocor, Malvern, Pennsylvania), if not contraindicated, immediately before the ...

After reperfused AMI, the degree of left ventricular dilation, when it occurs, is inversely related to the extent of residual myocardial viability in the infarct zone. Thus, the absence of residual infarct-zone viability discriminates patients who develop progressive left ventricular dilation after reperfused AMI from those who maintain normal left ventricular geometry.