Pre-revascularization coronary wedge pressure as marker of adverse long-term left ventricular remodelling in patients with acute ST-segment elevation myocardial infarction

Abstract

The aim of this study was to investigate the relationship between coronary wedge pressure (CWP), measured as a marker of pre-procedural microvascular obstruction, and left ventricular remodelling in high-risk ST-segment elevation myocardial infarction (STEMI) patients. Pre-revascularization CWP was measured in 25 patients with high-risk anterior STEMI. Left ventricular volumes and ejection fraction were echocardiographically measured at discharge and at follow-up. A 20% increase in left ventricular volumes was used to define remodelling. Patients with CWP ≤ 38 mmHg were characterized by late ventricular remodelling. Patients with CWP > 38 mmHg developed a progressive remodelling process which was associated with a significant 60 months increase in left ventricular volumes (P = 0.01 for end-systolic volume and 0.03 for end-diastolic volume) and a significant decrease in left ventricular ejection fraction (P = 0.05). A significant increase in both left ventricular end-systolic (P = 0.009) and end-diastolic volume (P = 0.02) from baseline to 60 months follow-up was recorded in patients with extracted thrombus length ≥2 mm. Pre-revascularization elevated CWP was associated with increased left ventricular volumes and decreased ejection fraction at long-term follow-up. CWP was a predictor of severe left ventricular enlargement, besides extracted thrombus quantity.Infarct size, microvascular obstruction (MVO) and most probably inflammation are important determinants of left ventricular remodelling after acute ST-segment elevation myocardial infarction (STEMI). Left ventricular remodelling is an important factor in the development of heart failure and a predictor of mortality [1][2][3] . Detection and treatment of MVO during acute STEMI is of the utmost importance since it frequently occurs even after timely culprit artery revascularization [1][2][3] . None of the prophylactic and therapeutic approaches available are effective for MVO treatment 3,4 . Recently, it has also been observed that intracoronary pressure measurement is significantly influenced by the presence and severity of MVO in STEMI. Moreover, it can predict the final extent of global and regional irreversible myocardial injury and left ventricular function at long term follow-up 5 . On the other hand, patients with high collateralization, defined as visible collaterals on the coronary angiogram or as Rentrop scores 1-3, had a 36% reduced all-cause mortality risk compared with patients with Rentrop score 0 6 . Pressure measurements can also define collateral flow. There are some controversies regarding collateral flow and pressure measurements in coronary arteries affected by MVO in acute myocardial infarction 7,8 .

Optical Coherence Tomography for In Vivo Identification, Characterization and Optimal Treatment of Spontaneous Recanalization of Coronary Thrombus

“…It was previously believed that the true prevalence of SRCT lesions might be underestimated, due to its angiographic non-specific aspect: namely haziness, braided and pseudo-dissection filling defects. This angiographic aspect can be related to other various conditions: fresh thrombosis on plaque rupture/erosion, spontaneous dissection, aneurysm or heavy calcification (2,(36)(37)(38)(39)(40). The diagnosis becomes possible only by intravascular imaging.…”

In ST‐segment elevation myocardial infarction, the echocardiographic parameters of microvascular obstruction are not associated with left ventricular remodeling at five years of follow‐up

“…The 38 mm Hg CWP cutoff value for left ventricular remodeling was used to divide patients into groups.…”

“…It has been demonstrated that invasively measured intracoronary physiology indices are correlated with the presence and severity of MVO in STEMI. They can predict the extent of irreversible myocardial injury and adverse left ventricular remodeling . Coronary wedge pressure (CWP) appears to be an accessible method for the diagnosis of severe compressive MVO.…”

A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction

“…However, total ischemic time could explain the magnitude of left ventricular remodeling and the difference in mortality only when associated to microvascular obstruction and an old coronary thrombus. 16,17 In recent guidelines, revascularization has gained a Class I indication, while MS only a Class IIa. 4,15 The 3% increase in mortality recorded between 2005 and 2014 in patients with CS following AMI in the NCDR Cath/ PCI registry is difficult to understand.…”