The Extent of Microvascular Damage During Myocardial Contrast Echocardiography Is Superior to Other Known Indexes of Post-Infarct Reperfusion in Predicting Left Ventricular Remodeling

Galiuto, Leonarda; Garramone, Barbara; Scarà, Antonio; Rebuzzi, Antonio Giuseppe; Crea, Filippo; Torre, Giuseppe La; Funaro, Stefania; Madonna, Mariapina; Fedele, Francesco; Agati, Luciano

doi:10.1016/j.jacc.2007.09.051

Cited by 187 publications

(125 citation statements)

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“…37 MBG 0-1 raised the risk of adverse remodelling at 6 months 38 and of total mortality after 16 months of follow-up. 39 MCE detected CMVO was associated with an enhancement of the risk of adverse remodelling at 6 months 33 and of cardiac death after 46 months. 40 CMR detected CMVO increased the risk of adverse remodelling at 6 months 41 and of death.…”

Section: Prognosis Of Coronary Microvascular Obstructionmentioning

confidence: 90%

“…In particular, lack of intra-myocardial contrast opacification, due to CMVO, is able to predict functional recovery after STEMI. 33 Cardiac magnetic resonance (CMR) allows an accurate quantification and localization of CMVO and IS relative to the entire left ventricle. 34 In particular, CMVO can be typified as: i) lack of gadolinium enhancement during first pass (<2 min); and ii) lack of gadolinium enhancement within a necrotic region, identified by late gadolinium hyper-enhancement (after 10-15 min).…”

Section: No-invasive Indexes Of Coronary Microvascular Obstructionmentioning

confidence: 99%

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Pathophysiological aspects and management workflow of coronary microvascular obstruction in ST-segment elevation myocardial infarction

2016

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Restoring blood flow to ischemic but viable myocardium and reducing infarct size constitute the goals of reperfusion therapy with fibrinolytic drugs or primary percutaneous intervention in patients with ST-segment elevation myocardial infarction (STEMI). However, in a sizable proportion of patients, this intervention gains to reopen the obstructed epicardial coronary artery but does not achieve myocardial reperfusion because of coronary microvascular obstruction phenomenon (CMVO). In the last years, consistent evidence has pointed out how CMVO has a negative impact on outcome in patients with acute STEMI. Of note, most of the trials in this setting, mainly targeting reperfusion damage, have failed to show beneficial effects. In this article we provide a revision of mechanisms, diagnosis and prognosis of CMVO in acute STEMI, also pointing out the need of an integrated approach in order to prevent and treat CMVO in the different time windows of the acute event.

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Section: Prognosis Of Coronary Microvascular Obstructionmentioning

confidence: 90%

Section: No-invasive Indexes Of Coronary Microvascular Obstructionmentioning

confidence: 99%

Pathophysiological aspects and management workflow of coronary microvascular obstruction in ST-segment elevation myocardial infarction

2016

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“…Various methods of microcirculatory evaluation related to risk stratification after AMI have been in use, among most common ST-segment resolution 19,22 , myocardial blush grade 12,23 , myocardial contrast echocardiography 24 , myocardial scintigraphy 25 or cardiac magnetic resonance 26,27 . However, as effective as these methods are, they are not always accessible for routine evaluation, may be costly or time consuming.…”

Section: Timi-3 Flow As An Outcome Predictormentioning

confidence: 99%

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion

Vichova¹,

Malý²,

Ulman³

et al. 2016

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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Background. Percutaneous coronary intervention (PCI) performed within 12 h from symptom onset enables complete blood flow restoration in infarct-related artery in 90% of patients. Nevertheless, even with complete restoration of epicardial blood flow in culprit vessel (postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3), myocardial perfusion at tissue level may be insufficient. We hypothesized that the outcome of patients with STEMI/ bundle branch block (BBB)-myocardial infarction and post-PCI TIMI 3 flow is related to the time to reperfusion. Methods. Observational study based on a retrospective analysis of population of 635 consecutive patients with STEMI/ BBB-MI and post-PCI TIMI 3 flow from January 2009 to December 2011 (mean age 63 years, 69.6% males). Mortality of patients was evaluated in relation to the time from symptom onset to reperfusion. Results. A total of 83 patients (13.07%) with postprocedural TIMI 3 flow after PCI had died at 1-year follow-up. Median TD in patients who survived was 3.92 h (iqr 5.43), in patients who died 6.0 h (iqr 11.42), P = 0.004. Multiple logistic regression analysis identified time delay ≥ 9 h as significantly related to 1-year mortality of patients with STEMI/BBB-MI and post-PCI TIMI 3 flow (OR 1.958, P = 0.026). Other significant variables associated with mortality in multivariate regression analysis were: left ventricle ejection fraction < 30% (P = 0.006), age > 65 years (P < 0.001), Killip class >2 (P <0.001), female gender (P = 0.019), and creatinine clearance < 30 mL/min (P < 0.001). Conclusion. Time delay to reperfusion is significantly related to 1-year mortality of patients with STEMI/BBB-MI and complete restoration of epicardial blood flow in culprit vessel after PCI.

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“…Myocardial contrast echocardiography: Until now, myocardial contrast echocardiography (MCE) has been the gold standard examination for diagnosing the no-refl ow phenomenon. [1][2][3]5,11,12) MCE uses intravascular contrast agents that contain microbubbles as blood tracers, and it enables us the assessment of microvascular integrity and blood flow dynamics in myocardial capillaries. The no-refl ow zone is documented as the region of contrast perfusion defect (Figure 2).…”

Section: Two Mechanisms Of the No-refl Ow Phenomenon: Capillary Injurmentioning

confidence: 99%

Etiology and Clinical Implications of Microvascular Dysfunction in Patients With Acute Myocardial Infarction

Ito

2014

Int. Heart J.

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SummaryIn patients with acute myocardial infarction (MI), coronary microvasculatures are often damaged irreversibly due to myocardial ischemia and reperfusion, and fl ow to the previously ischemic myocardium is markedly reduced, a phenomenon known as the "no-refl ow phenomenon". Percutaneous coronary intervention (PCI) may accelerate embolization of plaque gruels and microthrombi to the microvessels, which further reduces tissue perfusion. The extent of the no-refl ow zone correlates with infarct size, and it has additional prognostic information. Recent advances in imaging modalities have enabled us to diagnose the no-refl ow phenomenon and to assess the mechanisms of the no-refl ow phenomenon. Pharmacological interventions and catheter-based devices to retrieve embolic materials have been proposed, and some of them are associated with improvement in clinical outcomes. Thus, we should keep in mind that only the achievement of complete microvascular perfusion is associated with better functional and clinical outcomes in patients with acute MI. (Int Heart J 2014; 55: 185-189) Key words: Echocardiography, Myocardial perfusion, Reperfusion, Myocardial ischemia, Microcirculation, Myocardial viability, Prognosis, Ventricular function A cute myocardial infarction (MI) is caused by obstruction of a coronary artery by a thrombus on a ruptured plaque. Salvaging threatened myocardium after acute coronary occlusion has been a key therapeutic objective. Percutaneous coronary intervention (PCI) with coronary stenting is widely performed for this purpose. PCI, however, does not necessarily guarantee the recovery of blood fl ow at the microvascular level, because myocardial ischemia often injures the coronary microvasculature structurally.1-3) This is called the noreflow phenomenon.4) If this phenomenon occurs, it significantly attenuates the benefi cial impacts of reperfusion therapy, resulting in poor clinical and functional outcomes. [1][2][3]5) The PCI procedure itself may worsen the microvascular function. Balloon inflation and stenting may introduce embolization of plaque and thrombus debris, resulting in obstruction in distal coronary small arteries and arterioles. Atheroembolism and/or thromboembolism could limit the effi cacy of PCI. 6)Attention is currently shifting from "no-fl ow" to "no-refl ow". We should ascertain the patency to determine the status of the coronary microvasculature in each patient with acute MI in order perform risk stratifi cation. With the advancement of imaging modalities, which include myocardial contrast echocardiography, Doppler guidewire, and cardiac magnetic resonance imaging, the number of patients with the no-refl ow phenomenon has increased compared to the rates that we deemed. Our ultimate therapeutic goal is to achieve successful microvascular reperfusion. In this review, I attempt to provide an in-depth understanding of the no-refl ow phenomenon from the bench to the bedside.

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The Extent of Microvascular Damage During Myocardial Contrast Echocardiography Is Superior to Other Known Indexes of Post-Infarct Reperfusion in Predicting Left Ventricular Remodeling

Abstract: Among patients with TIMI flow grade 3, the extent of microvascular damage, detected and quantitated by MCE, is the most powerful independent predictor of LV remodeling after STEMI as compared with persistent ST-segment elevation and myocardial blush grade.

Cited by 187 publications

References 24 publications

Pathophysiological aspects and management workflow of coronary microvascular obstruction in ST-segment elevation myocardial infarction

Pathophysiological aspects and management workflow of coronary microvascular obstruction in ST-segment elevation myocardial infarction

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion

Etiology and Clinical Implications of Microvascular Dysfunction in Patients With Acute Myocardial Infarction

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