-
Kalpa De Silva,
Paul Foster,
Antoine Guilcher,
Asela Bandara,
Roy Jogiya,
Tim Lockie,
Phil Chowiencyzk,
Eike Nagel,
Michael Marber,
Simon Redwood,
Sven Plein, Divaka Perera
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: REVASCULARIZATION AFTER ACUTE CORONARY SYNDROMES PROVIDES PROGNOSTIC BENEFIT, PROVIDED THAT THE SUBTENDED MYOCARDIUM IS VIABLE. THE MICROCIRCULATION AND CONTRACTILITY OF THE SUBTENDED MYOCARDIUM AFFECT PROPAGATION OF CORONARY FLOW, WHICH CAN BE CHARACTERIZED BY WAVE INTENSITY ANALYSIS. THE STUDY OBJECTIVE WAS TO DETERMINE IN ACUTE CORONARY SYNDROMES WHETHER EARLY WAVE INTENSITY ANALYSIS-DERIVED MICROCIRCULATORY (BACKWARD) EXPANSION WAVE ENERGY PREDICTS LATE VIABILITY, DEFINED BY FUNCTIONAL RECOVERY.METHODS AND RESULTS: THIRTY-ONE PATIENTS (5811 YEARS) WERE ENROLLED AFTER NON-ST ELEVATION MYOCARDIAL INFARCTION. REGIONAL LEFT VENTRICULAR FUNCTION AND LATE-GADOLINIUM ENHANCEMENT WERE ASSESSED BY CARDIAC MAGNETIC RESONANCE IMAGING, BEFORE AND 3 MONTHS AFTER REVASCULARIZATION. THE BACKWARD-TRAVELING (MICROCIRCULATORY) EXPANSION WAVE WAS DERIVED FROM WAVE INTENSITY ANALYSIS OF PHASIC CORONARY PRESSURE AND VELOCITY IN THE INFARCT-RELATED ARTERY, WHEREAS MEAN VALUES WERE USED TO CALCULATE HYPEREMIC MICROVASCULAR RESISTANCE. TWELVE-HOUR TROPONIN T, LEFT VENTRICULAR EJECTION FRACTION, AND PERCENTAGE LATE-GADOLINIUM ENHANCEMENT MASS WERE 1.351.21 G/L, 5611%, AND 8.46.0%, RESPECTIVELY. THE INFARCT-RELATED ARTERY BACKWARD-TRAVELING (MICROCIRCULATORY) EXPANSION WAVE WAS INVERSELY CORRELATED WITH LATE-GADOLINIUM ENHANCEMENT INFARCT MASS (R=0.81; P0.0001) AND STRONGLY PREDICTED REGIONAL LEFT VENTRICULAR RECOVERY (R=0.68; P=0.001). BY RECEIVER OPERATING CHARACTERISTIC ANALYSIS, A BACKWARD-TRAVELING (MICROCIRCULATORY) EXPANSION WAVE THRESHOLD OF 2.8 W M2 S2105 PREDICTED FUNCTIONAL RECOVERY WITH SENSITIVITY AND SPECIFICITY OF 0.91 AND 0.82 (AUC 0.88). HYPEREMIC MICROVASCULAR RESISTANCE CORRELATED WITH LATE-GADOLINIUM ENHANCEMENT MASS (R=0.48; P=0.03) BUT NOT LEFT VENTRICULAR RECOVERY (R=0.34; P=0.07).CONCLUSIONS: The microcirculation-derived backward expansion wave is a new index that correlates with the magnitude and location of infarction, which may allow for the prediction of functional myocardial recovery. Coronary wave intensity analysis may facilitate myocardial viability assessment during cardiac catheterization.
Circulation Cardiovascular Interventions 03/2013; · 6.06 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The recently described angiographic BCIS-1 Myocardial Jeopardy Score (BCIS-JS) provides a semi-quantitative estimate of the extent of coronary artery disease (CAD). It is simple to use and applicable to all patients including those with bypass grafts. Our objective was to validate the BCIS-JS by evaluating its correlation with myocardial ischaemic burden and its accuracy at predicting a prognostic ischaemic threshold. Seventy-five patients with angina and known or suspected CAD referred for coronary angiography prospectively underwent high-resolution CMR perfusion imaging. There was good correlation between the BCIS-JS and myocardial ischaemic burden: r = 0·75, P<0·0001. Area under the ROC curve for BCIS-JS to detect ≥12% myocardial ischaemic burden was 0·87 (95% CI 0·78-0·96). BCIS-JS ≥6 predicted ≥12% myocardial ischaemic burden with a sensitivity of 68% and a specificity of 91%. The BCIS-JS correlates well with myocardial ischaemic burden. A BCIS-JS ≥6 predicts the prognostically important ischaemic threshold of 12% with high specificity. These findings demonstrate that the BCIS-JS has functional relevance and support its utility for classification of CAD burden in clinical trials and in clinical practice.
Clinical Physiology and Functional Imaging 03/2013; 33(2):101-8. · 1.33 Impact Factor
-
Andreas Schuster,
Geraint Morton,
Shazia T Hussain,
Roy Jogiya,
Shelby Kutty,
Kaleab N Asrress,
Marcus R Makowski,
Boris Bigalke, Divaka Perera,
Philipp Beerbaum,
Eike Nagel
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Cardiovascular magnetic resonance myocardial feature tracking (CMR-FT) is a promising novel method for quantification of myocardial wall mechanics from standard steady-state free precession (SSFP) images. We sought to determine whether magnetic field strength affects the intra-observer reproducibility of CMR-FT strain analysis. METHODS: We studied 2 groups, each consisting of 10 healthy subjects, at 1.5T or 3T Analysis was performed at baseline and after 4 weeks using dedicated CMR-FT prototype software (Tomtec, Germany) to analyze standard SSFP cine images. Right ventricular (RV) and left ventricular (LV) longitudinal strain (Ell(RV) and Ell(LV)) and LV long-axis radial strain (Err(LAX)) were derived from the 4-chamber cine, and LV short-axis circumferential and radial strains (Ecc(SAX), Err(SAX)) from the short-axis orientation. Strain parameters were assessed together with LV ejection fraction (EF) and volumes. Intra-observer reproducibility was determined by comparing the first and the second analysis in both groups. RESULTS: In all volunteers resting strain parameters were successfully derived from the SSFP images. There was no difference in strain parameters, volumes and EF between field strengths (p>0.05). In general Ecc(SAX) was the most reproducible strain parameter as determined by the coefficient of variation (CV) at 1.5T (CV 13.3% and 46% global and segmental respectively) and 3T (CV 17.2% and 31.1% global and segmental respectively). The least reproducible parameter was Ell(RV) (CV 1.5T 28.7% and 53.2%; 3T 43.5% and 63.3% global and segmental respectively). CONCLUSIONS: CMR-FT results are similar with reasonable intra-observer reproducibility in different groups of volunteers at 1.5T and 3T. CMR-FT is a promising novel technique and our data indicate that results might be transferable between field strengths. However there is a considerable amount of segmental variability indicating that further refinements are needed before CMR-FT can be fully established in clinical routine for quantitative assessment of wall mechanics and strain.
European journal of radiology 12/2012; · 2.65 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: There is conflicting evidence on the utility of elective intra-aortic balloon pump (IABP) use during high-risk percutaneous coronary intervention (PCI). Observational series have indicated a reduction in major in-hospital adverse events although randomized trial evidence does not support this. A recent study has suggested a mortality benefit trend early following PCI but there is currently no long-term outcome data from randomized trials in this setting. METHODS AND RESULTS: 301 patients with left ventricular impairment (ejection fraction <30%) and severe coronary disease (BCIS1 Jeopardy Score ≥ 8, where maximum possible=12) were randomized to receive PCI with elective IABP support (n=151) or without planned IABP support (n=150). Long-term all-cause mortality was assessed by tracking the databases held at the Office of National Statistics (in England and Wales) and the General Register Office (in Scotland). The groups were balanced in terms of baseline characteristics (LVEF 23.6%, BCIS-1 Jeopardy score 10.4) and the amount and type of revascularization performed. Mortality data were available for the entire cohort at a median of 51 months (IQR 41, 58) from randomization. All-cause mortality at follow-up was 33% in the overall cohort with significantly fewer deaths occurring in the Elective IABP group (n=42) than in the group that underwent PCI without planned IABP support (n=58) (HR 0.66, 95% CI: 0.44 - 0.98, p=0.039). CONCLUSIONS: In patients with severe ischemic cardiomyopathy treated with PCI, all-cause mortality was 33% at a median of 51 months. Elective IABP use during PCI was associated with a 34% relative reduction in all-cause mortality, compared to unsupported PCI. CLINICAL TRIAL REGISTRATION INFORMATION: isrctn.org. Identifier: ISRCTN40553718; clinicaltrials.gov. Identifier: NCT00910481.
Circulation 12/2012; · 14.74 Impact Factor
-
Timothy P E Lockie,
M Cristina Rolandi,
Antoine Guilcher, Divaka Perera,
Kalpa De Silva,
Rupert Williams,
Kaleab N Asrress,
Kiran Patel,
Sven Plein,
Phil Chowienczyk,
Maria Siebes,
Simon R Redwood,
Michael S Marber
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: The mechanisms of reduced angina on second exertion in patients with coronary arterial disease, also known as the warm-up angina phenomenon, are poorly understood. Adaptations within the coronary and systemic circulations have been suggested but never demonstrated in vivo. In this study we measured central and coronary hemodynamics during serial exercise. METHODS AND RESULTS: 16 patients (15 male, 61±4.3 yrs) with a positive exercise ECG and exertional angina completed the protocol. During cardiac catheterization via radial access they performed 2 consecutive exertions (Ex1, Ex2) using a supine cycle ergometer. Throughout exertions, distal coronary pressure and flow velocity were recorded in the culprit vessel using a dual sensor wire whilst central aortic pressure was recorded using a second wire. Patients achieved a similar workload in Ex2 but with less ischemia than in Ex1 (p<0.01). A 33% decline in aortic pressure augmentation in Ex2 (p<0.0001) coincided with a reduction in tension time index (TTI), a major determinant of LV afterload (p<0.001). Coronary stenosis resistance was unchanged. A sustained reduction in coronary microvascular resistance resulted in augmented coronary flow velocity on second exertion (both p<0.001). These changes were accompanied by a 21% increase in the energy of the early diastolic coronary backward-travelling expansion, or suction, wave on second exercise (p<0.05), indicating improved microvascular conductance and enhanced LV relaxation. CONCLUSIONS: On repeat exercise in patients with effort angina, synergistic changes in the systemic and coronary circulations combine to improve vascular-ventricular coupling and enhance myocardial perfusion, thereby potentially contributing to the warm-up angina phenomenon.
Circulation 11/2012; · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Several coronary disease scoring systems have been developed to predict procedural risk during revascularization. Many vary in complexity, do not specifically account for myocardium at risk, and are not applicable across all patient subsets. The Balloon pump-assisted Coronary Intervention study (BCIS-1) myocardial jeopardy score (BCIS-JS) addresses these limitations and is applicable to all patients, including those with coronary artery bypass grafts or left main stem disease. We assessed the prognostic relevance of the BCIS-JS in patients undergoing percutaneous coronary intervention (PCI). A total of 663 patients who underwent PCI with previous left ventricular function assessment were retrospectively assessed for inclusion, incorporating 221 with previous coronary artery bypass grafting. Blinded observers calculated the BCIS-JS, before (BCIS-JS(PRE)) and after (BCIS-JS(POST)) PCI, using the revascularization index (RI) (RI = [BCIS-JS(PRE) - BCIS-JS(POST)]/BCIS-JS(PRE)), quantifying the extent of revascularization, 1 indicating full revascularization and 0 indicating no revascularization. The primary end point was Office of National Statistics tracked, all-cause mortality. A total of 660 patients were included (66 ± 10.7 years), with 43 deaths (6.5%) during 2.6 ± 1.1 years after PCI. All-cause mortality was directly related to BCIS-JS(PRE) (hazard ratio [HR] 2.96, 95% confidence interval [CI] 1.71 to 5.15, p = 0.001) and BCIS-JS(POST) (HR 4.02, 95% CI 2.41 to 6.68, p = 0.001). A RI of <0.67 was associated with increased mortality compared to a RI of ≥0.67 (HR 4.13, 95% CI 1.91 to 8.91, p = 0.0001). On multivariate analysis, a RI <0.67 (HR 1.99, 95% confidence interval 1.03 to 3.87, p = 0.04), left ventricular dysfunction (HR 2.03, 95% CI 1.25 to 3.30, p = 0.004) and renal impairment (HR 3.75, 95% CI 1.48 to 8.64, p = 0.005) were independent predictors of mortality. In conclusion, the BCIS-JS predicts mortality after PCI and can assess the degree of revascularization. with more complete revascularization conferring a survival advantage in the medium term.
The American journal of cardiology 10/2012; · 3.58 Impact Factor
-
Shazia T Hussain,
Matthias Paul,
Sven Plein,
Ajay M Shah,
Gerry McCann,
Michael S Marber,
Philip Maccarthy,
Simon Redwood,
Amedeo Chiribiri,
Geraint Morton,
Andreas Schuster,
Masaki Ishida,
Mark A Westwood, Divaka Perera,
Eike Nagel
-
Shazia T Hussain,
Matthias Paul,
Sven Plein,
Ajay M Shah,
Gerry McCann,
Michael S Marber,
Philip Maccarthy,
Simon Redwood,
Amedeo Chiribiri,
Geraint Morton,
Andreas Schuster,
Masaki Ishida,
Mark A Westwood, Divaka Perera,
Eike Nagel
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: In patients with stable coronary artery disease (CAD), decisions regarding revascularisation are primarily driven by the severity and extent of coronary luminal stenoses as determined by invasive coronary angiography. More recently, revascularisation decisions based on invasive fractional flow reserve (FFR) have shown improved event free survival. Cardiovascular magnetic resonance (CMR) perfusion imaging has been shown to be non-inferior to nuclear perfusion imaging in a multi-centre setting and superior in a single centre trial. In addition, it is similar to invasively determined FFR and therefore has the potential to become the non-invasive test of choice to determine need for revascularisation.Trial designThe MR-INFORM study is a prospective, multi-centre, randomised controlled non-inferiority, outcome trial. The objective is to compare the efficacy of two investigative strategies for the management of patients with suspected CAD. Patients presenting with stable angina are randomised into two groups: 1) The FFR-INFORMED group has subsequent management decisions guided by coronary angiography and fractional flow reserve measurements. 2) The MR-INFORMED group has decisions guided by stress perfusion CMR. The primary end-point will be the occurrence of major adverse cardiac events (death, myocardial infarction and repeat revascularisation) at one year.Clinical trials.gov identifier NCT01236807 CONCLUSION: MR INFORM will assess whether an initial strategy of CMR perfusion is non-inferior to invasive angiography supplemented by FFR measurements to guide the management of patients with stable coronary artery disease. Non-inferiority of CMR perfusion imaging to the current invasive reference standard (FFR) would establish CMR perfusion imaging as an attractive non-invasive alternative to current diagnostic pathways.
Journal of Cardiovascular Magnetic Resonance 09/2012; 14(1):65. · 3.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The goal of this study was to determine the diagnostic accuracy of dynamic 3-dimensional (3D) whole heart myocardial perfusion cardiovascular magnetic resonance (CMR) against invasively determined fractional flow reserve (FFR) and to establish the correlation between myocardium at risk defined by using the invasive Duke Jeopardy Score (DJS) and noninvasive 3D whole heart myocardial perfusion CMR.
3D whole heart myocardial perfusion CMR overcomes the limited spatial coverage of conventional two-dimensional perfusion CMR methods and allows estimation of the extent of ischemia. The method has shown good diagnostic accuracy for the detection of coronary artery disease (CAD) as defined by using quantitative coronary angiography. However, quantitative coronary angiography does not provide a functional assessment of CAD as available from pressure wire-derived FFR. In the catheter laboratory, the DJS can complement FFR to estimate the myocardium at risk.
Fifty-three patients referred for angiography underwent rest and adenosine stress 3D whole heart myocardial perfusion CMR at 3-T. Perfusion was scored visually on a patient and coronary territory basis, and ischemic burden was calculated by quantitative segmentation of the volume of hypoenhancement. FFR was measured in vessels with ≥50% severity stenosis and an FFR <0.75 considered as hemodynamically significant. The DJS was calculated from the coronary angiograms to quantify the myocardium at risk.
FFR was measured in 64 of 159 coronary vessels, and 39 had an FFR <0.75. Sensitivity, specificity, and diagnostic accuracy of CMR for the detection of significant CAD were 91%, 90%, and 91%, on a patient basis and 79%, 92%, and 88%, respectively, by coronary territory. There was a strong correlation between the DJS and ischemic burden on CMR (p < 0.0001; Pearson's r = 0.82).
3D whole heart myocardial perfusion CMR accurately detects functionally significant CAD as defined by using FFR and provides an assessment of ischemic burden in agreement with the invasive DJS. The accurate detection of significant CAD combined with an estimation of ischemic burden by using 3D myocardial perfusion CMR holds promise for noninvasive guidance of therapy and risk stratification of patients with CAD.
Journal of the American College of Cardiology 07/2012; 60(8):756-65. · 14.16 Impact Factor
-
Circulation 04/2012; 125(16):e612; author reply e613. · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Left ventricular (LV) dysfunction was associated with adverse outcome after percutaneous coronary intervention (PCI) in the balloon-angioplasty and bare-metal stent era. Technological advances have reduced complications after PCI. The impact of left ventricular ejection fraction (LVEF) on outcomes in current clinical practice is unknown, with commonly used risk stratification models not consistently incorporating preprocedural LVEF.
A total of 2328 consecutive patients undergoing PCI in a single centre between April 2005 and July 2009 were analysed. Patients were eligible if LVEF had been categorized before PCI as good (LVEF ≥50%), moderate (LVEF 30-49%) or poor (LVEF <30%). Those in cardiogenic shock were excluded. Mortality data were tracked using the UK Office of National statistics database. Logistic regression analysis was used to predict the risk of mortality at 30-day and long-term follow-up.
Overall all-cause mortality was 1.0% at 30 days and 5% at long-term follow-up. Kaplan-Meier analysis revealed an early divergence in survival curves according to LVEF. Mortality rates stratified by LVEF category were 0.4, 1.3 and 6.3% at 30 days and 3.3, 5.7 and 12.0% in the long term (2.2±1.1 years) (P<0.0001). Multiple regression analysis confirmed that impaired LVEF (≤50%) independently predicts 30-day [hazard ratio 4.20 (confidence interval 2.50-7.04), P=0.001] and long-term all-cause mortality [hazard ratio 1.67 (1.28-2.19), P=0.001].
LV impairment remains a strong predictor of early and late mortality after PCI. LV function assessment is integral in risk stratification and patient optimization and should be recommended, wherever feasible, before PCI.
Coronary artery disease 03/2012; 23(3):155-61. · 1.56 Impact Factor
-
Heart International 02/2012; 7(1):e1.
-
Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:O92. · 3.72 Impact Factor
-
Shazia T Hussain,
Matthias Paul,
Sven Plein,
Gerry P McCann,
Ajay Shah,
Amedeo Chiribiri,
Geraint Morton,
Andreas Schuster,
Mark Westwood, Divaka Perera,
Michael Marber,
Eike Nagel
Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:O19. · 3.72 Impact Factor
-
Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:O91. · 3.72 Impact Factor
-
Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:P64. · 3.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Heart failure of ischemic origin has become increasingly common over the last decade because of the improved survival of patients with acute myocardial infarction. Revascularization with coronary bypass grafting or percutaneous coronary intervention plays a pivotal role in patients with ischemic cardiomyopathy, although these interventions are often associated with relatively high peri-procedural risk. The pathophysiological substrate of ischemic cardiomyopathy is heterogeneous, varying from predominantly hibernating myocardium to irreversible scarring. There is evidence to suggest that patients with hibernating myocardium benefit most from revascularization, whereas medical therapy is associated with an adverse prognosis. Therefore, noninvasive testing is recommended by relevant guidelines to guide optimal management in these patients. However, the role of noninvasive testing has recently been challenged. There are various imaging modalities available that provide information on different aspects of the disease, and therefore, they differ significantly in sensitivity and specificity. In clinical practice, choosing among the different imaging modalities can be difficult. Cardiac magnetic resonance has evolved into a comprehensive modality that can accurately determine the amount of hibernating myocardium as well as the presence and degree of myocardial ischemia and the extent of the scar. This paper reviews the indications, accuracy, and clinical utility of the available imaging techniques, with a special focus on cardiac magnetic resonance in ischemic cardiomyopathy, and provides an outlook on how this field might evolve in the future.
Journal of the American College of Cardiology 01/2012; 59(4):359-70. · 14.16 Impact Factor
-
Geraint Morton,
Amedeo Chiribiri,
Masaki Ishida,
Shazia T. Hussain,
Andreas Schuster,
Andreas Indermuehle, Divaka Perera,
Juhani Knuuti,
Stacey Baker,
Erik Hedström,
Paul Schleyer,
Michael O'Doherty,
Sally Barrington,
Eike Nagel
[show abstract]
[hide abstract]
ABSTRACT: Objectives The aim of this study was to compare fully quantitative cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) myocardial perfusion and myocardial perfusion reserve (MPR) measurements in patients with coronary artery disease (CAD).Background Absolute quantification of myocardial perfusion and MPR with PET have proven diagnostic and prognostic roles in patients with CAD. Quantitative CMR perfusion imaging has been established more recently and has been validated against PET in normal hearts. However, there are no studies comparing fully quantitative CMR against PET perfusion imaging in patients with CAD.Methods Forty-one patients with known or suspected CAD prospectively underwent quantitative 13N-ammonia PET and CMR perfusion imaging before coronary angiography.Results The CMR-derived MPR (MPRCMR) correlated well with PET-derived measurements (MPRPET) (r = 0.75, p < 0.0001). MPRCMR and MPRPET for the 2 lowest scoring segments in each coronary territory also correlated strongly (r = 0.79, p < 0.0001). Absolute CMR perfusion values correlated significantly, but weakly, with PET values both at rest (r = 0.32; p = 0.002) and during stress (r = 0.37; p < 0.0001). Area under the receiver-operating characteristic curve for MPRPET to detect significant CAD was 0.83 (95% confidence interval: 0.73 to 0.94) and for MPRCMR was 0.83 (95% confidence interval: 0.74 to 0.92). An MPRPET ≤1.44 predicted significant CAD with 82% sensitivity and 87% specificity, and MPRCMR ≤1.45 predicted significant CAD with 82% sensitivity and 81% specificity.Conclusions There is good correlation between MPRCMR and MPRPET. For the detection of significant CAD, MPRPET and MPRCMR seem comparable and very accurate. However, absolute perfusion values from PET and CMR are only weakly correlated; therefore, although quantitative CMR is clinically useful, further refinements are still required.
Journal of the American College of Cardiology 01/2012; 60(16):1546-1555. · 14.16 Impact Factor
-
Andreas Schuster,
Matthias Paul,
Nuno Bettencourt,
Geraint Morton,
Amedeo Chiribiri,
Masaki Ishida,
Shazia Hussain,
Roy Jogiya,
Shelby Kutty,
Boris Bigalke, Divaka Perera,
Eike Nagel
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Low dose dobutamine stress magnetic resonance imaging is valuable to assess viability in patients with ischemic cardiomyopathy. Analysis is usually qualitative with considerable operator dependency. The aim of the current study was to investigate the feasibility of cine images derived quantitative cardiac magnetic resonance (CMR) myocardial feature tracking (FT) strain parameters to assess viability in patients with ischemic cardiomyopathy. METHODS: 15 consecutive patients with ischemic cardiomyopathy referred for viability assessment were studied at 3T at rest and during low dose dobutamine stress (5 and 10μg/kg/min of dobutamine). Subendocardial and subepicardial circumferential (Ecc(endo) and Ecc(epi)) and radial (Err) strains were assessed using steady state free precession (SSFP) cine images orientated in 3 short axis slices covering 16 myocardial segments. RESULTS: Dysfunctional segments without scar (n=75) improved in all three strain parameters: Ecc(endo) (Rest: -10.5±6.9; 5μg: -12.1±6.9; 10μg: -14.1±9.2; p<0.05), Ecc(epi) (Rest: -7±4.8; 5μg: -8.2±5.5; 10μg: -9.1±5.9; p<0.05) and Err (Rest: 11.7±8.3; 5μg: 16±10.9; 10μg: 16.5±12.8; p<0.05). There was no response to dobutamine in dysfunctional segments with scar transmurality above 75% (n=6): Ecc(endo) (Rest: -4.7±3.0; 5μg: -2.9±2.5; 10μg: -6.6±3.3; p=ns), Ecc(epi) (Rest: -2.9±2.9; 5μg: -5.4±3.9; 10μg: -4.5±4.2; p=ns) and Err (Rest:9.5±5; 5μg:5.4±6.2; 10μg:4.9±3.3; p=ns). Circumferential strain (Ecc(endo), Ecc(epi)) improved in all segments up to a transmurality of 75% (n=60; p<0.05). Err improved in segments <50% transmurality (n=45; p<0.05) and remained unchanged above 50% transmurality (n=21; p=ns). CONCLUSIONS: CMR-FT is a novel technique, which detects quantitative wall motion derived from SSFP cine imaging at rest and with low dose dobutamine stress. CMR-FT holds promise of quantitative assessment of viability in patients with ischemic cardiomyopathy.
International journal of cardiology 11/2011; · 7.08 Impact Factor
-
Manesh R Patel,
Richard W Smalling,
Holger Thiele,
Huiman X Barnhart,
Yi Zhou,
Praveen Chandra,
Derek Chew,
Marc Cohen,
John French, Divaka Perera,
E Magnus Ohman
[show abstract]
[hide abstract]
ABSTRACT: Intra-aortic balloon counterpulsation (IABC) is an adjunct to revascularization in patients with cardiogenic shock and reduces infarct size when placed prior to reperfusion in animal models.
To determine if routine IABC placement prior to reperfusion in patients with anterior ST-segment elevation myocardial infarction (STEMI) without shock reduces myocardial infarct size.
An open, multicenter, randomized controlled trial, the Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction (CRISP AMI) included 337 patients with acute anterior STEMI but without cardiogenic shock at 30 sites in 9 countries from June 2009 through February 2011.
Initiation of IABC before primary percutaneous coronary intervention (PCI) and continuation for at least 12 hours (IABC plus PCI) vs primary PCI alone.
Infarct size expressed as a percentage of left ventricular (LV) mass and measured by cardiac magnetic resonance imaging performed 3 to 5 days after PCI. Secondary end points included all-cause death at 6 months and vascular complications and major bleeding at 30 days. Multiple imputations were performed for missing infarct size data.
The median time from first contact to first coronary device was 77 minutes (interquartile range, 53 to 114 minutes) for the IABC plus PCI group vs 68 minutes (interquartile range, 40 to 100 minutes) for the PCI alone group (P = .04). The mean infarct size was not significantly different between the patients in the IABC plus PCI group and in the PCI alone group (42.1% [95% CI, 38.7% to 45.6%] vs 37.5% [95% CI, 34.3% to 40.8%], respectively; difference of 4.6% [95% CI, -0.2% to 9.4%], P = .06; imputed difference of 4.5% [95% CI, -0.3% to 9.3%], P = .07) and in patients with proximal left anterior descending Thrombolysis in Myocardial Infarction flow scores of 0 or 1 (46.7% [95% CI, 42.8% to 50.6%] vs 42.3% [95% CI, 38.6% to 45.9%], respectively; difference of 4.4% [95% CI, -1.0% to 9.7%], P = .11; imputed difference of 4.8% [95% CI, -0.6% to 10.1%], P = .08). At 30 days, there were no significant differences between the IABC plus PCI group and the PCI alone group for major vascular complications (n = 7 [4.3%; 95% CI, 1.8% to 8.8%] vs n = 2 [1.1%; 95% CI, 0.1% to 4.0%], respectively; P = .09) and major bleeding or transfusions (n = 5 [3.1%; 95% CI, 1.0% to 7.1%] vs n = 3 [1.7%; 95% CI, 0.4% to 4.9%]; P = .49). By 6 months, 3 patients (1.9%; 95% CI, 0.6% to 5.7%) in the IABC plus PCI group and 9 patients (5.2%; 95% CI, 2.7% to 9.7%) in the PCI alone group had died (P = .12).
Among patients with acute anterior STEMI without shock, IABC plus primary PCI compared with PCI alone did not result in reduced infarct size.
clinicaltrials.gov Identifier: NCT00833612.
JAMA The Journal of the American Medical Association 08/2011; 306(12):1329-37. · 30.03 Impact Factor
