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Gupta DK, Skali H, Rivero J, Campbell P, Griffin L, Smith C, Foster C, Claggett B, Glynn RJ, Couper G, Givertz MM, Mehra MR, Di Carli M, Solomon SD, Pfeffer MA. Assessment of myocardial viability and left ventricular function in patients supported by a left ventricular assist device. J Heart Lung Transplant 2014; 33:372-81. [PMID: 24582837 DOI: 10.1016/j.healun.2014.01.866] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Chronically supported left ventricular assist device (LVAD) patients may be candidates for novel therapies aimed at promoting reverse remodeling and myocardial recovery. However, the effect of hemodynamic unloading with a LVAD on myocardial viability and LV function in chronically supported LVAD patients has not been fully characterized. We aimed to develop a non-invasive imaging protocol to serially quantify native cardiac structure, function, and myocardial viability while at reduced LVAD support. METHODS Clinically stable (n = 18) ambulatory patients (83% men, median age, 61 years) supported by a HeartMate II (Thoratec, Pleasanton, CA) LVAD (median durations of heart failure 4.6 years and LVAD support 7 months) were evaluated by echocardiography and technetium-99m ((99m)Tc)-sestamibi single photon emission computed tomography (SPECT) imaging at baseline and after an interval of 2 to 3 months. Echocardiographic measures of LV size and function, including speckle tracking-derived circumferential strain, were compared between ambulatory and reduced LVAD support at baseline and between baseline and follow-up at reduced LVAD support. The extent of myocardial viability by SPECT was compared between baseline and follow-up at reduced LVAD support. RESULTS With reduction in LVAD speeds (6,600 rpm; interquartile range: 6,200, 7,400 rpm), LV size increased, LV systolic function remained stable, and filling pressures nominally worsened. After a median 2.1 months, cardiac structure, function, and the extent of viable myocardium, globally and regionally, was unchanged on repeat imaging while at reduced LVAD speed. CONCLUSIONS In clinically stable chronically supported LVAD patients, intrinsic cardiac structure, function, and myocardial viability did not significantly change over the pre-specified time frame. Echocardiographic circumferential strain and (99m)Tc-sestamibi SPECT myocardial viability imaging may provide useful non-invasive end points for the assessment of cardiac structure and function, particularly for phase II studies of novel therapies aimed at promoting reverse remodeling and myocardial recovery in LVAD patients.
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Affiliation(s)
- Deepak K Gupta
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hicham Skali
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jose Rivero
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patricia Campbell
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Griffin
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colleen Smith
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Courtney Foster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Boston, Massachusetts
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert J Glynn
- Department of Biostatistics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Couper
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael M Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mandeep R Mehra
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Boston, Massachusetts
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc A Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Ugander M, Cain PA, Johnsson P, Palmer J, Arheden H. Chronic non-transmural infarction has a delayed recovery of function following revascularization. BMC Cardiovasc Disord 2010; 10:4. [PMID: 20082708 PMCID: PMC2823617 DOI: 10.1186/1471-2261-10-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 01/18/2010] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The time course of regional functional recovery following revascularization with regards to the presence or absence of infarction is poorly known. We studied the effect of the presence of chronic non-transmural infarction on the time course of recovery of myocardial perfusion and function after elective revascularization. METHODS Eighteen patients (mean age 69, range 52-84, 17 men) prospectively underwent cine magnetic resonance imaging (MRI), delayed contrast enhanced MRI and rest/stress 99m-Tc-tetrofosmin single photon emission computed tomography (SPECT) before, one and six months after elective coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). RESULTS Dysfunctional myocardial segments (n = 337/864, 39%) were classified according to the presence (n = 164) or absence (n = 173) of infarction. Infarct transmurality in dysfunctional segments was largely non-transmural (transmurality = 31 +/- 22%). Quantitative stress perfusion and wall thickening increased at one month in dysfunctional segments without infarction (p < 0.001), with no further improvement at six months. Despite improvements in stress perfusion at one month (p < 0.001), non-transmural infarction displayed a slower and lesser improvement in wall thickening at one (p < 0.05) and six months (p < 0.001). CONCLUSIONS Dysfunctional segments without infarction represent repetitively stunned or hibernating myocardium, and these segments improved both perfusion and function within one month after revascularization with no improvement thereafter. Although dysfunctional segments with non-transmural infarction improved in perfusion at one month, functional recovery was mostly seen between one and six months, possibly reflecting a more severe ischemic burden. These findings may be of value in the clinical assessment of regional functional recovery in the time period after revascularization.
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Affiliation(s)
- Martin Ugander
- Department of Clinical Physiology, Lund University Hospital, Lund University, Lund, SE-221 85 Sweden
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Crean A, Khan SN, Davies LC, Coulden R, Dutka DP. Assessment of Myocardial Scar; Comparison Between F-FDG PET, CMR and Tc-Sestamibi. Clin Med Cardiol 2009; 3:69-76. [PMID: 20508767 PMCID: PMC2872587 DOI: 10.4137/cmc.s730] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: Patients with heart failure and ischaemic heart disease may obtain benefit from revascularisation if viable dysfunctional myocardium is present. Such patients have an increased operative risk, so it is important to ensure that viability is correctly identified. In this study, we have compared the utility of 3 imaging modalities to detect myocardial scar. Design: Prospective, descriptive study. Setting: Tertiary cardiac centre. Patients: 35 patients (29 male, average age 70 years) with coronary artery disease and symptoms of heart failure (>NYHA class II). Intervention: Assessment of myocardial scar by 99Tc-Sestamibi (MIBI), 18F-flurodeoxyglucose (FDG) and cardiac magnetic resonance (CMR). Outcome Measure: The presence or absence of scar using a 20-segment model. Results: More segments were identified as nonviable scar using MIBI than with FDG or CMR. FDG identified the least number of scar segments per patient (7.4 +/− 4.8 with MIBI vs. 4.9 +/− 4.2 with FDG vs. 5.8 +/− 5.0 with CMR, p = 0.0001 by ANOVA). The strongest agreement between modalities was in the anterior wall with the weakest agreement in the inferior wall. Overall, the agreement between modalities was moderate to good. Conclusion: There is considerable variation amongst these 3 techniques in identifying scarred myocardium in patients with coronary disease and heart failure. MIBI and CMR identify more scar than FDG. We recommend that MIBI is not used as the sole imaging modality in patients undergoing assessment of myocardial viability.
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Affiliation(s)
- Andrew Crean
- Department of Radiology, Papworth Hospital, Papworth Everard, Cambridge, England
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Kendziorra K, Walther C, Foerster M, Möbius-Winkler S, Conradi K, Schuler G, Sabri O, Hambrecht R, Kluge R. Changes in myocardial perfusion due to physical exercise in patients with stable coronary artery disease. Eur J Nucl Med Mol Imaging 2005; 32:813-9. [PMID: 15776230 DOI: 10.1007/s00259-005-1768-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Accepted: 01/13/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Percutaneous transluminal coronary angioplasty (PTCA) is one of the main therapy options for patients with coronary artery disease (CAD), resulting in an improvement in myocardial perfusion and exercise capacity. Nevertheless, studies have also demonstrated a positive effect of regular exercise training on myocardial perfusion and maximum exercise capacity. The aim of this study was to evaluate changes in myocardial stress perfusion after 1 year of exercise training in comparison with the effects of PTCA in patients with CAD. METHODS In 66 male patients with angiographically confirmed significant coronary artery stenosis in one target vessel, myocardial perfusion scintigraphy was performed at baseline and 12 months after randomisation into either a physical exercise group or a PTCA group. Circumferential count rate profiles in 16 wall segments were classified according to their relative count rate and localisation within or outside the area supplied by the stenosed vessel. RESULTS Ischaemic segments showed a significant improvement in myocardial count rate within the target area after 12 months in both the PTCA and the training group (PTCA group: from 76.8+/-4.9% to 86.6+/-10.9%, p=0.03; training group: from 74.0+/-7.3% to 83.7+/-10.8%, p<0.01). Outside the target area only the training group showed a significant improvement (from 77.7+/-4.4% to 91.7+/-4.8%, p<0.01). CONCLUSION Our data indicate a significant improvement in stress myocardial perfusion in the training group after 12 months. The ischaemia is reduced not only in the target region of the leading stenosis but also in other ischaemic myocardial areas. In contrast, after PTCA stress perfusion improves only in the initially ischaemic parts of the target area.
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Affiliation(s)
- Kai Kendziorra
- Department of Nuclear Medicine, University of Leipzig, Stephanstrasse 9a, 04103, Leipzig, Germany.
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