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Lin Y, Guan X, Ren K, Zhu Y, Lu Y, Shang Y. Low-dose dobutamine stress myocardial contrast echocardiography for the evaluation of myocardial microcirculation and prediction of overall cardiac function recovery. Exp Ther Med 2020; 20:1315-1320. [PMID: 32742365 PMCID: PMC7388332 DOI: 10.3892/etm.2020.8813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
The study aimed to investigate the role of low-dose dobutamine stress myocardial contrast echocardiography (MCE) in evaluating myocardial local microcirculation and predicting cardiac function recovery in patients with myocardial infarction. A total of 50 patients with acute myocardial infarction (AMI) were enrolled in the present study. Positron emission tomography was used as a gold standard to determine viable/non-viable myocardial segments in infarcted myocardial region. MCE and dobutamine stress MCE were carried out 72 h after PCI. MCE was carried out again to evaluate myocardial condition at 6 months after PCI. As compared with normal myocardial segments, resting MCE revealed a significant decrease of the values of A (the peak intensity of the time-perfusion intensity curve, reflecting the myocardial blood volume), β (the slope of the curve, reflecting the myocardial blood flow (MBF) velocity) and A x β (reflecting MBF) of viable and non-viable myocardial segments. After being challenged by dobutamine, the values of A, β and A x β of normal coronary blood supply areas were significantly increased; while the segments A and A x β of viable myocardium were markedly decreased. Patients were further divided into two groups based on the changes in the contrast-enhanced index (CSI) following dobutamine loading. In the dobutamine stress echocardiography-positive group (the CSI increased or decreased by >0.2), the left ventricular ejection fraction was significantly increased and pro-B-type natriuretic peptide significantly decreased at 6 months following intervention. Low-dose dobutamine stress MCE was indicated to be an effective method to evaluate myocardial microcirculation perfusion in patients with AMI following PCI. In addition, CSI, as a simple semi-quantitative index, may predict left ventricular function in patients with AMI.
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Affiliation(s)
- Yunjia Lin
- Department of Ultrasound, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Xin Guan
- Department of Ultrasound, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Kai Ren
- Cardiac Intensive Care Unit, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Yanbo Zhu
- Department of Ultrasound, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Yaping Lu
- Department of Ultrasound, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Yanwen Shang
- Department of Ultrasound, Tianjin Chest Hospital, Tianjin 300222, P.R. China
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Abstract
PURPOSE OF REVIEW The current guidelines recommend the use of myocardial contrast echocardiography (MCE) to assess myocardial viability. There are two clinical scenarios where detection of myocardial viability has clinical significance: in ischemic cardiomyopathy and following acute myocardial infarction with significant left ventricular dysfunction. Myocardial contrast echocardiography (MCE), which utilizes microbubbles can assess the integrity of the microvasculature, which sustains myocardial viability in real time and can hence rapidly provide information on myocardial viability at the bedside without ionizing radiation. RECENT FINDINGS We discuss the value of MCE to predict myocardial viability through the detection of the integrity of myocardial microvasculature, the newer evidences behind the MCE-derived coronary flow reserve and use of MCE postmyocardial infarction to detect no-reflow. Newer studies have also demonstrated the comparable sensitivities and specificities of MCE to single photon-emission computed tomography (SPECT), cardiac myocardial resonance imaging and PET for the detection of myocardial viability. SUMMARY Ample evidence now exist that supports the routine use of MCE for the detection of viability as laid down in recent guidelines.
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Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancellotti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging 2018; 18:1205-1205af. [PMID: 28950366 DOI: 10.1093/ehjci/jex182] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 12/16/2022] Open
Abstract
Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.
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Affiliation(s)
- Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Imperial College, Sydney Street, London SW3 6NP, UK
| | | | | | | | - Jose Zamorano
- CIBERCV, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | - Patrizio Lancellotti
- University of Liege Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liege, Belgium
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Karogiannis N, Senior R. Contrast echocardiography for detection of myocardial perfusion abnormalities. Herz 2017; 42:287-294. [DOI: 10.1007/s00059-017-4536-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Gerbaud E, Faury A, Coste P, Erickson M, Corneloup O, Santos PD, Durrieu-Jaïs C, Laurent F, Montaudon M. Comparative analysis of cardiac magnetic resonance viability indexes to predict functional recovery after successful percutaneous coronary intervention in acute myocardial infarction. Am J Cardiol 2010; 105:598-604. [PMID: 20185003 DOI: 10.1016/j.amjcard.2009.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 10/19/2022]
Abstract
The aim of this study was to examine the relative value and the influence of the association of 4 cardiac magnetic resonance (CMR) viability indexes for predicting segmental functional recovery after optimal pharmacologic therapies and early percutaneous coronary intervention in acute myocardial infarction (AMI). CMR has been shown to predict functional recovery after AMI. The relative predictive value of CMR viability indexes remains disputed and has not been described in AMI reperfused within the first 12 hours. Sixty-nine patients with a first reperfused (<12 hours) Thrombolysis In Myocardial Infarction grade 3 AMI (61 men, 57.6 +/- 12.6 years) were studied on day 5 +/- 2. Low-dose (10 microg/kg/min) dobutamine response (DOB), microvascular obstruction (MVO), relative delayed enhancement extent (DE), and transmural DE pattern (TMDE) were assessed in each of the 17 left ventricular segments. Segmental functional outcome was assessed by CMR at 3 months. Logistic regression and Bayesian probabilities evaluated the association between viability indexes and functional segmental outcome. At rest, 27% of segments (314 of 1,173) were dysfunctional of which 53% (165 of 314) recovered at follow-up. Odd ratios for dobutamine response, MVO, DE, and TMDE were 15.8, 5.9, 2.6, and 2.5 respectively. The probability of segmental recovery was 0.84 when dobutamine response was positive and increased successively to 0.91 when adding MVO absence, 0.94 when adding TMDE absence, and 0.97 when adding DE absence. In conclusion, contractile response to low-dose dobutamine is the best predictive factor of segmental recovery after Thrombolysis In Myocardial Infarction grade 3 early reperfused AMI. Its value is further increased by other CMR viability indexes.
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Liu R, Deng Y, Bi X, Liu Y, Xiong L, Chen L. Assessment of myocardial perfusion and systolic function in patients with coronary artery disease after coronary artery bypass surgery by myocardial contrast echocardiography and two-dimensional strain echocardiography. ACTA ACUST UNITED AC 2009; 29:664-8. [DOI: 10.1007/s11596-009-0526-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Indexed: 11/28/2022]
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Abstract
The use of contrast echocardiography (CE) in cardiovascular medicine has grown significantly over the last 15 years. Depending on the site of injection, contrast enhancement of the right- or left-sided cardiac chambers or myocardium now can be achieved. Contrast echocardiography can improve the evaluation of patients with valvular heart disease by enhancing the Doppler signal; CE also improves detection of intracardiac or intrapulmonary shunts. In patients with coronary artery disease, enhancement of the endocardial blood-tissue boundary allows for improved visualization of endocardial wall motion, assessment of wall thickening, and calculation of ejection fraction. Contrast echocardiography promises to delineate myocardial perfusion and has the potential for quantitating coronary flow and assessing myocardial viability. These applications may add important physiologic information to the anatomic information readily available from noncontrast echocardiography. Because it can be rapidly performed at the bedside, CE may be a valuable tool for use with inpatients with acute myocardial ischemia. When CE has been used after recanalization of occluded coronary arteries, the assessment of myocardial salvage conveys information concerning reflow, stunning, and prognosis, and in the case of an angioplasty it provides immediate information regarding the success of the procedure. Contrast echocardiography can also assess myocardial areas at risk of irreversible damage and the presence or absence of collateral flow. When performed with transesophageal or epicardial echocardiography in the operating room, CE is emerging as a valuable tool in the assessment of cardioplegia distribution and graft patency as well as in the delineation of the regional supply of each graft. With the continued development of newer contrast agents and refinement of ultrasound imaging equipment, the applications of CE will continue to grow.
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Affiliation(s)
- J E Pérez
- Barnes and Jewish Hospital, Washington University, St. Louis, Missouri 63110, USA
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Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P. Contrast echocardiography: evidence-based recommendations by European Association of Echocardiography. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 10:194-212. [DOI: 10.1093/ejechocard/jep005] [Citation(s) in RCA: 246] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barmeyer AA, Stork A, Bansmann M, Muellerleile K, Heuer M, Bavastro M, Adam G, Meinertz T, Lund GK. Prediction of myocardial recovery by dobutamine magnetic resonance imaging and delayed enhancement early after reperfused acute myocardial infarction. Eur Radiol 2007; 18:110-8. [PMID: 17701182 DOI: 10.1007/s00330-007-0728-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2007] [Revised: 06/18/2007] [Accepted: 07/06/2007] [Indexed: 12/29/2022]
Abstract
The purpose was to study dobutamine magnetic resonance cine imaging (DOB-MRI) and delayed myocardial contrast enhancement (DE) early after reperfused acute myocardial infarction (AMI) for the predicion of segmental myocardial recovery and to find the optimal dose of dobutamine. Fifty patients (56+/-12 years, 42 males) with reperfused AMI underwent DOB-MRI and DE studies 3.5 (1-19) days after reperfusion. In DOB-MRI systolic wall thickening (SWT) was measured in 18 segments at rest and during dobutamine at 5, 10 and 20 microg*kg(-1)*min(-1). Dysfunctional segments were identified and the extent of DE was measured for each segment. Segmental recovery was examined after 8 (5-15) months. Two hundred-forty-eight segments were dysfunctional with presence of DE in 193. DOB-MRI showed the best prediction of recovery at 10 microg*kg(-1)*min(-1) of dobutamine with sensitivity of 67%, specificity of 63% and accuracy of 66% using a cut-off value for SWT of 2.0 mm. DE revealed a sensitivity of 68%, specificity of 65% and accuracy of 67% using a cut-off value of 46%. Combined analysis of DOB-MRI and DE did not improve diagnostic performance. Early prediction of segmental myocardial recovery after AMI is possible with DOB-MRI and DE. No improvement is achieved by dobutamine >10 microg*kg(-1)*min(-1) or a combination of DOB-MRI and DE.
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Affiliation(s)
- Achim A Barmeyer
- Clinic of Cardiology/Angiology, University Heart-Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Dijkmans PA, Senior R, Becher H, Porter TR, Wei K, Visser CA, Kamp O. Myocardial Contrast Echocardiography Evolving as a Clinically Feasible Technique for Accurate, Rapid, and Safe Assessment of Myocardial Perfusion. J Am Coll Cardiol 2006; 48:2168-77. [PMID: 17161241 DOI: 10.1016/j.jacc.2006.05.079] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 04/21/2006] [Accepted: 05/15/2006] [Indexed: 11/22/2022]
Abstract
Intravenous myocardial contrast echocardiography (MCE) is a recently developed technique for assessment of myocardial perfusion. Up to now, many studies have demonstrated that the sensitivity and specificity of qualitative assessment of myocardial perfusion by MCE in patients with acute and chronic ischemic heart disease are comparable with other techniques such as cardiac scintigraphy and dobutamine stress echocardiography. Furthermore, quantitative parameters of myocardial perfusion derived from MCE correlate well with the current clinical standard for this purpose, positron emission tomography. Myocardial contrast echocardiography provides a promising and valuable tool for assessment of myocardial perfusion. Although MCE has been primarily performed for medical research, its implementation in routine clinical care is evolving. This article is intended to give an overview of the current status of MCE.
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Affiliation(s)
- Pieter A Dijkmans
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
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Sbano JCN, Tsutsui JM, Andrade JL, Carlos Nicolau J, Meneghetti JC, Franchini Ramires J, Mathias W. Detection of Functional Recovery Using Low-Dose Dobutamine and Myocardial Contrast Echocardiography After Acute Myocardial Infarction Treated with Successful Thrombolytic Therapy. Echocardiography 2005; 22:496-502. [PMID: 15966934 DOI: 10.1111/j.1540-8175.2005.04007.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE We studied the value of low-dose dobutamine stress echocardiography (LDDE) and myocardial contrast echocardiography (MCE) in early prediction of left ventricular functional recovery (LVFR) after acute myocardial infarction (AMI) treated with successful thrombolysis. DESIGN LDDE and MCE using second-harmonic intermittent imaging were performed in first week after AMI. LVFR was defined as an absolute > or =5% increase in ejection fraction, from early to 6 months of follow-up by Technetium-99m-Sestamibi single-photon emission computed tomography. PATIENTS Out of 50 patients studied, 19 evolved with LVFR (group 1) and 31 without LVFR (group 2). Regional dysfunction was detected in 103 (37%) infarcted-related segments in group 1 and in 173 (63%) segments in group 2. RESULTS Sensitivity, specificity, positive, and negative predictive values and accuracy for detecting LVFR by LDDE were 94.7% (18/19), 87.1% (27/31), 81.8% (18/22), 96.4% (27/28), and 90% (45/50), respectively, and by MCE were 94.7% (18/19), 51.6% (16/31), 54.5% (18/33), 94.1% (16/17), and 68% (34/50). In group 1, functional improvement was observed in 86.9% (53/61) of segments with contractile reserve by LDDE and in 65.8% (52/79) of segments with microvascular perfusion by MCE. In group 2, functional improvement was observed in 78.3% (18/23) of segments with contractile reserve by LDDE and in 25.5% (25/98) of segments with microvascular perfusion by MCE. All segments without perfusion by MCE evolved without functional recovery. CONCLUSION LDDE was an accurate predictor of late left ventricular function recovery after AMI, while MCE was sensitive and has a high negative predictive value demonstrating that microvascular perfusion is essential for LVFR.
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12
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Serra V, Pérez de Isla L, Zamorano J, Almería C, Rodrigo JL, Pérez M, Florit J, Azcona L, Hernández RA, Macaya C. Utilidad de la ecocardiografía de contraste miocárdico con cuantificación basada en imagen paramétrica para la predicción de la recuperación funcional de segmentos acinéticos en pacientes con infarto agudo de miocardio sometidos a angioplastia primaria. Rev Esp Cardiol 2005. [DOI: 10.1157/13076417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Leung JM, Bellows WH. Post-CABG dobutamine stress echocardiography. Anesth Analg 2005; 100:1861. [PMID: 15920233 DOI: 10.1213/01.ane.0000156599.34224.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, (Leung) Department of Cardiovascular Anesthesiology, Kaiser Permanente Medical Center, San Francisco, CA (Bellows)
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Abstract
MCE is a reliable, bedside technique for assessment of a patient with acute coronary syndrome. It can be used to estimate the myocardial risk-area and infarct size and to establish peri-infarct viability. This information is critical in both management decision-making and in assigning prognosis in the setting of acute coronary syndromes.
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Affiliation(s)
- Roxy Senior
- Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ, UK.
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Dourado PMM, Tsutsui JM, Mathias W, Andrade JL, da Luz PL, Chagas ACP. Evaluation of stunned and infarcted canine myocardium by real time myocardial contrast echocardiography. Braz J Med Biol Res 2003; 36:1501-9. [PMID: 14576906 DOI: 10.1590/s0100-879x2003001100009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Differentiation between stunned and infarcted myocardium in the setting of acute ischemia is challenging. Real time myocardial contrast echocardiography allows the simultaneous assessment of myocardial perfusion and function. In the present study we evaluated infarcted and stunned myocardium in an experimental model using real time myocardial contrast echocardiography. Sixteen dogs underwent 180 min of coronary occlusion followed by reperfusion (infarct model) and seven other dogs were submitted to 20 min of coronary occlusion followed by reperfusion (stunned model). Wall motion abnormality and perfusional myocardial defect areas were measured by planimetry. Risk and infarct areas were determined by tissue staining. In the infarct model, the wall motion abnormality area during coronary occlusion (5.52 1.14 cm(2) ) was larger than the perfusional myocardial defect area (3.71 1.45 cm (2); P < 0.001). Reperfusion resulted in maintenance of wall motion abnormality (5.45 1.41 cm (2); P = 0.43 versus occlusion) and reduction of perfusional myocardial defect (1.51 1.29 cm (2); P = 0.004 versus occlusion). Infarct size determined by contrast echocardiography correlated with tissue staining (r = 0.71; P = 0.002). In the stunned model, the wall motion abnormality area was 5.49 0.68 cm (2) during occlusion and remained 5.1 0.63 cm (2) after reperfusion (P = 0.07). Perfusional defect area was 2.43 0.79 cm (2) during occlusion and was reduced to 0.2 0.53 cm(2) after reperfusion (P = 0.04). 2,3,5-Triphenyl tetrazolium chloride staining confirmed the absence of necrotic myocardium in all dogs in the stunned model. Real time myocardial contrast echocardiography is a noninvasive technique capable of distinguishing between stunned and infarcted myocardium after acute ischemia.
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Affiliation(s)
- P M M Dourado
- Instituto do Coraço, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
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Hillis GS, Mulvagh SL, Pellikka PA, Hagen ME, Gunda M, Wright RS, Oh JK. Comparison of intravenous myocardial contrast echocardiography and low-dose dobutamine echocardiography for predicting left ventricular functional recovery following acute myocardial infarction. Am J Cardiol 2003; 92:504-8. [PMID: 12943867 DOI: 10.1016/s0002-9149(03)00715-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Akinesia after acute myocardial infarction (AMI) may be reversible or irreversible. Distinguishing these 2 entities early after AMI is difficult, but clinically important. Previous studies have shown that myocardial contrast echocardiography (MCE) and low-dose dobutamine echocardiography (DE) may both be useful in this setting. However, there are few data regarding the relative and combined value of these techniques. The aim of this study was to compare the utility of real-time intravenous MCE and low-dose DE in the early prediction of functional recovery of akinetic myocardium after AMI. Thirty-seven patients were studied 3 +/- 2 days after an AMI. Each subject underwent real-time MCE using an intravenous infusion of perflutren microbubbles. Immediately after this, low-dose DE was performed. Contrast opacification and wall motion were determined by experienced observers blinded to clinical data. Repeat echocardiograms were obtained 51 +/- 19 days later and wall motion at rest was scored by an observer blinded to clinical data. Normal contrast opacification predicted functional recovery with a positive predictive value of 63%, a negative predictive value of 73%, and an accuracy of 66%. Residual contractility during low-dose DE had a positive predictive value of 82%, a negative predictive value of 72%, and a predictive accuracy of 76%. When the 2 tests were concordant (64%), they had a positive predictive value of 81%, a negative predictive value of 85%, and a predictive accuracy of 83%. Low-dose DE was superior to intravenous MCE in the prediction of functional recovery of akinetic myocardium after AMI, but the combination of both maximizes predictive accuracy.
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Affiliation(s)
- Graham S Hillis
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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Sieswerda GT, Yang L, Boo MBD, Kamp O. Real-time perfusion imaging: a new echocardiographic technique for simultaneous evaluation of myocardial perfusion and contraction. Echocardiography 2003; 20:545-55. [PMID: 12859369 DOI: 10.1046/j.1540-8175.2003.03093.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myocardial contrast echocardiography (MCE) with high acoustic energy and triggered harmonic imaging is the best established ultrasound technique to date for the assessment of myocardial perfusion. With this technique, however, the ultimate goal of MCE (noninvasive real-time simultaneous assessment of myocardial perfusion and function after an intravenous injection of microbubbles) is not met. Recently, technologic advances have enabled myocardial opacification to be visualized during low-energy real-time imaging. During real-time perfusion imaging, wall motion and myocardial perfusion may be assessed simultaneously, obviating the need of the presently time-consuming combination of different imaging modalities. When high-energy ultrasound bursts are periodically transmitted to produce bubble destruction during low-power imaging, the consecutive frames after destruction delineate the restoration of contrast intensity. Microbubble replenishment rate and peak intensity may be determined subsequently, and provide reliable quantitative parameters of regional microcirculatory flow. This review will introduce the modalities used for real-time perfusion imaging with focus on power pulse inversion imaging and quantitative analysis. Furthermore, we will describe the clinical role the technique may have in the identification of coronary artery disease, quantification of coronary stenosis severity, assessment of myocardial viability, determination of infarction size, and evaluation of reflow and no- or low-reflow after acute myocardial infarction.
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Affiliation(s)
- Gertjan T Sieswerda
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
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Agati L, Majo FD, Madonna MP, Celani F, Funaro S, Tonti G. Assessment of Myocardial Viability in Patients With Postischemic Left Ventricular Dysfunction: Role of Myocardial Contrast Echocardiography. Echocardiography 2003; 20 Suppl 1:S19-29. [DOI: 10.1046/j.1540-8175.20.s1.4.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hillis GS, Mulvagh SL, Gunda M, Hagen ME, Reeder GS, Oh JK. Contrast echocardiography using intravenous octafluoropropane and real-time perfusion imaging predicts functional recovery after acute myocardial infarction. J Am Soc Echocardiogr 2003; 16:638-45. [PMID: 12778024 DOI: 10.1016/s0894-7317(03)00212-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Akinesia after acute myocardial infarction (MI) may be reversible, secondary to stunning, or irreversible, as a result of extensive myocyte necrosis. Distinguishing these 2 entities soon after MI is difficult, but has important clinical implications. The current study assessed the use of intravenous myocardial contrast echocardiography (MCE) in this setting. A total of 35 patients were studied 2 (+/- 1) days after an acute MI. Of these, 31 (91%) underwent myocardial revascularization. Perfusion was assessed using real-time MCE and an intravenous infusion of octafluoropropane microbubbles. Repeated echocardiograms were obtained 56 (+/- 29) days later. Normal perfusion predicted functional recovery with a positive predictive value of 66% and a negative predictive value of 81%. The accuracy of the technique was superior in myocardial segments supplied by the left anterior descending coronary artery (positive and negative predictive value: 70% and 90%, respectively). In multivariable analysis, the mean MCE perfusion score in akinetic segments was the most powerful independent predictor of functional recovery (odds ratio 8.6, P =.02). These data suggest that real-time intravenous MCE is a useful predictor of functional recovery of akinetic myocardium after acute MI.
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Affiliation(s)
- Graham S Hillis
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Palagi C, Mengozzi G, Rovai D, Volterrani D, Dell'Anna R, Giorgi D, Petronio AS, Di Bello V, Mariani M. Assessment of myocardial perfusion with intravenous contrast echocardiography: comparison with (99) Tc-tetrofosmin single photon emission computed tomography and dobutamine echocardiography. Echocardiography 2003; 20:37-45. [PMID: 12848696 DOI: 10.1046/j.1540-8175.2003.00005.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the study was to evaluate the accuracy of intermittent, harmonic power Doppler (HPD) during intravenous Levovist infusion in identifying myocardial perfusion abnormalities in patients with recent infarction. Fifty-five patients with first acute myocardial infarction, successfully treated by primary PTCA, were studied after 1 month by myocardial contrast echocardiography (MCE), 99mTc tetrofosmin single photon emission computed tomography (SPECT), and low dose dobutamine echocardiography (DE). Scoring myocardial perfusion as normal, moderately, or severely reduced; MCE and SPECT were in agreement in 71% of segments(k = 0.414). Discordance was mainly due to ventricular walls with normal enhancement by MCE and moderate perfusion abnormalities by SPECT. Scoring perfusion as present or absent, the agreement significantly improved up to 86% (k = 0.59). Sensitivity and specificity of HPD for identifying SPECT perfusion defects were 63% and 93%, respectively. The agreement between MCE and SPECT was higher(85%, k = 0.627)in patients with anterior infarction. An improvement in regional contractile function was noted after dobutamine in 79 dysfunctional segments. A normal perfusion or a moderate perfusion defect by MCE were detected in 71 of 79 of these segments, while a severe perfusion defect was observed in 59 of 85 ventricular segments without dobutamine-induced wall-motion improvement. Sensitivity and specificity by HPD in detecting segments with contractile reserve were 90% and 69%, respectively. Thus, intermittent HPD during Levovist infusion allows myocardial perfusion abnormalities to be detected in patients with recent infarction. This method has a limited sensitivity but a high specificity in detecting SPECT perfusion defects, and a good sensitivity but a limited specificity in detecting contractile reserve.
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Main ML, Magalski A, Morris BA, Coen MM, Skolnick DG, Good TH. Combined assessment of microvascular integrity and contractile reserve improves differentiation of stunning and necrosis after acute anterior wall myocardial infarction. J Am Coll Cardiol 2002; 40:1079-84. [PMID: 12354431 DOI: 10.1016/s0735-1097(02)02124-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to determine the relative accuracy of myocardial contrast echocardiography (MCE) and low-dose dobutamine echocardiography (LDDE) in predicting recovery of left ventricular (LV) function in patients with a recent anterior wall myocardial infarction (MI). BACKGROUND Left ventricular dysfunction after acute MI may be secondary to myocardial stunning or necrosis. Myocardial contrast echocardiography allows real-time echocardiographic perfusion assessment from a venous injection of a fluorocarbon-based contrast agent. Although this technique is promising, it has not been compared with LDDE. METHODS Forty-six patients underwent baseline wall motion assessment, MCE, and LDDE two days after admission, as well as follow-up echocardiography after a mean period of 53 days. RESULTS Perfusion by MCE predicted recovery of segmental function with a sensitivity of 69%, specificity of 85%, positive predictive value of 74%, negative predictive value of 81%, and overall accuracy of 78%. Contractile reserve by LDDE predicted recovery of segmental function with a sensitivity of 50%, specificity of 88%, positive predictive value of 72%, negative predictive value of 73%, and overall accuracy of 73%. Concordant test results occurred in 74% of segments and further increased the overall accuracy to 85%. The mean wall motion score at follow-up was significantly better in perfused versus nonperfused segments (1.9 vs. 2.6, p < 0.0001) and in segments with contractile reserve, compared with segments lacking contractile reserve (1.9 vs. 2.5, p < 0.0001). CONCLUSION Myocardial contrast echocardiography compares favorably with LDDE in predicting recovery of regional LV dysfunction after acute anterior wall MI. Concordant contractile reserve and myocardial perfusion results further enhance the diagnostic accuracy.
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Affiliation(s)
- Michael L Main
- Mid America Heart Institute, Kansas City, Missouri 64111, USA.
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22
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Main ML, Magalski A, Chee NK, Coen MM, Skolnick DG, Good TH. Full-motion pulse inversion power Doppler contrast echocardiography differentiates stunning from necrosis and predicts recovery of left ventricular function after acute myocardial infarction. J Am Coll Cardiol 2001; 38:1390-4. [PMID: 11691513 DOI: 10.1016/s0735-1097(01)01574-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The goal of this study was to determine, in patients with a recent myocardial infarction (MI) and residual wall motion abnormalities within the distribution of the infarct-related artery, whether normal perfusion by myocardial contrast echocardiography (MCE) would accurately predict recovery of segmental left ventricular (LV) function. BACKGROUND Left ventricular dysfunction after acute MI may be secondary to myocardial stunning or necrosis. Recent technical innovations in contrast echocardiography, including pulse inversion imaging and power Doppler, now allow full-motion echocardiographic perfusion assessment from a venous injection of fluorocarbon-based contrast agent. METHODS Thirty-four patients with recent MI underwent baseline wall motion assessment and MCE two days after admission and follow-up echocardiography a mean of 55 days later. RESULTS Perfusion by MCE predicted recovery of segmental function with a sensitivity of 77%, specificity of 83%, positive predictive value of 90% and overall accuracy of 79%. The mean wall motion score at follow-up was significantly better in perfused, compared with nonperfused, segments (1.4 vs. 2.2, p < 0.0001). Additionally, 90% of perfused segments improved, while the majority of nonperfused segments remained unchanged. CONCLUSIONS Full-motion MCE utilizing an intravenous fluorocarbon-based agent and pulse inversion power Doppler techniques, identifies stunned myocardium, and accurately predicts recovery of segmental LV function in patients with recent MI.
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Affiliation(s)
- M L Main
- Mid America Heart Institute, Kansas City, Missouri 64111, USA.
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23
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Agati L, Funaro S, Bilotta F. Assessment of no-reflow phenomenon after acute myocardial infarction with harmonic angiography and intravenous pump infusion with Levovist: comparison with intracoronary contrast injection. J Am Soc Echocardiogr 2001; 14:773-81. [PMID: 11490325 DOI: 10.1067/mje.2001.113235] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Myocardial contrast echocardiography (intracoronary application) has emerged as an accurate method to detect the "no-reflow phenomenon." To investigate the diagnostic value of harmonic angiography after intravenous infusion of Levovist in assessing "no-reflow," both intracoronary and intravenous contrast injections were performed in a group of patients with acute myocardial infarction. Seventeen consecutive patients with a successfully reperfused acute myocardial infarction within 6 hours of symptom onset were selected for this study. All patients underwent contrast echocardiography with harmonic angiography with Levovist (400 mg/mL, intravenous pump infusion, trigger intervals 1:4 to 1:8) and sonicated albumin (0.5 to 1 mL, intracoronary bolus) on day 1 after the achievement of a sustained coronary reflow. Myocardial perfusion was qualitatively assessed with a 12-segment model. The endocardial length of the residual contrast defect after reflow was also calculated. Forty-four of 204 segments were not analyzed after intravenous contrast echocardiography and 37 after intracoronary contrast echocardiography because of artifacts. Intracoronary and intravenous injections showed a perfusion defect in 31 (19%) segments, with a concordance of 89% (kappa coefficient, 0.72). Concordance in anteroseptal, anterolateral, and inferolateral segments was 95% (kappa = 0.92), 88% (kappa = 0.66), and 83% (kappa = 0.57), respectively. With intracoronary injection used as the reference method, intravenous injection had a sensitivity of 74% and a specificity of 93% for diagnosing contrast defects. The endocardial extent of no-reflow was 18 +/- 19 after intravenous and 21 +/- 17 after intracoronary contrast echocardiography (P = not significant). Intravenous contrast echocardiography with Levovist reliably identifies the no-reflow phenomenon after successful reperfusion, especially in acute anteroseptal myocardial infarction.
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Affiliation(s)
- L Agati
- Department of Cardiology, "La Sapienza" University of Rome, Italy.
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24
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Swinburn JM, Lahiri A, Senior R. Intravenous myocardial contrast echocardiography predicts recovery of dysynergic myocardium early after acute myocardial infarction. J Am Coll Cardiol 2001; 38:19-25. [PMID: 11451273 DOI: 10.1016/s0735-1097(01)01317-1] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We aimed to ascertain whether triggered intravenous myocardial contrast echocardiography (MCE) can predict functional recovery in patients with acute myocardial infarction (AMI) and to determine the optimal triggering interval in this setting. BACKGROUND Detection of myocardial viability early after AMI has both therapeutic and prognostic implications. Myocardial contrast echocardiography using intracoronary injections of contrast can detect viable myocardium, but there is little data on the use of recently developed intravenous MCE techniques for this purpose. METHODS Ninety-six patients with recent AMI (4.8 +/- 1.7 days) underwent echocardiography at baseline and six months later or three months after revascularization to determine regional function (score 1 = normal to 3 = akinetic). Myocardial contrast echocardiography was performed at baseline using intravenous injections of Optison. Triggering intervals of 1:1 (early) and 1:10 (delayed) cardiac cycles were used. Segments were deemed viable if they demonstrated homogeneous contrast opacification. RESULTS Of 400 akinetic segments at baseline, 109 (27%) improved during the follow-up period, and 375 (94%) were adequately visualized with MCE, of which 59 (16%) were homogeneously opacified by early and 125 (33%) by delayed MCE (negative predictive value for recovery of contractile function 74% and 84%, positive predictive value 29% and 47%, respectively). Independent predictors of functional recovery were delayed MCE (odds ratio [OR]: 4.0, p < 0.001), revascularization (OR: 6.0, p < 0.001), and log creatine kinase (OR: 0.5, p = 0.03). However, the presence or absence of >90% stenosis of the infarct-related artery did not influence the ability of triggered MCE to predict functional recovery. CONCLUSIONS Intravenous delayed triggered MCE can independently detect myocardial viability early after AMI.
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Affiliation(s)
- J M Swinburn
- Department of Cardiac Research, Northwick Park Hospital, Harrow, United Kingdom
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25
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Agati L, Autore C, Funaro S, Veneroso G, Dagianti A, Lamberti A, Fedele F. Noninvasive assessment of myocardial perfusion: preliminary results in patients with acute myocardial infarction. Am J Cardiol 2000; 86:28G-29G. [PMID: 10997349 DOI: 10.1016/s0002-9149(00)00987-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- L Agati
- Department of Cardiology, La Sapienza, University of Rome, Italy
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26
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Castaldo M, Funaro S, Veneroso G, Agati L. Detection of residual tissue viability within the infarct zone in patients with acute myocardial infarction: ultrasonic integrated backscatter analysis versus dobutamine stress echocardiography. J Am Soc Echocardiogr 2000; 13:358-67. [PMID: 10804433 DOI: 10.1016/s0894-7317(00)70005-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The goals of this study were to analyze temporal changes in cardiac cyclic variation of integrated backscatter (CVIB) in acute myocardial infarction (AMI) and to investigate the predictive value of CVIB normalization compared with that of dobutamine stress echocardiography (DSE) in the assessment of functional recovery after revascularization. BACKGROUND The normal CVIB is blunted by ischemia and recovers early after reperfusion, faster than wall motion improvement. Analysis of CVIB has been widely investigated for its potential to detect viable myocardium in the early stage of infarction. No studies have compared CVIB analysis with other techniques for viability assessment in patients with acute ischemic. METHODS AND RESULTS Integrated backscatter images were obtained in 12 patients with AMI on days 1, 3, and 7 after admission and 1 month after revascularization. On day 7, DSE was performed in all patients. On admission, 22 of 144 segments were dyssynergic. On day 1, CVIB was abnormal in all 22 infarcted segments, on day 3, in 16, and on day 7, in only 10 infarcted segments. Eight of 10 segments nonviable by CVIB (CVIB-nonviable) were also nonrespondent by DSE; whereas 12 of 14 segments viable by DSE (DSE-viable) were also CVIB-viable. At follow-up, 10 CVIB-viable segments and 1 CVIB-nonviable segment showed functional recovery; whereas 10 of 14 DSE-viable segments showed functional recovery. Thus the positive predictive value of CVIB and DSE was 83% and 72%, respectively, with a diagnostic agreement between techniques in 77% of segments. CONCLUSIONS Our data suggest that the normalization in CVIB in the first week after AMI accurately predicts residual tissue viability within the infarct zone. We also observed that the initial pattern of cyclic variation may be predictive of functional recovery. Finally, we found a good correlation between the recovery of a normal CVIB in segments that were still dysfunctional and a more validated method to assess tissue viability, such as the dobutamine test.
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Affiliation(s)
- M Castaldo
- Department of Cardiology, "La Sapienza" University, Rome, Italy
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27
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Mulvagh SL, DeMaria AN, Feinstein SB, Burns PN, Kaul S, Miller JG, Monaghan M, Porter TR, Shaw LJ, Villanueva FS. Contrast echocardiography: current and future applications. J Am Soc Echocardiogr 2000; 13:331-42. [PMID: 10756254 DOI: 10.1067/mje.2000.105462] [Citation(s) in RCA: 199] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent updates in the field of echocardiography have resulted in improvements in image quality, especially in those patients whose ultrasonographic (ultrasound) evaluation was previously suboptimal. Intravenous contrast agents are now available in the United States and Europe for the indication of left ventricular opacification and enhanced endocardial border delineation. The use of contrast enables acquisition of ultrasound images of improved quality. The technique is especially useful in obese patients and those with lung disease. Patients in these categories comprise approximately 10% to 20% of routine echocardiographic examinations. Stress echocardiography examinations can be even more challenging, as the image acquisition time factor is critically important for accurate detection of coronary disease. Improvements in image quality with intravenous contrast agents can facilitate image acquisition and enhance delineation of regional wall motion abnormalities at the peak level of exercise. Recent phase III clinical trial data on the use of Optison and several other agents (currently under evaluation) have revealed that for approximately half of patients, image quality substantively improves, which enables the examination to be salvaged and/or increases diagnostic accuracy. For the "difficult-to-image" patient, this added information results in (1) enhanced laboratory efficiency, (2) a reduction in downstream testing, and (3) possible improvements in patient outcome. In addition, substantial research efforts are underway to use ultrasound contrast agents for assessment of myocardial perfusion. The detection of myocardial perfusion during echocardiographic examinations will permit the simultaneous assessment of global and regional myocardial structure, function, and perfusion-all of the indicators necessary to enable the optimal noninvasive assessment of coronary artery disease. Despite the added benefit in improved efficacy of testing, few data exist regarding the long-term effectiveness of these agents. Currently under evaluation are the clinical and economic outcome implications of intravenous contrast agent use for daily clinical decision making in a variety of patient subsets. Until these data are known, this document offers a preliminary synthesis of available evidence on the value of intravenous contrast agents for use in rest and stress echocardiography. At present, it is the position of this guideline committee that intravenous contrast agents demonstrate substantial value in the difficult-to-image patient with comorbid conditions limiting an ultrasound evaluation of the heart. For such patients, the use of intravenous contrast agents should be encouraged as a means to provide added diagnostic information and to streamline early detection and treatment of underlying cardiac pathophysiology. As with all new technology, this document will require updates and revisions as additional data become available.
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Affiliation(s)
- S L Mulvagh
- American Society of Echocardiography, Raleigh, NC 27607, USA
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28
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Shaw LJ, Monaghan MJ, Nihoyannopolous P. Clinical and economic outcomes assessment with myocardial contrast echocardiography. Heart 1999; 82 Suppl 3:III16-21. [PMID: 10534326 PMCID: PMC1766514 DOI: 10.1136/hrt.82.2008.iii16] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- L J Shaw
- Emory University, Atlanta, Georgia, USA.
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29
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Abstract
Several perfusion techniques have definitively shown that microvascular dysfunction plays a crucial role in patients with acute myocardial infarction. In those patients, despite a rapid and sustained restoration of flow throughout a previously occluded epicardial coronary artery, microvascular damage still may be observed. Duration of ischemia and/or time to recanalization are the most powerful determinants of microvascular dysfunction. However, the amount of tissue perfusion in infarcted patients is dependent on many other complex interrelated factors including extent of collateral circulation before recanalization, residual stenosis severity of the culprit artery, vasodilator reserve in the infarct territory, extent of reperfusion injury, and loading conditions. Because microvascular dysfunction is associated with progressive left ventricular dilation and a high frequency of postinfarction complications, all of the efforts to improve the relation between coronary reflow and microvascular perfusion are justified.
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Affiliation(s)
- L Agati
- Department of Cardiology, "La Sapienza" University of Rome, Italy
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30
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Leclercq F, Messner-Pellenc P, Descours Q, Daures JP, Pasquié JL, Hager FX, Davy JM, Grolleau-Raoux R. Combined assessment of reflow and collateral blood flow by myocardial contrast echocardiography after acute reperfused myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 1999; 82:62-7. [PMID: 10377311 PMCID: PMC1729108 DOI: 10.1136/hrt.82.1.62] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the combined assessment of reflow and collateral blood flow by myocardial contrast echocardiography after myocardial infarction. DESIGN Myocardial contrast echocardiography was performed in patients with acute myocardial infarction shortly after successful coronary reperfusion (TIMI 3 patency) by direct angioplasty. Collateral flow was assessed before coronary angioplasty, and contrast reflow was evaluated 15 minutes after reperfusion. The presence of contractile reserve was assessed by low dose dobutamine echocardiography (5 to 15 micrograms/kg/min) at (mean (SD)) 3 (2) days after myocardial infarction. Recovery of segmental function (myocardial viability) was evaluated by resting echocardiography at a two month follow up. The study was prospective. PATIENTS 35 consecutive patients referred for acute transmural myocardial infarction. RESULTS Contrast reflow was observed in 20 patients (57%) and collateral flow in 14 (40%). Contrast reflow and collateral contrast flow were both correlated with reversible dysfunction on initial dobutamine echocardiography and at follow up (p < 0.05). The presence of reflow or collateral flow on myocardial contrast echocardiography was a highly sensitive (100%) but weakly specific (60%) indicator of segmental dysfunction recovery. Simultaneous presence of contrast reflow and collateral flow was more specific of reversible dysfunction than reflow alone (90% v 60%). CONCLUSIONS Combined assessment of reflow and collateral blood flow enhanced the sensitivity of myocardial contrast echocardiography in predicting myocardial viability after acute, reperfused myocardial infarction. The simultaneous presence of reflow and collateral blood flow was highly specific of recovery of segmental dysfunction.
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Affiliation(s)
- F Leclercq
- Department of Cardiology, Hôpital Arnaud de Villeneuve, Avenue du Doyen Giraud, 34295 Montpellier Cedex 5, France
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31
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Czitrom D, Karila-Cohen D, Brochet E, Juliard JM, Faraggi M, Aumont MC, Assayag P, Steg PG. Acute assessment of microvascular perfusion patterns by myocardial contrast echocardiography during myocardial infarction: relation to timing and extent of functional recovery. Heart 1999; 81:12-6. [PMID: 10220538 PMCID: PMC1728895 DOI: 10.1136/hrt.81.1.12] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine the relation between the initial microvascular perfusion pattern, as assessed by intracoronary myocardial contrast echocardiography (MCE), immediately after restoration of TIMI (thrombolysis in myocardial infarction) (TIMI) grade 3 flow during acute myocardial infarction, and the extent and timing of functional recovery in the area at risk. SETTING Referral centre for interventional cardiology. METHODS Intracoronary MCE was performed 15 minutes after TIMI grade 3 recanalisation of the infarct artery in 25 patients. Segmental myocardial contrast patterns were graded semiquantitatively (0, none; 0.5, heterogeneous; 1, homogeneous). Functional recovery was assessed by echocardiography on days 9 and 42. RESULTS Among 174 myocardial segments in the area at risk, wall motion recovery on day 9 was observed in 40% of MCE grade 1 segments but there was no significant recovery in grade 0 or 0.5 segments. On day 42, recovery had occurred in 56% of MCE grade 1 segments (p < 0. 0001 v MCE grade 0 and 0.5; p = 0.0001 v MCE grade 1 on day 9), and 22% of MCE grade 0.5 segments (p = 0.02 v MCE grade 0; p = 0.0005 v MCE grade 0.5 on day 9); MCE grade 0 segments did not recover. Negative predictive value in predicting recovery by contrast enhancement was 95% and 89% by days 9 and 42, respectively. CONCLUSIONS Contractile recovery occurs earliest in well reperfused segments. Up to one quarter of segments with heterogeneous contrast enhancement show wall motion recovery within the first six weeks. Myocardial perfusion after recanalisation in acute myocardial infarction, even if heterogeneous, is a prerequisite for postischaemic functional recovery. Thus preservation of acute myocardial perfusion is associated with more complete and early functional recovery.
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Affiliation(s)
- D Czitrom
- Cardiology Department, Hôpital Bichat, 46 rue Henri Huchard, 75877 Paris Cedex, France
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32
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Brochet E, Czitrom D, Karila-Cohen D, Seknadji P, Faraggi M, Benamer H, Aubry P, Steg PG, Assayag P. Early changes in myocardial perfusion patterns after myocardial infarction: relation with contractile reserve and functional recovery. J Am Coll Cardiol 1998; 32:2011-7. [PMID: 9857886 DOI: 10.1016/s0735-1097(98)00483-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to assess early temporal changes in myocardial perfusion pattern by myocardial contrast echocardiography (MCE) and their relation to myocardial viability in patients with reperfused acute myocardial infarction (AMI). BACKGROUND Myocardial contrast echocardiography no-reflow is associated with poor contractile recovery after AMI. However, little is known regarding early reversibility of microvascular dysfunction and its relation to myocardial viability. METHODS Intracoronary MCE was performed immediately after reflow and 9 days later in 28 patients with a first AMI and successful coronary recanalization (Thrombolysis in Myocardial Infarction trial grade 3 flow). Semiquantitative contrast score and wall motion score (WMS) were assessed in each initially asynergic segment at initial and repeat MCE study. Low dose dobutamine echocardiography (DE) was performed at day 10, and follow-up (FU) rest echocardiography was performed 6 weeks later. RESULTS Among 200 initially asynergic segments, 49% exhibited no or heterogeneous contrast enhancement at initial MCE versus 24% at restudy (p < 0.001). Three groups of segments were defined according to early changes in contrast pattern: group A, "sustained no-reflow" (n = 17); group B, improved contrast score (n = 68), and group C, "sustained reflow" (n = 112). Group A segments showed no improvement in WMS at FU. In contrast, group B segments showed significant improvement in WMS at FU (p < 0.0001), and exhibited more frequently contractile reserve at DE (36% vs. 6%, p = 0.02) and contractile recovery at FU (34% vs. 7%, p = 0.03) than group A segments. Group C segments exhibited contractile reserve and contractile recovery in 47% and 51% of segments respectively. CONCLUSIONS Improvement in MCE perfusion pattern may occur after initial no-reflow in the days following reperfused AMI and is associated with preservation of contractile reserve and gradual regional functional recovery.
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Affiliation(s)
- E Brochet
- Department of Cardiology, Hopital Bichat, Paris, France.
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33
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Firschke C. [Diagnosis of myocardial vitality using contrast echocardiography--ready for routine clinical use?]. Herz 1998; 23:483-90. [PMID: 10023582 DOI: 10.1007/bf03043755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The most benefit from the evaluation of myocardial viability in coronary artery disease is expected in patients with reduced left ventricular function. There is increasing evidence that the outcome of this patient group is better after revascularization if viable myocardium was present before as compared to patients without pre-reperfusion myocardial viability. Therefore, diagnostic tools for the detection of viable myocardium are of enormous therapeutic and economic relevance. The contrast echocardiographic demonstration of myocardial microvascular integrity has been demonstrated to be a corollary of myocellular viability in the experimental and clinical setting. In animal models of reperfusion in acute myocardial infarction, it could be demonstrated that myocardial echocontrast defects, however, only accurately estimate the extent of microvascular damage and the amount of viable tissue after reactive hyperemia has abated. In patients, immediately after reperfusion of the infarct-related artery in acute myocardial infarction, myocardial areas of no reflow could be detected using contrast echocardiography. It has been shown that these myocardial segments exhibit significantly reduced recovery of regional contractile function weeks after reperfusion. In contrast, regions with myocardial microvascular integrity as defined by contrast echocardiography recover function to a significantly higher degree. Furthermore, in patients with remote myocardial infarction, myocardial opacification by contrast echocardiography indicates myocardial collateral perfusion with preserved tissue viability and a high probability of functional recovery after reperfusion. In patients with chronic coronary artery disease and reduced left ventricular ejection fraction, functional recovery could be predicted by myocardial contrast echocardiography with a very high sensitivity in several studies. The lower specificity of the technique may be due to the fact that recovery of contractile function after reperfusion may not be expected in all segments at rest (which was used as the gold standard for viability evaluation in these studies) but rather during physical or pharmacological stress. Therefore, post-reperfusion demonstration of contractile reserve might be a more adequate criterion for the assessment of diagnostic accuracy of myocardial contrast echocardiography for pre-reperfusion viability detection. So far, for the evaluation of myocardial viability, myocardial contrast echocardiography has been exclusively performed using intracoronary injection of echo contrast media; based on the evidence from various studies, this technique is ready for routine clinical application; the place of venous myocardial contrast echocardiography for this purpose, which is an extremely promising technique, however, remains to be defined.
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Affiliation(s)
- C Firschke
- Deutsches Herzzentrum und 1. Medizinische Klinik, Technischen Universität München.
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34
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Agati L, Autore C, Iacoboni C, Castaldo M, Veneroso G, Voci P, Fedele F, Dagianti A. The complex relation between myocardial viability and functional recovery in chronic left ventricular dysfunction. Am J Cardiol 1998; 81:33G-35G. [PMID: 9662225 DOI: 10.1016/s0002-9149(98)00051-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Preserved myocardial viability and recurrent symptomatic ischemia are the most widely accepted criteria indicating that coronary revascularization should take place in patients with postischemic left ventricular dysfunction. However, the presence of viable myocardium within the infarct zone does not necessarily imply recovery of function after coronary revascularization. The complex relation between the extent of transmural necrosis and the degree of residual perfusion within the infarct area plays an important role. However, independently of functional recovery, cell viability may have important clinical implications, since it may improve long-term prognosis by attenuating left ventricular remodeling processes. Several different methods are used to detect hibernating myocardium. Mounting evidence suggests that thallium-201 scintigraphy is most sensitive in identifying tissue viability, whereas dobutamine echocardiography is most specific in predicting functional recovery after revascularization. In between, myocardial contrast echocardiography is the only technique able to evaluate the microvascular integrity that is a condition sine qua non for both cell viability and later functional recovery. Combined information derived from these 3 different approaches might be considered as the best way to understand how the combination of contractile, viable but noncontractile, and dead tissue affect resultant function and prognosis.
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Affiliation(s)
- L Agati
- Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy
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35
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Abstract
Functional evaluation of coronary vasomotion encompasses the assessment of dynamic changes in coronary lumen, vessel wall, blood flow, intracoronary pressure and myocardial perfusion in response to specific pharmacologic stimuli. These parameters are obtained to characterize mechanisms of physiologic regulation and to evaluate pathophysiologic processes and potential therapeutic strategies, especially with regard to the development of coronary atherosclerosis. To this end, a variety of direct (invasive) and indirect (non-invasive) diagnostic tools are employed. Among the invasive methods are registration of intracoronary Doppler flow, coronary pressure measurements, quantitative coronary angiography and intravascular ultrasound. The non-invasive modalities consist of coronary Doppler echocardiography, positron emission tomography, myocardial scintigraphy and magnetic resonance imaging. Because of the different technical and physiological principles involved, these methods are complementary by providing independent access to different aspects. The combined invasive functional testing as employed in the cardiac catheterization laboratory allows for a simultaneous synopsis of high-resolution coronary imaging and direct measurement of physiologic parameters during local application of defined pharmacologically active substances. However, the demands in terms of equipment, time and operator skills are high and limit this combined invasive approach to specialized centers. Besides these research purposes, a number of functional methods has entered the clinical arena. They are employed to evaluate the hemodynamic significance of coronary lesions and to assess functional outcome of therapeutic interventions in the catheterization laboratory. The underlying principles and applications of the different methods are described and an overview of selected results is presented.
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Affiliation(s)
- M Elsner
- Medizinische Klinik IV (Kardiologie/Nephrologie), Johann-Wolfgang-Goethe-Universität Frankfurt.
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36
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Agati L, Voci P, Hickle P, Vizza DC, Autore C, Fedele F, Feinstein SB, Dagianti A. Tissue-type plasminogen activator therapy versus primary coronary angioplasty: impact on myocardial tissue perfusion and regional function 1 month after uncomplicated myocardial infarction. J Am Coll Cardiol 1998; 31:338-43. [PMID: 9462577 DOI: 10.1016/s0735-1097(97)00487-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to compare the impact of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) on 1-month infarct size and microvascular perfusion. BACKGROUND The effect of the reperfusion strategies of primary coronary angioplasty and thrombolytic therapy on microvascular integrity still remains to be determined. METHODS Sixty-two consecutive patients with a first AMI, undergoing intravenous tissue-type plasminogen activator (t-PA) therapy (32 patients, Group I) or primary angioplasty (30 patients, Group II), were studied. Only patients with 1-month Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 were selected for the study. Patients in whom primary angioplasty was unsuccessful or those with clinical evidence of failed reperfusion were excluded. Microvascular perfusion was assessed at 1 month by intracoronary injection of sonicated microbubbles. Contrast score index (CSI) and wall motion score index (WMSI) were derived using qualitative methods. RESULTS At baseline there were no significant differences between groups for age, risk factors, time to hospital presentation, Killip class on admission, prevalence of multivessel disease or anterior infarct site, infarct area extension before reperfusion, peak creatine kinase levels and postinfarction treatment. Conversely, significant differences between groups were found at follow-up for percent residual infarct related-artery (IRA) stenosis (70 +/- 12 vs 36 +/- 14 [mean +/- SD], p = 0.0001), CSI (1.02 +/- 0.4 vs. 1.49 +/- 0.5, p = 0.0003) and WMSI (1.67 +/- 0.3 vs. 1.45 +/- 0.3, p = 0.015). In particular, in the subset of patients with TIMI grade 3 flow, a perfusion defect occurred in one or more segments subtended by the IRA in 72% of Group I versus 31% of Group II patients (p < 0.00001) and in 27% of Group I versus 8% of Group II segments (p < 0.00001). CONCLUSIONS The present study shows, in a highly selected cohort with successful IRA recanalization, that primary angioplasty is more effective than thrombolysis in preserving microvascular flow and preventing extension of myocardial damage at 1-month after AMI.
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Affiliation(s)
- L Agati
- Department of Cardiology and Cardiac Surgery, La Sapienza University of Rome, Italy.
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