Risk factors of asymptomatic restenosis in patients with first anterior ST elevation myocardial infarction treated by primary percutaneous coronary intervention.

BACKGROUND: The issue of predicting coronary artery restenosis, especially silent, in patients following primary percutaneous coronary intervention (PCI) has been extensively studied, however, risk factors have not been fully defined. AIM: To asses the frequency of silent restenosis and its predictors in patients with anterior ST elevation myocardial infarction (STEMI) treated with primary PCI and implantation of bare metal stents (BMS). METHODS: We recruited a cohort of 114 patients with first anterior STEMI treated with primary PCI within 12 hours of the onset of symptoms, and with the left anterior descending coronary artery occlusion (TIMI 0) and successful flow restoration (TIMI 3). A 12-lead ECG was performed before and 60 minutes after PCI. Troponin I and CK-MB were measured on admission and after six, 12 and 24 hours. Transthoracic echocardiography (TTE) was performed at discharge. Resting TTE and coronary angiography were performed after a six month follow-up in asymptomatic patients. RESULTS: The frequency of silent restenosis in our study group was 23.9%. The best multivariate models in logistic regression of restenosis prediction were: lower end-systolic volume of the left ventricle assessed two days after infarction longer lesion and smaller reference diameter of the stented vessel. CONCLUSIONS: Silent restenosis in patients with first anterior STEMI treated by primary PCI with the use of BMS is still frequent. The best ways to identify patients with silent restenosis at six month follow-up, apart from the lower end systolic volume in the echocardiographic study, are longer narrowing in the infarct-related artery and lower reference diameter of the treated vessel.

Prediction of long-term outcome after primary percutaneous coronary intervention for acute anterior myocardial infarction.

BACKGROUND: Despite the widespread use of reperfusion methods, the long-term outcome after primary percutaneous coronary intervention (PCI) is variable, and accurate risk stratification is of clinical importance. AIM: To assess the predictors of long term outcome after PCI for acute anterior myocardial infarction (AMI). METHODS: One hundred and twenty-seven consecutive patients undergoing PCI within 12 hours from the onset of the first AMI were enrolled. Troponin I, CK-MB, creatinine, NT-proBNP, echocardiographic left ventricular (LV) function, myocardial contrast perfusion, results of coronary angiography, ECG, 24-hour Holter ECG, and T-wave alternans (TWA) were analysed as predictors of major adverse cardiac events (MACE), defined as death, non-fatal reinfarction, sustained ventricular tachycardia, and rehospitalisation for decompensated heart failure. Patients were followed up for two years. RESULTS: Twenty-seven patients developed MACE. The best predictive model for MACE consisted of impaired perfusion (MCE, myocardial contrast echocardiography), higher CK-MB at 24 hours, discharge NT-proBNP, and non-negative TWA. The combination of elevated creatinine level, decreased LV ejection fraction, and a non-negative TWA proved the best for identification of patients at risk of cardiac death. The best multivariate model for predicting heart failure hospitalisation consisted of higher 24-hour CK-MB, discharge NT-proBNP, impaired perfusion and prolonged duration of ST elevation. CONCLUSIONS: Our study showed that the rate of MACE in patients with anterior ST-segment elevation myocardial infarction undergoing primary PCI at two years follow-up is low. A combined assessment of myocardial contrast perfusion, TWA, CK-MB and discharge NT-proBNP seems to optimally predict patients at risk of MACE.

Aneurysm of the aortic root and valve­sparing aortic root replacement: long-term outcomes from a single Polish center.

BACKGROUND: Valve-sparing aortic root replacement (VSARR) techniques are an alternative to the classic Bentall procedure when aortic root aneurysm is not accompanied by aortic valve stenosis, and the regurgitant aortic valve is amenable to repair. AIMS: The aim of the study was to assess long -term outcomes of valve sparing aortic root replacement using the David technique and the Yacoub technique. METHODS: A total of 101 consecutive, elective VSARR procedures were performed from January 2010 to April 2020 including 52 David procedures (51.5%) and 49 Yacoub procedures (48.5%). We analyzed mortality, freedom from reoperation, and freedom from aortic valve regurgitation. The analysis was performed for the entire study cohort and for 2 subgroups: the David technique and the Yacoub technique. RESULTS: The mean (SD) age was 50.2 (16.1) years; 90 (89.1%) patients were male. The median (interquartile range [IQR]) EuroScore II was 3.7 (2.7‒5.8). At 1, 5, and 8 years after surgery, survival (SE) was 98% (3%), 91.8% (8%), and 91.8% (8%), respectively, whereas freedom from reoperation (SE) was 100%, 97% (3%), and 97% (3%), respectively. Follow­up echocardiography performed at a median (IQR) of 18.7 (2.5‒36.7) months postsurgery revealed freedom from aortic valve regurgitation in 90.8% of patients. No significant differences in mortality, freedom from reoperation, and freedom from aortic valve regurgitation were noted between the David and Yacoub subgroups. CONCLUSIONS: VSARR is a safe and effective surgical technique in patients with aortic root aneurysm, as the associated mortality, reoperation rate, and aortic valve regurgitation recurrence are low.

Chemotherapy and echocardiographic indices in patients with non-Hodgkin lymphoma: the ONCO-ECHO study.

The cardiotoxicity of chemotherapy (CTx) for non-Hodgkin's lymphomas is not well recognized. In order to facilitate individual risk counseling for patients, we analyzed the effect of CTx on echocardiographic indices in regard to clinical data in patients treated for non-Hodgkin's lymphoma (NHL). A prospective multicenter ONCO-ECHO trial included 67 patients with NHL (45 patients with DLBCL (diffuse large B cell lymphoma) and 22 with non-DLBCL). Patients received standard CTx, primarily R-CHOP, CHOP, R-COP and COP regimens. Clinical data and echocardiographic indices were obtained at baseline, 3-, 6- and 12-month follow-up. The primary end point representing CTx cardiotoxicity was defined as a ≥ 10% decrease in the left ventricular ejection fraction (LVEF) during 12-month observation. In a 12-month follow-up five (7.5%) deaths occurred, while no clinical manifestations of heart failure were reported. There was an increase in left ventricular end-systolic diameter (p = 0.002) and E/e' index (p = 0.036) in 12-month observation. Preexisting coronary artery disease was associated with significant decrease in the ΔLVEF (p = 0.008), increase in ΔLVEDV (p = 0.03) and ΔLVESV (p = 0.02) and increase in the Δ left atrium diameter (p = 0.02); while history of arterial hypertension was related to significant decrease in the ΔLVEF (p = 0.039), diabetes mellitus was related to significant increase in the ΔE/e' index (p = 0.002). The primary end point was reported in ten (14.9%) patients. There were no independent risk factors for cardiotoxicity in the study population. Chemotherapy administered to NHL patients may induce dilatation and impaired LV diastolic function. Standard cardiovascular risk factors may predispose patients to negative LV remodeling.

Prediction of infarct size by speckle tracking echocardiography in patients with anterior myocardial infarction.

BACKGROUND: Speckle tracking echocardiography (STE) is based on tracing of pixel groups in grayness scale for the quantitative measurement of myocardium strain and myocardium strain rate. Recent data suggest that evaluation of STE could be a tool for myocardial function assessment similar to MRI. AIM: To assess the predictive value of STE for the evaluation of infarct size in patients with anterior ST-elevation myocardial infarction (STEMI). MATERIALS AND METHODS: We enrolled 39 patients with the first anterior wall STEMI (mean age 59±10 years, 29 men). All patients were treated with a primary percutaneous coronary intervention, and the time from the symptom onset to reperfusion was 298±195 min. Left ventricular ejection fraction assessed in three-dimensional echocardiography was 47±9%. On the day of discharge, STE was performed to determine the average global value of peak longitudinal strain (GLS) of 16 myocardial segments. The average value of the peak longitudinal strain for nine segments supplied by the left anterior descending artery anterior wall global longitudinal strain was assessed separately. Infarct size was assessed 3 months after STEMI by MRI using late gadolinium enhancement, and a large infarct was defined as at least 20% left ventricle myocardium covered by the scar. RESULTS: According to the results of MRI, we defined two groups: 22 patients with a large infarct (≥20%, group A) and 17 patients with a small infarct (<20%, group B). There were no differences between both groups in the demographics and cardiovascular risk factors. There was a significant correlation between GLS and the degree of myocardium injury assessed by MRI (r=0.62, P=0.001). The correlation was higher for anterior wall global longitudinal strain (r=0.68, P=0.001). With the receiver operating characteristic curve, the cut-off point for GLS was calculated (-12.3), which defined a large infarct with 82% sensitivity and 87% specificity (area under the curve=83). For segments supplied by the left anterior descending artery, the cut-off value for the prediction of a large infarct was -11.5 (sensitivity 90%, specificity 73%, area under the curve=84). CONCLUSION: STE seems to be a very promising tool in the prediction of infarct size in patients with anterior STEMI.

Effect of postconditioning on infarction size, adverse left ventricular remodeling, and improvement in left ventricular systolic function in patients with first anterior ST­segment elevation myocardial infarction.

INTRODUCTION: A key method in the treatment of ST-elevation myocardial infarction (STEMI) is recanalization of the infarct-related artery, but this causes heart reperfusion injury. One of the methods to reduce this injury is postconditioning. The available data on the efficacy of this method are contradictory. OBJECTIVES: The aim of the study was to determine the safety of postconditioning as well as its effect on infarction size, improvement in left ventricular ejection fraction (LVEF), and adverse LV remodeling during a 3-month follow-up. PATIENTS AND METHODS: The study involved 39 patients with first anterior STEMI (aged 58 ± 10 years) up to 12 hours from the onset of symptoms. They were randomly assigned to a traditional-reperfusion group (n = 21) or to a postconditioning group (n = 18). The area at risk (AAR) was assessed angiographically. LV remodeling and LVEF were evaluated using echocardiography at 6 days and at 3 months. The infarction size was defined on the basis of magnetic resonance imaging (MRI) at 3 months. RESULTS: In a univariate logistic regression analysis, postconditioning did not affect the improvement of LVEF (odds ratio [OR], 1.63; 95% confidence interval [CI], 0.34-7.7; P = 0.52) or the development of adverse LV remodeling (OR, 0.62; 95% CI, 0.15-2.53; P = 0.5). Moreover, there were no significant differences in infarction size between the groups as measured by MRI after adjustment for the AAR, time to reperfusion, and ST-segment elevation prior to percutaneous coronary intervention. CONCLUSIONS: Postconditioning is a safe method but its application did not affect the volume of the infarction as well as did not improve LVEF or the development of adverse LV remodeling in a 3-month follow-up.

Value of speckle-tracking echocardiography for prediction of left ventricular remodeling in patients with ST-elevation myocardial infarction treated by primary percutaneous intervention.

BACKGROUND: Left ventricular remodeling (LVr) is still common after ST-segment elevation myocardial infarction (STEMI). Early predictors of remodeling are being investigated. The aims of this study were to evaluate the prognostic value of speckle-tracking echocardiography for the prediction of LVr 3 months after primary percutaneous coronary intervention in patients with STEMI and to analyze the relationship between values of peak longitudinal strain of particular LV segments and relative changes of their subvolumes. METHODS: Patients with first STEMI were enrolled. Baseline enzymes were collected, and electrocardiography and echocardiography (transthoracic echocardiography, speckle-tracking echocardiography, and three-dimensional studies) were preformed. Three months after myocardial infarction, two-dimensional and three-dimensional ultrasonographic studies were done. RESULTS: Sixty-six patients were divided into two groups: 44 patients without LVr and 22 patients with LVr. Among 31 patients with anterior wall STEMI, the rate of LVr was 42%. On the basis of assessments of baseline and follow-up myocardial wall contractility, 1,041 segments were analyzed. All segments were divided into normal (n = 842), reversibly dysfunctional (n = 68), and irreversibly dysfunctional (n = 131). Receiver operating characteristic curve analysis showed that global longitudinal strain predicted LVr with an optimal cutoff value of -12.5% (area under the curve, 0.77). In multivariate analysis, diabetes mellitus (odds ratio, 4.61; 95% confidence interval, 1.19-18.02) and global longitudinal strain (odds ratio, 1.19; 95% confidence interval, 1.04-1.37) were determinants of LVr. Positive correlations were found between peak longitudinal strain and changes in subvolumes for all segments (R = 0.11, P = .005) and for those irreversibly dysfunctional (R = 0.22, P = .04). CONCLUSIONS: In patients with STEMI treated by primary percutaneous coronary intervention, the frequency of LVr during 3-month follow-up was high and mainly affected the population with anterior wall myocardial infarction. The results of this study show the clinical value of global longitudinal strain measured by speckle-tracking echocardiography in the prediction of LVr. A moderate correlation was found between the value of peak longitudinal strain and changes in subvolumes attributed to irreversibly dysfunctional segments.

Prediction of left ventricular remodeling in patients with STEMI treated with primary PCI: use of quantitative myocardial contrast echocardiography.

OBJECTIVES: We sought to determine the frequency of left ventricular remodeling in the 6-month follow-up after anterior ST elevation myocardial infarction and the value of quantitative parameters of perfusion contrast echocardiography for prognosis of left ventricular remodeling against other established risk. METHODS: A total of 60 patients with anterior ST elevation myocardial infarction treated by primary percutaneous intervention were examined. In 28 patients, thromboaspiration was performed before stent implantation with Driver catheter. Before and after successful angioplasty, perfusion in myocardial blush grade (MBG) scale was assessed. Various electrocardiogram parameters were analyzed. Resting perfusion with myocardial contrast echocardiography was performed. RESULTS: Logistic regression has permitted one to conclude that higher value of MBG, higher left ventricular ejection fraction at discharge, and higher value of parameter A at quantitative echocardiography in dysfunctional segments were prognostic for lack of remodeling over 6 months. The receiver operating characteristics curves for parameters of quantitative perfusion echocardiography (A, ß, A×ß) allowed us to conclude that value A>1.96 dB, value ß>0.155 s, and value A×ß>0.57 dB/s are optimal cut-off points prognostic for remodeling. Area under the curve was 0.8 for A and 0.85 for ß. CONCLUSION: The best predictors of remodeling in 6 months' observation have appeared to be lower left ventricular ejection fraction at discharge, poorer perfusion assessed angiographically (MBG scale), and the rate of signal intensity increase reflecting the mean bubble velocity of the myocardium by contrast as assessed by contrast echocardiography. Quantitative perfusion angiography independently has high predictive value for the development of remodeling in long-term follow-up.

Predictive value of ischemic mitral regurgitation during the acute phase of ST elevation myocardial infarction treated with primary coronary intervention for left ventricular remodeling in long-term follow-up.

UNLABELLED: Reperfusion therapy, mainly primary percutaneous coronary intervention (PCI), has improved survival and lowered complication rate in patients with ST elevation myocardial infarction (STEMI). Nevertheless, some patients develop left ventricular remodeling (LVR) during long-term follow-up. AIMS: To assess the incidence of ischemic mitral regurgitation (MR) in the acute phase of STEMI treated with primary PCI. To assess prognostic value of MR during acute STEMI for prediction of LVR during long-term follow-up. METHODS: This is a prospective, single-center study in 83 patients with the first STEMI. Inclusion criteria were as follows: time from symptom onset to PCI less than 12 h and successful restoration of blood flow (thrombolysis in myocardial infarction 3) in the infarct-related coronary artery. Transthoracic echocardiography was performed at discharge and 6 months after the MI. RESULTS: At hospital discharge, ischemic MR was found in 35 (42%) patients. At 6 months follow-up, LVR was present in 21 (25%) patients. Univariate analysis revealed that remodeling could be predicted by age, weight, treatment with abciximab, left ventricular ejection fraction (LVEF), leaflets coaptation, coaptation height, tenting area, presence of MR, degree of MR. The best multivariate logistic regression model for remodeling prediction at 6 months was combination of ischemic MR degree (odds ratio (OR)=14.5; 95% confidence interval (CI): 3.89-54.0, P<0.00005), abciximab therapy (OR=0.09; 95% CI: 0.01-0.84, P<0.03) and LVEF (OR=0.89; 95% CI: 0.81-0.99, P<0.03). CONCLUSION: Ischemic MR in STEMI is frequent, even despite effective primary PCI. The regurgitation grade and lower LVEF assessed at hospital discharge and lack of abciximab administration could predict development of LVR at 6 months.

Microvascular damage prevention with thrombaspiration during primary percutaneous intervention in acute myocardial infarction.

BACKGROUND: Despite rapid and complete recanalization of infarct-related artery with percutaneous coronary intervention, microvascular integrity is not often preserved. Several mechanical devices have been proposed to prevent distal embolization, but the impact of these devices on myocardial perfusion remains controversial. AIM: The aim of our study was to assess microvascular damage reduction with quantitative myocardial contrast perfusion echocardiography among patients with the first anterior acute myocardial infarction treated with thromboaspiration during percutaneous coronary intervention. METHODS: Forty-two patients (57.4+/-10 years, 74% males) with first anterior acute myocardial infarction were randomized 1 : 1 to intracoronary thromboaspiration followed by stenting, or to a conventional strategy of stenting alone. Echocardiogram and quantitative myocardial contrast echocardiography were performed 7 days and 1 month later, respectively. Parameter A (reflecting myocardial blood volume), beta (reflecting velocity, myocardial blood flow), and product of A and beta as indicator of myocardial blood flow were analyzed. For each patient mean value of A, beta, and A x beta from all dysfunctional segments was calculated. RESULTS: The study population was divided into two groups: thromboaspiration (group I, 19 patients) and stenting alone (group II, 23 patients). No difference was observed between the both groups in demographic, clinical, echocardiographic, and angiographic data. Parameter A and A x beta were significantly higher in group I than in group II: 8.58+/-2.54 versus 5.29+/-3.18 dB (P<0.001) and 5.29+/-3.73 versus 2.78+/-3.03 dB/s (P<0.001). Multivariate step-down regression analysis revealed that only thromboaspiration before stenting and lower maximum troponin I have been associated with viability preservation in infarcted region. CONCLUSION: Thromboaspiration before stenting in patients with the first anterior myocardial infarction improves myocardial perfusion at the tissue level assessed by quantitative myocardial contrast echocardiography.