Galiuto Leonarda, Garramone Barbara, Scarà Antonio, Rebuzzi Antonio G, Crea Filippo, La Torre Giuseppe, Funaro Stefania, Madonna Mariapina, Fedele Francesco, Agati Luciano
Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
J Am Coll Cardiol. 2008 Feb 5;51(5):552-9. doi: 10.1016/j.jacc.2007.09.051.
We sought to evaluate the value of the extent of microvascular damage as assessed with myocardial contrast echocardiography (MCE) in the prediction of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) as compared with established clinical and angiographic parameters of reperfusion.
Early identification of post-percutaneous coronary intervention microvascular dysfunction may help in tailoring appropriate pharmacological interventions in high-risk patients. The ideal method to establish effective microvascular reperfusion after percutaneous coronary intervention remains to be determined.
A total of 110 patients with first successfully reperfused STEMI were enrolled in the AMICI (Acute Myocardial Infarction Contrast Imaging) multicenter study. After reperfusion, peak creatine kinase, ST-segment reduction, and Thrombolysis In Myocardial Infarction (TIMI) and myocardial blush grade were calculated. We evaluated perfusion defects with MCE by using continuous infusion of Sonovue (Bracco, Milan, Italy) in real-time imaging. The endocardial length of contrast defect (CD) on day 1 after reperfusion was calculated. Wall motion score index, the extent of wall motion abnormalities, LV end-diastolic volume, and ejection fraction after reperfusion and at follow-up also were calculated.
Of 110 patients, 25% evolved in LV remodeling and 75% did not. Although peak creatine kinase, ST-segment reduction >70%, and myocardial blush grade were not different between groups, in patients exhibiting LV remodeling, TIMI flow grade 3 was less frequent (p < 0.001), wall motion score index was greater (p < 0.001), and CD was greater (p < 0.001). At multivariate analysis, only TIMI flow grade <3 and CD with a cutoff of >25% were independently associated with LV remodeling. Among patients with TIMI flow grade 3, CD was the only independent variable associated with LV remodeling.
Among patients with TIMI flow grade 3, the extent of microvascular damage, detected and quantitated by MCE, is the most powerful independent predictor of LV remodeling after STEMI as compared with persistent ST-segment elevation and myocardial blush grade.
我们试图评估经心肌对比超声心动图（MCE）评估的微血管损伤程度在预测ST段抬高型心肌梗死（STEMI）后左心室（LV）重构方面的价值，并与已确立的临床和血管造影再灌注参数进行比较。
经皮冠状动脉介入治疗后早期识别微血管功能障碍可能有助于为高危患者制定合适的药物干预措施。确定经皮冠状动脉介入治疗后有效微血管再灌注的理想方法仍有待确定。
总共110例首次成功再灌注的STEMI患者被纳入AMICI（急性心肌梗死对比成像）多中心研究。再灌注后，计算肌酸激酶峰值、ST段降低程度以及心肌梗死溶栓（TIMI）和心肌 blush 分级。我们通过在实时成像中持续输注声诺维（意大利米兰的Bracco公司），用MCE评估灌注缺损。计算再灌注后第1天造影剂缺损（CD）的心内膜长度。还计算再灌注后及随访时的室壁运动评分指数、室壁运动异常程度、左心室舒张末期容积和射血分数。
在110例患者中，25%发生了左心室重构，75%未发生。尽管两组之间的肌酸激酶峰值、ST段降低>70%以及心肌 blush 分级无差异，但在发生左心室重构的患者中，TIMI血流3级的发生率较低（p<0.001），室壁运动评分指数较高（p<0.001），且造影剂缺损较大（p<0.001）。多变量分析显示，只有TIMI血流分级<3以及造影剂缺损>25%的截断值与左心室重构独立相关。在TIMI血流3级的患者中，造影剂缺损是与左心室重构相关的唯一独立变量。
在TIMI血流3级的患者中，与持续性ST段抬高和心肌 blush 分级相比，经MCE检测和定量的微血管损伤程度是STEMI后左心室重构最有力的独立预测指标。
