ST段抬高型心肌梗死患者慢性完全闭塞病变经皮冠状动脉介入治疗后局部左心室功能恢复改善：随机对照EXPLORE试验的心血管磁共振研究
Improved recovery of regional left ventricular function after PCI of chronic total occlusion in STEMI patients: a cardiovascular magnetic resonance study of the randomized controlled EXPLORE trial.
作者信息
Elias Joëlle, van Dongen Ivo M, Hoebers Loes P, Ouweneel Dagmar M, Claessen Bimmer E P M, Råmunddal Truls, Laanmets Peep, Eriksen Erlend, van der Schaaf René J, Ioanes Dan, Nijveldt Robin, Tijssen Jan G, Hirsch Alexander, Henriques José P S
机构信息
Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands.
Sahlgrenska University Hospital, Gothenburg, Sweden.
出版信息
J Cardiovasc Magn Reson. 2017 Jul 19;19(1):53. doi: 10.1186/s12968-017-0369-z.
BACKGROUND
The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) trial did not show a significant benefit of percutaneous coronary intervention (PCI) of the concurrent chronic total occlusion (CTO) in ST-segment elevation myocardial infarction (STEMI) patients on global left ventricular (LV) systolic function. However a possible treatment effect will be most pronounced in the CTO territory. Therefore, we aimed to study the effect of CTO PCI compared to no-CTO PCI on the recovery of regional LV function, particularly in the CTO territory.
METHODS
Using cardiovascular magnetic resonance (CMR) we studied 180 of the 302 EXPLORE patients with serial CMR (baseline and 4 months follow-up). Segmental wall thickening (SWT) was quantified on cine images by an independent core laboratory. Dysfunctional segments were defined as SWT < 45%. Dysfunctional segments were further analyzed by viability (transmural extent of infarction (TEI) ≤50%.). All outcomes were stratified for randomization treatment.
RESULTS
In the dysfunctional segments in the CTO territory recovery of SWT was better after CTO PCI compared to no-CTO PCI (ΔSWT 17 ± 27% vs 11 ± 23%, p = 0.03). This recovery was most pronounced in the dysfunctional but viable segments(TEI < 50%) (ΔSWT 17 ± 27% vs 11 ± 22%, p = 0.02). Furthermore in the CTO territory, recovery of SWT was significantly better in the dysfunctional segments in patients with Rentrop grade 2-3 collaterals compared to grade 0-1 collaterals to the CTO (16 ± 26% versus 11 ± 24%, p = 0.04).
CONCLUSION
CTO PCI compared with no-CTO PCI is associated with a greater recovery of regional systolic function in the CTO territory, especially in the dysfunctional but viable segments. Further research is needed to evaluate the use of CMR in selecting post-STEMI patients for CTO PCI and the effect of regional LV function recovery on clinical outcome.
TRIAL REGISTRATION
Trialregister.nl NTR1108 , Date registered NTR: 30-okt-2007.
背景
评估急性ST段抬高型心肌梗死（STEMI）后慢性完全闭塞病变（CTO）经皮冠状动脉介入治疗（PCI）中Xience支架与左心室功能（EXPLORE）试验未显示在全球左心室（LV）收缩功能方面，STEMI患者并发CTO的PCI有显著益处。然而，可能的治疗效果在CTO区域最为明显。因此，我们旨在研究与非CTO PCI相比，CTO PCI对局部LV功能恢复的影响，特别是在CTO区域。
方法
使用心血管磁共振（CMR），我们对302例EXPLORE患者中的180例进行了连续CMR检查（基线和4个月随访）。由独立核心实验室在电影图像上对节段性室壁增厚（SWT）进行量化。功能失调节段定义为SWT<45%。通过存活心肌（梗死透壁范围（TEI）≤50%）对功能失调节段进行进一步分析。所有结果根据随机治疗进行分层。
结果
在CTO区域的功能失调节段中，与非CTO PCI相比，CTO PCI后SWT的恢复更好（SWT变化17±27%对11±23%，p=0.03）。这种恢复在功能失调但存活的节段（TEI<50%）中最为明显（SWT变化17±27%对11±22%，p=0.02）。此外，在CTO区域，Rentrop 2-3级侧支循环患者功能失调节段的SWT恢复明显优于CTO为0-1级侧支循环的患者（16±26%对11±24%，p=0.04）。
结论
与非CTO PCI相比，CTO PCI与CTO区域局部收缩功能的更大恢复相关，特别是在功能失调但存活的节段。需要进一步研究以评估CMR在选择STEMI后适合CTO PCI患者中的应用以及局部LV功能恢复对临床结局的影响。
试验注册
Trialregister.nl NTR1108，注册日期：2007年10月30日。
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