Giovanni Maria Santoro

Left ventricular remodeling after primary coronary angioplasty: patterns of left ventricular dilation and long-term prognostic implications.

Background—We prospectively evaluated the prevalence, pattern, and prognostic impact of left ventricular (LV) remodeling after acute myocardial infarction (AMI) successfully treated with primary PTCA. The prevalence, course, and prognostic value of LV remodeling after primary PTCA are still to be clarified. Methods and Results—In 284 consecutive patients with AMI treated with primary PTCA, serial echocardiographic and angiographic studies, within 24 hours (T1), at 1 (T2) and 6 months (T3) after AMI were performed. Long-term (61±14 months) clinical follow-up data were collected for 98.6% patients enrolled in the study. Overall, 85 (30%) patients showed LV dilation (>20% end-diastolic volume increase) at T3 as compared with T1. Early (from T1 to T2), late (from T2 to T3), and progressive dilation patterns (from T1 to T2 to T3) were detected in 42 (15%), 41 (14%), and 36 (13%) patients, respectively. Cardiac death and combined events rate was significantly higher among patients with than among those without LV dilation (P =0.005 and P =0.025, respectively). The pattern of LV dilation during 6 months did not significantly affect survival. Cox survival analysis identified end-systolic volume at T1 and age as baseline predictors and end-systolic volume at T3 and age as 6-month predictors of cardiac death, respectively. Conclusions—LV remodeling after successful PTCA occurs despite sustained patency of the infarct-related artery and preservation of regional and global LV function. LV dilation at 6 months after AMI but not the specific pattern of LV dilation is clearly associated with worse long-term clinical outcome.

A Clinical Trial Comparing Primary Stenting of the Infarct-Related Artery With Optimal Primary Angioplasty for Acute Myocardial Infarction: Results From the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO) Trial

OBJECTIVES This study sought to compare stenting of the primary infarct-related artery (IRA) with optimal primary percutaneous transluminal coronary angioplasty (PTCA) with respect to clinical and angiographic outcomes of patients with an acute myocardial infarction. BACKGROUND Early and late restenosis or reocclusion of the IRA after successful primary PTCA significantly contributes to increased patient morbidity and mortality. Coronary stenting results in a lower rate of angiographic and clinical restenosis than standard PTCA in patients with angina and with previously untreated, noncomplex lesions. METHODS After successful primary PTCA, 150 patients were randomly assigned to elective stenting or no further intervention. The primary end point of the trial was a composite end point, defined as death, reinfarction or repeat target vessel revascularization as a consequence of recurrent ischemia within 6 months of randomization. The secondary end point was angiographic evidence of restenosis or reocclusion at 6 months after randomization. RESULTS Stenting of the IRA was successful in all patients randomized to stent treatment. At 6 months, the incidence of the primary end point was 9% in the stent group and 28% in the PTCA group (p=0.003); the incidence of restenosis or reocclusion was 17% in the stent group and 43% in the PTCA group (p=0.001). CONCLUSIONS Primary stenting of the IRA, compared with optimal primary angioplasty, results in a lower rate of major adverse events related to recurrent ischemia and a lower rate of angiographically detected restenosis or reocclusion of the IRA.

Impact of Microvascular Dysfunction on Left Ventricular Remodeling and Long-Term Clinical Outcome After Primary Coronary Angioplasty for Acute Myocardial Infarction

Background—We hypothesized that preserved microvascular integrity in the area at risk would favorably influence left ventricular (LV) remodeling and long-term outcome after acute myocardial infarction. Methods and Results—Before and after successful primary angioplasty (percutaneous transluminal coronary angioplasty [PTCA]), 124 patients with acute myocardial infarction underwent intracoronary myocardial contrast echo (MCE). An MCE score index (MCESI) was derived by averaging the single-segment score (0=not visible, 1=patchy, 2=homogeneous contrast effect) within the area at risk. An MCESI ≥1 was considered adequate reperfusion. Mean follow-up was 46±32 months. After PTCA, 100 patients showed adequate reperfusion (no microvascular dysfunction, NoMD), whereas 24 did not (MD). MD patients had a higher mean creatine kinase (4153±2422 versus 2743±1774 U/L; P =0.002) and baseline wall-motion score index (2.61±0.31 versus 2.25±0.42; P <0.001) and a lower baseline ejection fraction (33±8% versus 40±7%; P <0.001). From day 1 on, LV volumes progressively increased in the MD patients (n=19) and were larger than those of NoMD patients (n=85) at 6 months (end-diastolic volume 170±55 versus 115±29 mL; P <0.001). MCESI was the most important independent predictor of LV dilation (OR 0.61, 95% CI 0.52 to 0.71, P <0.000001). By Cox analysis, MD represented the only predictor of cardiac death (OR 0.26, 95% CI 0.09 to 0.72, P =0.010) and combined events (cardiac death, reinfarction, and heart failure; OR 0.44, 95% CI 0.23 to 0.85, P =0.014). MD patients showed worse survival in terms of cardiac death (P <0.0001) and combined events (P <0.0001). Conclusions—In reperfused acute myocardial infarction, MD within the risk area is an important predictor of both LV remodeling and unfavorable long-term outcome.

Left Ventricular Remodeling After Primary Coronary Angioplasty

Background— We prospectively evaluated the prevalence, pattern, and prognostic impact of left ventricular (LV) remodeling after acute myocardial infarction (AMI) successfully treated with primary PTCA. The prevalence, course, and prognostic value of LV remodeling after primary PTCA are still to be clarified. Methods and Results— In 284 consecutive patients with AMI treated with primary PTCA, serial echocardiographic and angiographic studies, within 24 hours (T1), at 1 (T2) and 6 months (T3) after AMI were performed. Long-term (61±14 months) clinical follow-up data were collected for 98.6% patients enrolled in the study. Overall, 85 (30%) patients showed LV dilation (>20% end-diastolic volume increase) at T3 as compared with T1. Early (from T1 to T2), late (from T2 to T3), and progressive dilation patterns (from T1 to T2 to T3) were detected in 42 (15%), 41 (14%), and 36 (13%) patients, respectively. Cardiac death and combined events rate was significantly higher among patients with than among those withou...

Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina

The frequency and characteristics of asymptomatic ischemic attacks were investigated in 39 patients with effort angina. During 24 hour Holter monitoring, 32 of the 39 patients displayed one or more episodes of ischemic ST depression. Eight patients had attacks (n = 25) always accompanied by pain; 9 patients had only asymptomatic ischemic episodes (n = 40) and 15 patients had both symptomatic (n = 29) and asymptomatic attacks (n = 76). In the 15 patients exhibiting both symptomatic and asymptomatic attacks, mean duration of symptomatic episodes was longer (probability [p] less than 0.001) and mean maximal ST depression was greater (p less than 0.001). When patients exhibiting only symptomatic episodes were compared with those exhibiting only asymptomatic attacks, differences were not significant. All symptomatic and asymptomatic attacks during Holter monitoring were correlated with the results of stress testing: patients experiencing a delayed response to pain after the onset of St ischemic depression during stress testing had a higher ratio of asymptomatic to symptomatic attacks during Holter monitoring compared with those patients reporting pain before or at the moment of the appearance of ischemic electrocardiographic features during stress testing. It is concluded that: 1) asymptomatic episodes of ischemia are more frequent than symptomatic episodes in patients with effort angina; 2) in the same patient, the severity of ischemia is generally a fundamental factor in determining the presence or absence of pain during an ischemic attack; and 3) differences among patients with respect to predominance of symptomatic or asymptomatic attacks probably depend on individual factors.

Relation between ST-segment changes and myocardial perfusion evaluated by myocardial contrast echocardiography in patients with acute myocardial infarction treated with direct angioplasty

The aim of this study was to evaluate the relation between myocardial perfusion and ST-segment changes in patients with acute myocardial infarction treated with successful direct angioplasty. Thirty-seven patients, successfully treated with direct angioplasty, underwent myocardial contrast echocardiography before and after angioplasty. The sum of ST-segment elevation divided by the number of the leads involved (ST-segment elevation index) was calculated at 1, 5, 10, 20, and 30 minutes after restoration of a Thrombolysis In Myocardial Infarction trial grade 3 flow. After recanalization, myocardial reperfusion within the risk area was observed in 26 patients, whereas a no-reflow phenomenon occurred in 11. In patients with myocardial reperfusion, the ST-segment elevation index progressively declined, whereas in patients with no reflow, no significant change was observed. Reduction of > or = 50% in the ST-segment elevation index occurred in 20 of the 26 patients with reflow and in 1 of the 11 with no reflow (p = 0.0002). An additional increase of > or = 30% in the ST-segment elevation index occurred in 3 patients with reflow and in 7 with no reflow (p = 0.003). Sensitivity, specificity, positive and negative predictive values, and accuracy of the reduction in the ST-segment elevation index for predicting microvascular reflow were 77%, 91%, 95%, 62%, and 81%, respectively. The corresponding values of the increase in ST-segment elevation index for predicting no reflow were 64%, 88%, 70%, 85%, and 81%, respectively. In conclusion, after successful angioplasty, different patterns of myocardial perfusion are associated with different ST-segment changes. Analysis of ST-segment changes predicts the degree of myocardial reperfusion.

Abciximab-Supported Infarct Artery Stent Implantation for Acute Myocardial Infarction and Long-Term Survival A Prospective, Multicenter, Randomized Trial Comparing Infarct Artery Stenting Plus Abciximab With Stenting Alone

Background—The impact on survival of routine use of abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction is not defined. We sought to determine the effect of abciximab on 1-year survival and other major adverse cardiac events of patients with acute myocardial infarction undergoing routine infarct artery stenting. Methods and Results—The Abciximab and Carbostent Evaluation (ACE) Trial is an unblinded, randomized, controlled trial that compared abciximab with placebo in patients undergoing routine infarct artery stent implantation for acute myocardial infarction. At 1 year, the survival rate was 95±2% in the abciximab group and 88±2% in the stent-alone group (P =0.017). The reinfarction rate was 1% in the abciximab group and 6.0% in the stent-alone group, whereas there were no differences between groups in target vessel revascularization rate (16.5% in the abciximab group, 17.5% in the stent-alone group). Conclusions—Abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction resulted in improved 1-year survival and lower reinfarction rates.

Myocardial Contrast Echocardiography Versus Dobutamine Echocardiography for Predicting Functional Recovery After Acute Myocardial Infarction Treated With Primary Coronary Angioplasty

OBJECTIVES We sought to compare myocardial contrast echocardiography with low dose dobutamine echocardiography for predicting 1-month recovery of ventricular function in acute myocardial infarction treated with primary coronary angioplasty. BACKGROUND The relation between myocardial perfusion and contractile reserve in patients with acute myocardial infarction, in whom anterograde flow is fully restored without significant residual stenosis, is still unclear. METHODS Thirty patients with acute myocardial infarction treated successfully with primary coronary angioplasty underwent intracoronary contrast echocardiography before and after angioplasty and dobutamine echocardiography 3 days after the index infarction. One month later, two-dimensional echocardiography and coronary angiography were repeated in all patients and contrast echocardiography in 18 patients. RESULTS After coronary recanalization, 26 patients showed myocardial reperfusion within the risk area, although 4 did not. At 1-month follow-up, all patients had a patient infarct-related artery without significant restenosis. Both left ventricular ejection fraction and wall motion score index within the risk area significantly improved in the patients with reperfusion ([mean +/- SD] 38 +/- 8% vs. 48 +/- 12%, p < 0.005; and 2.35 +/- 0.5 vs. 2 +/- 0.6, p < 0.001, respectively), but not in those with no reflow. Of the 72 nonperfused segments before angioplasty, 27 showed functional improvement at follow-up. Myocardial contrast echocardiography had a sensitivity and a negative predictive value similar to dobutamine echocardiography in predicting late functional recovery (96% vs. 89% and 89% vs. 93%, respectively), but a lower specificity (18% vs. 91%, p < 0.001), positive predictive value (41% vs. 86%, p < 0.001) and overall accuracy (47% vs. 90%, p < 0.001). CONCLUSIONS Microvascular integrity is a prerequisite for myocardial viability after acute myocardial infarction. However, contrast enhancement shortly after recanalization does not necessarily imply a late functional improvement. Thus, contractile reserve elicited by low dose dobutamine is a more accurate predictor of regional functional recovery after reperfused acute myocardial infarction than microvascular integrity.

Systematic direct angioplasty and stent-supported direct angioplasty therapy for cardiogenic shock complicating acute myocardial infarction : In-hospital and long-term survival

OBJECTIVES This prospective observational study was conducted to examine the apparent impact of a systematic direct percutaneous transluminal coronary angioplasty (PTCA) strategy on mortality in a series of 66 consecutive patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and to analyze the predictors of outcome after successful direct PTCA. BACKGROUND Previous studies have reported encouraging results with PTCA in patients with AMI complicated by cardiogenic shock, but a biased case selection for PTCA may have heavily influenced the observed outcomes. METHODS All patients admitted with AMI were considered eligible for direct PTCA, including those with the most profound shock, and no upper age limit was used. The treatment protocol also included stenting of the infarct-related artery for a poor or suboptimal angiographic result after conventional PTCA. RESULTS Between January 1995 and March 1997, 364 consecutive patients underwent direct PTCA, and in 66 patients AMI was complicated by cardiogenic shock. In patients with cardiogenic shock, direct PTCA had a success rate of 94%; an optimal angiographic result was achieved in 85%; primary stenting of the infarct-related artery was accomplished in 47%; and the in-hospital mortality rate was 26%. Univariate analysis showed that patient age, chronic coronary occlusion and completeness of revascularization were significantly related to in-hospital mortality. The mean follow-up period was 16 +/- 8 months. Survival rate at 6 months was 71%. Comparison of event-free survival in patients with a stented or nonstented infarct-related artery suggests an initial and long-term benefit of primary stenting. CONCLUSIONS Systematic direct PTCA, including stent-supported PTCA, can establish a Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the great majority of patients presenting with AMI and early cardiogenic shock. High performance criteria, including new devices such as coronary stents, should be considered in randomized trials where mechanical revascularization therapy is being tested.

Influence of Infarct-Zone Viability on Left Ventricular Remodeling After Acute Myocardial Infarction

BACKGROUND The relation between residual myocardial viability after acute myocardial infarction (AMI) and ventricular remodeling has yet to be fully elucidated. We hypothesized that the presence of residual viability would favorably influence left ventricular remodeling after AMI and that serial changes in left ventricular dimensions might be related to the extent of myocardial viability in the infarct zone. METHODS AND RESULTS Ninety-three patients with a first AMI successfully treated with primary coronary angioplasty underwent two-dimensional echocardiography within 24 hours of admission and low-dose dobutamine echocardiography at a mean of 3 days after AMI. Two-dimensional echocardiography and coronary angiography were obtained in all patients 1 and 6 months after coronary angioplasty. On the basis of dobutamine echocardiography responses, patients were divided in two subsets: those with (n=48; group I) and those without (n=45; group II) infarct-zone viability. There was no difference in minimal lesion diameter and infarct-related artery patency at 1 and 6 months between the two groups. Group II patients had significantly greater end-diastolic (76+/-18 versus 53+/-14 mL/m2; P<.0003) and end-systolic (42+/-17 versus 22+/-11 mL/m2; P<.0003) volumes at 6 months than did patients in group 1. The extent of infarct-zone viability was significantly inversely correlated with percent changes in end-diastolic volumes at 6 months (r=-.66; P<.000001) and was the most powerful independent predictor of late left ventricular dilation. CONCLUSIONS After reperfused AMI, the degree of left ventricular dilation, when it occurs, is inversely related to the extent of residual myocardial viability in the infarct zone. Thus, the absence of residual infarct-zone viability discriminates patients who develop progressive left ventricular dilation after reperfused AMI from those who maintain normal left ventricular geometry.