Max Pichler

Left ventricular ejection fraction determined by radionuclide ventriculography in early stages of first transmural myocardial infarction: Relation to short-term prognosis

Left ventricular ejection fraction was determined with multiple gated equilibrium cardiac blood pool scintigraphy within 24 hours of the onset of symptoms of a first acute transmural myocardial infarction in 56 patients (23 with anterior and 33 with inferior infarction). A depressed ejection fraction (less than 0.54) was more frequent in patients with anterior (96 percent) than in those with inferior (61 percent) infarction (p The overall data thus indicate that left ventricular ejection fraction is significantly reduced in acute anterior myocardial infarction but not in inferior infarction except in patients with associated precordial S-T segment depression. An ejection fraction of 0.30 or less is of prognostic value in predicting a high risk of hospital morbidity and mortality from pump failure in patients with a first acute transmural infarction.

Noninvasive identification of a high risk subset of patients with acute inferior myocardial infarction

Abstract Although S-T segment depression of various degrees is known to occur in the precordial electrocardiogram of patients with acute inferior myocardial infarction its prognostic significance is unknown. Left ventricular ejection fraction and regional wall motion were therefore measured noninvaslvely with radionucilde ventriculography and related to the electrocardiographic changes within 48 hours of the onset of acute transmural inferior infarction in 44 patients who had had no previous infarction. The mean ejection fraction of 0.45 ± 0.13 (standard deviation) in Group A (24 patients with greater than 1 mm S-T segment depression in at least two of six precordial leads) was lower (p The overall data indicate that patients with inferior wall infarction who have associated precordial S-T segment depression have greater global and regional left ventricular dysfunction presumably due to associated ischemia or infarction in areas remote from the inferior wall and they have relatively high in-hospital mortality and morbidity rates. Early noninvasive detection of this high risk subset may permit the testing of aggresive modes of therapy designed to limit the extent of myocardial ischemic damage with resultant decrease in mortality and morbidity.

Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction

To determine the spectrum and prognostic implications of left and right ventricular (LV and RV) ejection fractions (EFs) in acute myocardial infarction (AMI), radionuclide ventriculography was performed in 114 consecutive patients, admitted without (Killip class I, 78 patients) or with (killip class II, 36 patients) clinical signs of pulmonary congestion within 24 hours of onset of symptoms of a transmural AMI. Mean LVEF was significantly lower in patients in Killip class II than in those in class I (0.32 +/- 0.11 vs 0.46 +/- 0.15, p less than 0.001) and in patients with anterior than inferior AMI (0.34 +/- 0.11 vs 0.52 +/- 0.14, p less than 0.001). Of the 36 patients with a severely depressed (0.30 or less) LVEF, 15 (42%) were in Killip class I. Mean RVEF did not differ significantly between Killip class I and II patients (0.42 +/- 0.11 vs 0.40 +/- 0.12, difference not significant) but was significantly lower in patients with inferior than anterior AMI (0.38 +/- 0.09 vs 0.44 +/- 0.11, p = 0.005). In patients with inferior AMI, a depressed RVEF (0.38 or less) was associated with a normal LVEF in 30% and a depressed LVEF in 20%, whereas in those with anterior AMI, a depressed RVEF, observed in 25% of patients, occurred only in association with a depressed LVEF.(ABSTRACT TRUNCATED AT 250 WORDS)

Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction: clinical and hemodynamic correlates and implications for therapy and prognosis

To determine the clinical and hemodynamic correlates as well as therapeutic and prognostic implications of predominant right ventricular dysfunction complicating acute myocardial infarction, 43 consecutive patients with scintigraphic evidence of right ventricular dyssynergy and a depressed right ventricular ejection fraction (less than 0.39) in association with normal or near normal left ventricular ejection fraction (greater than or equal to 0.45) were prospectively evaluated. All 43 patients had acute inferior infarction, forming 40% of patients with acute inferior infarction, and only eight (24%) had elevated jugular venous pressure on admission. On hemodynamic monitoring, 74% of patients had a depressed cardiac index (less than or equal to 2.5 liters/min per m2), averaging 2.0 +/- 0.05 for the group. Of these, 30% did not demonstrate previously described hemodynamic criteria of predominant right ventricular infarction (right atrial pressure greater than or equal to 10 mm Hg or right atrial to pulmonary capillary wedge pressure ratio greater than or equal to 0.8, or both). The left ventricular end-diastolic volume was reduced to 49 +/- 11 ml/m2 (n = 22) and correlated significantly with the stroke volume index (r = 0.82; p less than 0.0001) and cardiac index (r = 0.57; p = 0.005). The follow-up right ventricular ejection fraction, determined in 33 patients, showed an increase of 10% or greater in 26 (79%), increasing from a mean value of 0.30 +/- 0.06 to 0.40 +/- 0.09 (p less than 0.0001) without a significant overall change in the mean left ventricular ejection fraction (0.56 +/- 0.10 to 0.56 +/- 0.11, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Wall motion abnormalities and electrocardiographic changes in acute transmural myocardial infarction: Implications of reciprocal ST segment depression

Left ventricular ejection fraction and regional wall motion were assessed by multigated equilibrium radionuclide ventriculography within 24 hours of onset of first acute transmural myocardial infarction (MI) in 32 patients. Abnormal left ventricular wall motion was noted in all 16 patients with anterior infarction and in 14 of 16 (87.5%) patients with inferior infarction. Regional wall motion abnormalities frequently included areas adjacent to and remote from those predicted by the ECG location of ST elevation and pathologic Q waves. Such remote wall motion abnormalities were associated with reciprocal ST segment depression in 17 of 18 (94%) patients, and conversely reciprocal ST segment depressions were associated with remote wall motion abnormalities in 17 of 24 (71%) patients. The left ventricular ejection fraction was lower in patients with a reciprocal ST segment depression compared to those without (anterior MI 0.29 +/- 0.07 vs 0.43 +/- 0.08, p less than 0.01; inferior MI 0.45 +/- 0.11 vs 0.63 +/- 0.06, p less than 0.001). In addition, the peak MB-CK levels were higher in patients with compared to those without reciprocal ST segment depression (anterior MI 268 +/- 183 vs 102 +/- 60, p less than 0.05; inferior MI 186 +/- 120 vs 67 +/- 20, p less than 0.05). Thirteen of 18 (72%) patients with reciprocal ST segment depression compared to 4 of 13 (31%) patients without reciprocal ST segment depression had a complicated clinical course during their hospital stay. These observation suggest that global left ventricular dysfunction in first acute transmural MI is greater when reciprocal ST segment depression is present on the 12-lead ECG.(ABSTRACT TRUNCATED AT 250 WORDS)

Radionuclide assessment of sequential changes in left and right ventricular function following first acute transmural myocardial infarction

The purpose of this study was to define the sequential changes in left and right ventricular ejection fraction (LVEF, RVEF) and regional LV wall motion following first transmural acute myocardial infarction (AMI). Fifty-four patients with either anterior (n = 28) or inferior (n = 26) infarction underwent radionuclide ventriculography (RNV) within 48 hours of onset of chest pain (study 1), between days 3 and 6 (study 2), and again between days 7 and 25 (study 3). Twenty-six of the patients with anterior MI (93%) had initial LVEF less than 0.54, compared with 13 of 26 patients (50%) with inferior MI (p less than 0.01). Eleven of 26 patients (42.3%) with inferior MI had initial RVEF less than 0.39, compared with 8 of 27 patients (29.6%) with anterior MI (p less than 0.01). There were no overall significant serial changes in mean LVEF or mean RVEF in patients with either anterior or inferior MI. From study 1 to study 2, LVEF did not change in 24 patients (44%), improved in 13 (24%), and worsened in 17 (31%). From study 1 to study 3, LVEF remained unchanged in 15 patients (35%), improved in 17 (39%), and worsened in 11 (26%). From study 1 to study 2, RVEF did not change in 25 of 51 patients (49%), improved in 17 (31%), and worsened in 9 (17%). From study 1 to study 3, RVEF remained unchanged in 14 (38%), improved in 18 (48%), and worsened in five (14%). Changes in EF tended to occur early in the hospital course, with little subsequent changes. Serial changes in EF could not be predicted by clinical or demographic variables or by location of infarction. Significant changes in LVEF typically occurred without concurrent change in regional LV wall motion, suggesting alteration in ventricular loading rather than change in intrinsic myocardial performance. Initial depression of LVEF correlated with in-hospital mortality as well as with development of congestive heart failure and conduction defects. However, sequential changes in LVEF did not correlate with short-term prognosis. We conclude that sequential changes in LVEF and RVEF occur frequently following AMI, appear to reflect ventricular loading conditions rather than intrinsic change in myocardial performance, and do not correlate well with short-term prognosis.

Photokymography: A noninvasive method of detecting ischemic segmental myocardial wall motion abnormalities

The photokymograph is a new and simple noninvasive device for assessing epicardial segmental myocardial wall motion utilizing cardiac fluoroscopy and image intensification. The validity of this technique in detecting wall motion changes occurring with ischemia was assessed in seven closed chest dogs undergoing acute balloon occlusion of the left circumflex coronary artery. Acute occlusion resulted in a prompt change in the analog signal of the photokymogram, characterized first by a decreased systolic inward motion and late systolic outward movement that later became akinetic and dyskinetic. Systolic amplitude decreased 18 +/- 7 percent (mean +/- standard error of the mean) within 5 seconds of occlusion and progressed to systolic outward motion (- 106 +/- 24 percent) at 2 minutes. The time course and type of morphologic changes observed after occlusion were similar to those previously described using invasive methods. Furthermore, such changes preceded electrocardiographic S-T segment elevation. These data suggest that photokymography is a sensitive technique for noninvasive detection of acute ischemic segmental wall motion abnormalities and holds promise as a simple method of detecting ischemic heart disease in man.