Prediction of Transmural Extent of Infarction with Contrast Echocardiographically Derived Index of Myocardial Blood Flow and Myocardial Blood Volume Fraction: Comparison with Contrast-enhanced Magnetic Resonance Imaging

doi:10.1016/j.echo.2006.04.027

Journal of the American Society of Echocardiography

Volume 19, Issue 10, October 2006, Pages 1211-1219

Presented in part at the Annual Scientific Session of the American Heart Association, November 2005, Dallas, Texas.

https://doi.org/10.1016/j.echo.2006.04.027 Get rights and content

Background

We sought to determine the accuracy of myocardial contrast echocardiography (MCE)-derived index of myocardial blood flow and myocardial blood volume fraction (MBVF) in predicting transmural extent of infarction and wall-motion recovery.

Methods

Low and high mechanical index MCE and contrast-enhanced magnetic resonance imaging were performed 5 to 7 days after successful percutaneous revascularization in 30 patients with acute myocardial infarction and regional wall-motion change was assessed 3 months later. The index of myocardial blood flow was calculated as A × β (dB/s) using the equation y = A (1 − e^−βt), which fits the replenishment curve of low mechanical index MCE. The MBVF (mL/100 g myocardium) was calculated as 100 × 10^{relative contrast intensity [CI]/10}, using the relative CI by subtracting the cavity CI from the adjacent transmural CI using high mechanical index MCE. The contrast-enhanced magnetic resonance imaging–derived transmural extent of delayed hyperenhancement (DE) in 16 segments were measured and compared with corresponding MCE data.

Results

Among 480 segments, 382 measurable segments were subdivided into 5 groups as follows: no DE, 1% to 25% DE, 26% to 50% DE, 51% to 75% DE, and 76% to 100% DE. An increment of the extent of DE was significantly related to a decrement of A × β (P < .001) and MBVF (P < .001). The optimal cut-off MBVF for predicting greater than 50% DE was 1.92 mL (sensitivity 82%, specificity 73%, P < .01), and persistently dysfunctional motion was 1.81 mL (sensitivity 74%, specificity 75%, P < .01).

Conclusion

The MCE-derived A × β and MBVF can be effective predictors of transmural extent of infarction and wall-motion recovery in the reperfused acute myocardial infarction.

Section snippets

Study Population

Thirty consecutive patients who underwent successful percutaneous coronary intervention (PCI) within 48 hours of symptom onset for AMI were included in the study. After PCI all the patients were given a daily dose of aspirin (100 mg) and clopidogrel (75 mg) for at least 3 months. The exclusion criteria were as follows: (1) history of myocardial infarction; (2) absence of thrombolysis in myocardial infarction grade 3 coronary flow in the infarct-related artery after PCI; (3) additional clinical

Reproducibility of Data

Interobserver variability for measuring relative CI, A × β in MCE, and percentage DE in ceMRI was 12.3%, 10.7%, and 4.1%, respectively. Intraobserver variability was 9.2%, 8.3%, and 2.7%, respectively.

Patient Characteristics

Of the 30 patients (mean age 59.2 ± 10.7 years), 25 (83%) were male and 5 (17%) were female. In all, 24 patients had left anterior descending coronary artery (LAD)-, two had left circumflex coronary artery (LCx)-, and 4 had right coronary artery (RCA)-territory myocardial infarction. A total of 25

Discussion

Using the myocardial contrast replenishment curve and the new method of measuring the relative CI (pixel-by-pixel method), we could successfully obtain the index of MBF and absolute MBVF. Our results demonstrate that MCE-derived A × β and MBVF can be effective predictors of the TEI and later wall-motion improvement in patients with reperfused AMI with acceptable sensitivity and specificity.

References (24)

A. Yano et al.
Myocardial contrast echocardiography with a new calibration method can estimate myocardial viability in patients with myocardial infarction
J Am Coll Cardiol
(2004)
R. Vogel et al.
The quantification of absolute myocardial perfusion in humans by contrast echocardiography
J Am Coll Cardiol
(2005)
H. Leong-Poi et al.
Quantification of myocardial perfusion and determination of coronary stenosis severity during hyperemia using real-time myocardial contrast echocardiography
J Am Soc Echocardiogr
(2001)
K. Wei et al.
The basis for stenosis detection using venous administration of microbubbles during myocardial contrast echocardiographyBolus of continuous infusion?
J Am Coll Cardiol
(1998)
T. Sakuma et al.
Prediction of short- and intermediate-term prognoses of patients with acute myocardial infarction using myocardial contrast echocardiography one day after recanalization
J Am Coll Cardiol
(1998)
E. Brochet et al.
Early changes in myocardial perfusion patterns after myocardial infarction: relation with contractile reserve and functional recovery
J Am Coll Cardiol
(1998)
L. Bolognese et al.
Myocardial contrast echocardiography versus dobutamine echocardiography for predicting functional recovery after acute myocardial infarction treated with primary coronary angioplasty
J Am Coll Cardiol
(1996)
J.M. Swinburn et al.
Intravenous myocardial contrast echocardiography predicts recovery of dyssynergic myocardium early after acute myocardial infarction
J Am Coll Cardiol
(2001)
S. Kaul et al.
Microvasculature in acute myocardial ischemia, part II: evolving concepts in pathophysiology, diagnosis, and treatment
Circulation
(2003)
K.C. Wu et al.
Noninvasive imaging of myocardial viability: current techniques and future development
Circ Res
(2003)

R.J. Kim et al.

Relationship of MRI delayed contrast enhancement to irreversible injury, infracted age, and contractile function

Circulation

(1999)

W.A. Zoghbi

Evaluation of myocardial viability with contrast echocardiography

Am J Cardiol

(2002)

Cited by (15)

Functional Recovery After Acute Myocardial Infarction. Comparison Between Angiography, Electrocardiography, and Cardiovascular Magnetic Resonance Measures of Microvascular Injury
2008, Journal of the American College of Cardiology
We examined the relation between angiographic, electrocardiographic, and gadolinium-enhanced cardiovascular magnetic resonance (CMR) characteristics of microvascular obstruction (MVO), and their predictive value on functional recovery after acute myocardial infarction (AMI).
Microvascular obstruction on CMR has been shown to predict left ventricular (LV) remodeling, but it is not well known how it compares with commonly used criteria of microvascular injury, and earlier reports have produced conflicting results on the significance and extent of MVO.
Thrombolysis In Myocardial Infarction (TIMI) flow grade, myocardial blush grade (MBG), and ST-segment resolution were assessed in 60 patients with AMI treated with primary stenting. Cardiovascular magnetic resonance was performed between 2 and 9 days after revascularization to determine early MVO on first-pass perfusion imaging, late MVO on late gadolinium-enhanced imaging, and infarct size and transmural extent. Cine imaging was used to determine LV volumes and global and regional function at baseline and 4-month follow-up.
Early and late MVO were both related to incomplete ST-segment resolution (p = 0.002 and p = 0.01, respectively), but not to TIMI flow grade and MBG. Of all angiographic, electrocardiographic, and CMR variables, late MVO was the strongest parameter to predict changes in end-diastolic volume (β = 0.53; p = 0.001), end-systolic volume (β = 8.67; p = 0.001), and ejection fraction (β = 3.94; p = 0.006) at follow-up. Regional analysis showed that late MVO had incremental diagnostic value to transmural extent of infarction (odds ratio: 0.18; p < 0.0001).
In patients after revascularized AMI, late MVO proved a more powerful predictor of global and regional functional recovery than all of the other characteristics, including transmural extent of infarction.
Contrast Echocardiography: Evidence for Clinical Use
2008, Journal of the American Society of Echocardiography
Citation Excerpt :
MCE may also play a pivotal role in the prediction of functional recovery in patients after ST-segment-elevation myocardial infarction by visualizing reflow of blood to the area at risk. The ability of MCE to predict functional recovery is comparable with that of cardiovascular magnetic resonance imaging.73,74 MCE has been shown to provide greater accuracy than SPECT in the assessment of myocardial viability in patients after acute myocardial infarction.75,76
Continuing Medical Education Activity for “Contrast Echocardiography: Evidence for Clinical Use”
The American Society of Echocardiography is accredited by the Accreditation Council for continuing Medical Education to provide continuing medical education for physicians.
The American Society of Echocardiography designates this activity for a maximum of 1.0 AMA PRA Category 1 Credits^™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
ARDMS and CCI recognize ASE's certificates and have agreed to honor the credit hours towards their registry requirements for sonographers.
The American Society of Echocardiography is committed to resolving all conflict of interest issues, and its mandate is to retain only those authors with financial interests that can be reconciled with the goals and educational integrity of the educational activity. Disclosure of faculty and commercial support sponsor relationships, if any, will be made known before the activity.
1. Cardiologists, physicians, physician's assistants, and nurses with an interest in cardiac echocardiography and cardiac imaging 2. Cardiac ultrasonographers
Upon completing this activity, participants will be able to: (1). Appreciate why contrast agents are required (2). State the desirable properties of an ideal contrast agent (3). Understand the benefits of using contrast agents in various clinical settings (4). Be aware of the commonest reported side-effects and FDA cautions on the use of contrast agents
Vinay K Bhatia BSc (Hons.), MBBS, MRCP, PhD
No disclosures
Roxy Senior MBBS, MD, DM, FRCP, FESC, FACC
Research grants:
Accusphere
Bracco
Bristol-Myers Squibb Medical Imaging had no influence on the manuscript nor provided grant support. Bristol-Myers Squibb Medical Imaging did submit a requested literature search and performed a requested formatting of the manuscript to conform to the technical requirements of the journal.
Estimated time to complete this activity: 1 hour
The failure of echocardiography to give diagnostically useful information in a significant proportion of patients has led to the development of specific contrast agents to enhance imaging. Suitable contrast media must have the ability to modify ultrasound characteristics, be capable of crossing the pulmonary capillary bed, show stability over the duration of a procedure, offer low blood solubility with low toxicity and be rapidly eliminated. The current generation of ultrasound contrast agents comprises microbubbles of a high molecular–weight gas encapsulated in a shell of phospholipid or protein. A review of the clinical evidence shows that these agents are clinically effective in enhancing echocardiographic imaging. They enable the rescue of failed procedures, often sparing patients from invasive tests, but appear not to add to the burden of side effects. Indeed, the benefits of using contrast agents in stress echocardiography have been recommended in recently published American Society of Echocardiography guidelines. Myocardial contrast echocardiography has now developed to the stage where assessment of myocardial perfusion for the detection of coronary artery disease is possible with the same diagnostic accuracy as radionuclide imaging. However, in comparison with the latter technique, it is less expensive, is more portable, and avoids the use of ionizing radiation. It is precisely the ability of myocardial contrast echocardiography to simultaneously assess function and perfusion at the bedside that has given it a unique role in clinical practice. This review provides an overview of the clinical evidence supporting the efficacy of contrast echocardiography in the assessment of myocardial structure, function, and perfusion.
The clinical applications of myocardial contrast echocardiography
2007, European Journal of Echocardiography
Sonothrombolysis Improves Myocardial Dynamics and Microvascular Obstruction Preventing Left Ventricular Remodeling in Patients With ST Elevation Myocardial Infarction
2020, Circulation: Cardiovascular Imaging
Role of coronary microcirculation in no-reflow phenomenon in myocardial infarction with ST segment elevation
2019, Microcirculation: From Bench to Bedside
Value of contrast-enhanced echocardiography of left cardiac chambers for clinical practice
2018, Kardiologiya

View all citing articles on Scopus

: Supported by Yonsei University College of Medicine Research Fund of 2005.

View full text

Original articlePrediction of Transmural Extent of Infarction with Contrast Echocardiographically Derived Index of Myocardial Blood Flow and Myocardial Blood Volume Fraction: Comparison with Contrast-enhanced Magnetic Resonance Imaging

Background

Methods

Results

Conclusion

Section snippets

Study Population

Reproducibility of Data

Patient Characteristics

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Microvasculature in acute myocardial ischemia, part II: evolving concepts in pathophysiology, diagnosis, and treatment

Circulation

Noninvasive imaging of myocardial viability: current techniques and future development

Circ Res

Relationship of MRI delayed contrast enhancement to irreversible injury, infracted age, and contractile function

Circulation

Evaluation of myocardial viability with contrast echocardiography

Am J Cardiol

Original article
Prediction of Transmural Extent of Infarction with Contrast Echocardiographically Derived Index of Myocardial Blood Flow and Myocardial Blood Volume Fraction: Comparison with Contrast-enhanced Magnetic Resonance Imaging