Tissue viability by contrast echocardiography - EHJ Cardiovascular ...

Eur J Echocardiography 7 Suppl. 2 (2006) S22–S29
Tissue viability by contrast echocardiography
Luciano Agati a, *, Stefania Funaro b , Mariapina Madonna a ,
Mariella Montano a , Emanuela Berardi a , Maria Novella Picardi a ,
Carmine Dario Vizza a , Alessandra Labbadia a , Marco Francone c ,
Iacopo Carbone c , Francesco Fedele a
a Department of Cardiology, La Sapienza University of Rome; b Department of Cardiology, Catholic
University of Campobasso; c Department of Radiology, La Sapienza University of Rome, Italy
KEYWORDS
Contrast media;
Microcirculation;
Myocardial infarction;
Tissue viability.
Introduction
Despite improved clinical care, myocardial infarction
and sudden death still remain the leading
Abstract Residual tissue viability within the infarct area is one of the major
determinants of regional functional recovery after acute myocardial infarction,
playing also a protective role against LV remodelling. However, viability and
functional recovery are not synonymous: functional recovery is only one of the
aspects of viability. Several studies have shown how important it is to maintain
perfusion independently from functional recovery. In patients with an extensive
endocardial necrosis and a preserved normal perfusion in the middle and epicardial
myocardium layers, even though functional recovery does not occur, remodelling
processes may be attenuated. Tissue viability may be detected using several
different methods. Perfusion-based techniques (i.e. PET, SPECT, MRI and MCE) are
more accurate in predicting global function and LV remodelling whereas inotropic
reserve-based methods (i.e. DE) are more accurate in predicting functional recovery.
Several studies support the hypothesis that either LV remodelling or the possibility
of myocardial dysfunction to recover are strictly dependent on the extent of
microvascular damage. To date, myocardial contrast echocardiography and magnetic
resonance imaging have shown to be very effective techniques for assessing
microvascular perfusion. Our initial experience showed a very close correlation
between these two perfusional techniques. In particular by MCE, it has been
demonstrated that the persistence of residual anterograde or retrograde blood flow
within the infarct zone can maintain myocardial viability for a prolonged time span.
The incidence of LV remodelling is significantly lower in dysfunctioning but still
perfused segments than in non-perfused ones. Therefore MCE can be used to identify
viable segments that may help to prevent infarct expansion and remodelling, and
thus improve patient outcomes.
© 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rights
reserved.
* Corresponding author. Luciano Agati, MD. Associate Professor
of Cardiology, Department of Cardiology, “La Sapienza”
University of Rome, Italy. E-mail address: luciano.agati@uniroma1.it
(L. Agati).
causes of death in western countries. Recent data
from the CRUSADE trial 1 aimed to assess the
impact of congestive heart failure (CHF) after
non ST-segment elevation myocardial infarction
(NSTEMI) showed that CHF frequently occurs
in these patients and is associated with less
aggressive treatment and higher risk of mortality.
1525-2167/$30 © 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
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Tissue viability by contrast echocardiography S23
Thus, there is a strong need for preventing postischemic
left ventricular (LV) dysfunction and for
new markers able to identify high risk patients
after acute coronary syndromes.
Prevention of post-ischemic LV dysfunction
The best way to prevent LV dysfunction after acute
myocardial infarction (AMI) is to reduce the time
to treat. There is a general agreement based on
several multicentre trials that independently of
reperfusion strategies, time to reperfusion is the
key determinant of myocardial salvage in patients
with AMI 2 . However, whereas primary percutaneous
coronary intervention (PPCI) or fibrinolysis
are equally recommended for patients presenting
within 3 h of symptom onset, PPCI is superior to
lysis when reperfusion starts 3 h after symptom
onset 3 . A recent survey showed that

S24 L. Agati et al.
Fig. 1. New software is used to identify and track the
endocardial border during contraction. The illustration shows
the endocardial contours at end-diastole and the arrows the
excursion during systole.
an improvement in the definition of all cavities and
borders (Fig. 2).
To increase the diagnostic capability of echocardiography
we do not need fast but non-diagnostic
procedures in our echo labs. We absolutely need
to spend some more time to produce good and
diagnostic images and this is now feasible with
contrast.
Assessment of myocardial infarction and residual
ischemia after AMI
Two recent studies showed in a large series of patients
the additional value of myocardial contrast
echo in the diagnosis of acute coronary syndrome.
In the first study 21 the authors hypothesized that
regional function and myocardial perfusion may
Fig. 2. Live 3D. Left ventricular opacification for endocardial border enhancement. By using Tomtec software, endocardial surface is
automatically recognized and a 3D reconstruction of LV volume is obtained. Upper panel: two perpendicular long-axis views. Lower
panel: (left) short axis, (right) 3D reconstruction of LV volume.
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Tissue viability by contrast echocardiography S25
be superior to the TIMI score for diagnosis and
prognosis in patients presenting to the emergency
department with chest pain and a non-diagnostic
electrocardiogram. They were able to show that
myocardial contrast echo can rapidly and accurately
provide short-, intermediate- and long-term
prognostic information in patients presenting to
the emergency department with suspected cardiac
chest pain even before serum cardiac markers
are known. The second study 22 showed that in
patients with regional wall motion abnormalities,
the contemporary presence of abnormal perfusion
increases the likelihood of adverse events in the
follow-up.
In the first large study 23 in patients undergoing
dobutamine stress for detecting residual ischemia
after acute myocardial infarction, the additional
role of myocardial perfusion over wall motion in
identifying the amount of myocardium at risk has
been clearly demonstrated. Patients with normal
perfusion have a better outcome than patients with
normal wall motion.
The explanation for the additional prognostic
value of myocardial contrast perfusion echocardiography
is related to the way in which bubbles
behave: during hyperaemia all bubbles arrive
quickly in the ROI and at 2 frames after the flash
there is complete replenishment of the bubbles
into the myocardium; if there is a stenosis,
bubbles arrive more slowly and at 1–2 frames
after flash it is not possible to see a complete
replenishment of ROI but only after 4–8 frames.
The majority of inducible perfusion abnormalities
occur at an intermediate phase of stress, without
wall motion abnormalities, thus explaining the
higher sensitivity of perfusion imaging over wall
motion. Myocardial contrast echo may be of great
help in identifying residual area of ischemia into
the infarction area or surrounding area.
Assessment of microvascular perfusion within the
infarct area (true infarct size)
Tissue viability is the main determinant of functional
recovery after acute myocardial infarction.
However, myocyte viability and functional recovery
are not synonymous, but the latter has to be
considered as one aspect of the former 24 . Tissue
viability is also very important to prevent postischemic
LV remodelling. In patients with extensive
subendocardial necrosis but preserved normal
perfusion in mid wall and epicardium, even though
functional recovery is not observed, attenuation of
the LV remodelling process may occur. Thus, all the
efforts to assess and maintain tissue viability are
strongly justified.
Several techniques 25–33 have been developed
to identify dysfunctional but viable myocardium.
Perfusion-based techniques (i.e. PET, SPECT, MRI
and MCE) are more accurate in predicting global
function recovery and LV remodelling whereas
inotropic reserve-based methods (i.e. dobutamine
stress echo) are more accurate in predicting
regional functional recovery 25–33 . Dobutamine
stress is the best method to assess regional
functional recovery 28,29 . Several studies 30–33 agree
that dobutamine has a high positive predictive accuracy
for predicting functional recovery whereas
thallium has high negative predictive value in
predicting functional recovery, as have MCE or MRI.
Therefore nuclear imaging is highly sensible for cell
viability but it overestimates functional recovery.
Dobutamine echocardiography is highly specific but
it underestimates the amount of viability; MCE
and MRI are the only techniques able to evaluate
microvascular integrity which is a “conditio sine
qua non” for cell viability and later functional
improvement 28–33 .
The role of contrast echocardiography and
magnetic resonance in predicting wall motion
recovery and LV remodelling in patients with
previous MI has been elucidated by several
studies 25–33 . In particular, MRI may be considered
as the reference method to detect scar tissue in
post-ischemic LV dysfunction 25–27 . Late gadolinium
enhancement (LGE) is inversely related to recovery
of systolic thickening. There is a >7-fold increase in
major adverse coronary events in patients with late
enhancement, finally there is a close correlation
between LGE and life-threatening arrhythmias.
Thus, the extent of scar tissue can be considered
as a new marker for identifying patients at high
risk of sudden cardiac death caused by ventricular
dysrhytmia and who could be candidates for ICD
implantation.
Similar data has been obtained by MCE, as
depicted in Figs. 3 and 4. Balcells et al. 34 showed a
close correlation between contrast score at 3 days
after MI and wall motion score at 4 weeks. Lepper
et al. 35 and Badano et al. 36 demonstrated that the
best predictor of left ventricular recovery is the
extent of perfusion defect.
In our study 37,38 we showed a closer correlation
between contrast defect at day 1 and wall motion
abnormalities at follow-up than between the initial
and final extent of wall motion abnormalities
(Fig. 5). In other words, the status of microvascular
perfusion after reperfusion is the most powerful
predictor of EF and definitive extent of infarct size
at follow-up.
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S26 L. Agati et al.
Fig. 3. Patient with acute apical myocardial infarction treated
with primary angioplasty within 3 hours from symptom onset.
No late enhancement or residual contrast defect is detected
by either (A) magnetic resonance imaging or (B) myocardial
contrast echo.
Fig. 4. Patient with acute apical myocardial infarction treated
with primary angioplasty within 3 hours from symptom onset.
Similar extent of late enhancement and residual contrast
defect is detected both by (A) magnetic resonance imaging and
(B) myocardial contrast echo.
Fig. 5. Linear regression analysis shows a closer correlation between contrast defect at day 1 (CD%-T1) and wall motion abnormalities
at follow up (WMA%-T3) (left panel) than between the initial (WMRA-T1) and final (WMA%-T3) extent of wall motion abnormalities
(right panel).
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Tissue viability by contrast echocardiography S27
Fig. 6. ROC curves analysis considering all clinical, echocardiographic and angiographic parameters together. Contrast defect (CD%)
shows the best sensitivity/specificity ratio. Abbreviations: RWMSI, regional wall motion score index; RCSI, regional contrast score
index; WMA%, wall motion abnormalities; CD%, contrast defect; EDV, end-diastolic volume; EF, ejection fraction.
Assessment of left ventricular remodelling
After acute myocardial infarction, aging and time
to treat are the major determinants of subsequent
LV dysfunction, thus of the initial extent of wall
motion abnormalities (WMA) and end-diastolic LV
volume (EDV). All these parameters play a major
role in inducing LV remodelling 39–46 . However, the
initial extent of regional wall motion abnormalities
provides indirect measures of infarct size whereas
myocardial contrast echocardiography by assessing
the extent of microvascular perfusion defect
represents a direct measure of true infarct size.
For these reasons, patients with similar extent
of WMA and EDV soon after reperfusion may have
different LV remodelling. The missing link is the
microvascular damage, which explains why for
similar volumes, ejection fraction and extent of
regional wall motion abnormalities, LV remodelling
can be different. LV remodelling may occur from
24–48 hours after reperfusion to pre-discharge
(early LV remodelling) or from pre-discharge to
6 months (late LV remodelling). Different parameters
may predict early and late remodelling. According
to the GISSI 3 echo sub-study 43 EDV and the
extent of WMA are important for predicting early
remodelling; however for late remodelling prediction,
EDV is not always so specific. Late remodelling
is associated with progressive deterioration of
global ventricular function over time: patients
with extensive WMA and not significantly enlarged
ventricular volume before discharge are at higher
risk for progressive dilation and LV dysfunction.
Nicolau et al. 44 pointed out for the first time the
importance of microvascular perfusion, showing
that the presence of ST-segment resolution after
MI precludes the occurrence of remodelling.
Similar conclusions were drawn by Bolognese
et al. 42,45 demonstrating the correlation between
microvascular dysfunction within the risk area and
LV remodelling and survival at follow-up.
Our data obtained during a multicentre Acute
Myocardial Infarction Imaging (A.M.I.C.I) study
conducted at 4 institutions in Italy on 120 patients
with first acute ST-elevation acute myocardial
infarction undergoing different reperfusion strategies
within 6 hours from symptom onset 14,37,39,46 ,
further confirm the key role of MCE in predicting
LV remodelling. From multivariate analysis
using Cox regression, the most important echo
parameters for predicting LV remodelling at day 1
after reperfusion are contrast defect (CD) and
WMA extent and ejection fraction. However from
analysis of ROC curves the most powerful predictor
of LV remodelling with the best sensitivity/
specificity ratio is the CD extent (Fig. 6).
Considering all clinical, echocardiographic and
angiographic parameters together (i.e. ST-segment
reduction, all echo and angio parameters) the
CD extent, TIMI post and ejection fraction are the
most important parameters to predict remodelling
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S28 L. Agati et al.
Table 1
Multivariate analysis: Cox regression
Independent LVR predictors
CD1 cut-off 21.7 (HR = 3.75; 95% CI: 1.19–11.80)
TIMI post cut-off 3 (HR = 0.40; 95% CI: 0.17–0.99)
Selecting only TIMI 3 after reperfusion
CD1 cut-off 21.7 (HR = 4.91; 95% CI: 1.32–18.17)
(Table 1). Therefore, contrast defect as compared
to ST-segment reduction after reperfusion more
strongly reflects the efficacy of reperfusion and
it should be used routinely for assessing different
reperfusion strategies. In the subset of patients
reaching TIMI 3 score after reperfusion, multivariate
analysis shows CD extent is the only independent
parameter for LV remodelling (Table 1).
Conclusions
Microvascular damage is the missing link between
LV remodelling infarct size and LV volumes.
After acute myocardial infarction, MCE or MRI
are the ideal methods for (1) assessing residual
tissue viability, (2) following perfusional changes,
and (3) evaluating the efficacy of treatment.
The extent of scar tissue as detected by MRI
or MCE can be considered as a new marker for
identifying patients at high risk for sudden cardiac
death caused by ventricular dysrhytmia, and it
may be used for a better selection of patients as
candidates for ICD implantation.
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