Myocardial Work, an Echocardiographic Measure of Post Myocardial Infarct Scar on Contrast-Enhanced Cardiac Magnetic Resonance
2021; Elsevier BV; Volume: 151; Linguagem: Inglês
10.1016/j.amjcard.2021.04.009
ISSN1879-1913
AutoresMohammed El Mahdiui, Pieter van der Bijl, Rachid Abou, Rodolfo de Paula Lustosa, Rob J. van der Geest, Nina Ajmone Marsan, Victoria Delgado, Jeroen J. Bax,
Tópico(s)Advanced MRI Techniques and Applications
ResumoThis study investigates the relation of non-invasive myocardial work and myocardial viability following ST-segment elevation myocardial infarction (STEMI) assessed on late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) and characterizes the remote zone using non-invasive myocardial work parameters. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were included. Several non-invasive myocardial work parameters were derived from speckle tracking strain echocardiography and sphygmomanometric blood pressure, e.g.: myocardial work index (MWI), constructive work (CW), wasted work (WW) and myocardial work efficiency (MWE). LGE was quantified to determine infarct transmurality and scar burden. The core zone was defined as the segment with the largest extent of transmural LGE and the remote zone as the diametrically opposed segment without LGE. A total of 53 patients (89% male, mean age 58 ± 9 years) and 689 segments were analyzed. The mean scar burden was 14 ± 7% of the total LV mass, and 76 segments (11%) demonstrated transmural hyperenhancement, 280 (41%) non-transmural hyperenhancement and 333 (48%) no LGE. An inverse relation was observed between segmental MWI, CW and MWE and infarct transmurality (p < 0.05). MWI, CW and MWE were significantly lower in the core zone compared to the remote zone (p<0.05). In conclusion, non-invasive myocardial work parameters may serve as potential markers of segmental myocardial viability in post-STEMI patients who underwent primary PCI. Non-invasive myocardial work can also be utilized to characterize the remote zone, which is an emerging prognostic marker as well as a therapeutic target. This study investigates the relation of non-invasive myocardial work and myocardial viability following ST-segment elevation myocardial infarction (STEMI) assessed on late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) and characterizes the remote zone using non-invasive myocardial work parameters. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were included. Several non-invasive myocardial work parameters were derived from speckle tracking strain echocardiography and sphygmomanometric blood pressure, e.g.: myocardial work index (MWI), constructive work (CW), wasted work (WW) and myocardial work efficiency (MWE). LGE was quantified to determine infarct transmurality and scar burden. The core zone was defined as the segment with the largest extent of transmural LGE and the remote zone as the diametrically opposed segment without LGE. A total of 53 patients (89% male, mean age 58 ± 9 years) and 689 segments were analyzed. The mean scar burden was 14 ± 7% of the total LV mass, and 76 segments (11%) demonstrated transmural hyperenhancement, 280 (41%) non-transmural hyperenhancement and 333 (48%) no LGE. An inverse relation was observed between segmental MWI, CW and MWE and infarct transmurality (p < 0.05). MWI, CW and MWE were significantly lower in the core zone compared to the remote zone (p 50% luminal stenosis in more than 1 vessel. Transthoracic echocardiography was performed according to the institutional, guideline-based, clinical care track protocol (MISSION!),10Liem SS van der Hoeven BL Oemrawsingh PV Bax JJ van der Bom JG Bosch J Viergever EP van Rees C Padmos I Sedney MI van Exel HJ Verwey HF Atsma DE van der Velde ET Jukema JW van der Wall EE Schalij MJ MISSION!: optimization of acute and chronic care for patients with acute myocardial infarction.Am Heart J. 2007; 153 (14.e11-11)Crossref PubMed Scopus (110) Google Scholar while CMR was performed at the discretion of the treating physician. Demographic and clinical data were collected from the departmental cardiology information system (EPD-vision; LUMC, Leiden, The Netherlands) and from electronic medical records (HiX; ChipSoft, Amsterdam, The Netherlands). For retrospective analysis of clinically acquired data, the institutional review board waived the need for individual patient written informed consent. Using commercially available echocardiographic systems (E9 and E95, General Electric Vingmed Ultrasound, Milwaukee, Wisconsin) transthoracic echocardiographic images were recorded in patients at rest. Electrocardiogram-triggered echocardiographic data were acquired with M5S transducers and digitally stored in cine-loop format for offline analysis (EchoPac 202, General Electric Vingmed Ultrasound). Echocardiographic images from the study closest in time to CMR acquisition were used for analysis. The median interval between echocardiographic and CMR acquisition was 1 month (interquartile range (IQR) 0 to 2 months) and the median interval between STEMI and CMR acquisition was 2 months (IQR 1 to 3 months). LV end-systolic and end-diastolic volumes were measured in apical 2- and 4-chamber views and LV ejection fraction (LVEF) was calculated using the biplane Simpson's method.11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (3333) Google Scholar Quantification of non-invasive myocardial work was performed using a commercially available software package (EchoPac 202, General Electric Vingmed Ultrasound). Calculation and validation of LV myocardial work analysis from non-invasive LV pressure-strain loops has been described previously.8Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Remme EW Haugaa KH Opdahl A Fjeld JG Gjesdal O Edvardsen T Smiseth OA A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work.Eur Heart J. 2012; 33: 724-733Crossref PubMed Scopus (214) Google Scholar,9Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Gjesdal O Edvardsen T Smiseth OA Assessment of wasted myocardial work: a novel method to quantify energy loss due to uncoordinated left ventricular contractions.Am J Physiol Heart Circ Physiol. 2013; 305: H996-1003Crossref PubMed Scopus (124) Google Scholar Non-invasive myocardial work was derived from LV pressure-strain loops by integrating LV strain data and non-invasively estimated LV pressure. This approach to echocardiographic quantification of LV work has shown a high degree of correlation with invasively-measured LV myocardial work8Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Remme EW Haugaa KH Opdahl A Fjeld JG Gjesdal O Edvardsen T Smiseth OA A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work.Eur Heart J. 2012; 33: 724-733Crossref PubMed Scopus (214) Google Scholar,9Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Gjesdal O Edvardsen T Smiseth OA Assessment of wasted myocardial work: a novel method to quantify energy loss due to uncoordinated left ventricular contractions.Am J Physiol Heart Circ Physiol. 2013; 305: H996-1003Crossref PubMed Scopus (124) Google Scholar,12Hubert A Le Rolle V Leclercq C Galli E Samset E Casset C Mabo P Hernandez A Donal E Estimation of myocardial work from pressure–strain loops analysis: an experimental evaluation.Eur Heart J Cardiovasc Imaging. 2018; 19: 1372-1379Crossref PubMed Scopus (77) Google Scholar and has been validated in several patient subgroups.8Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Remme EW Haugaa KH Opdahl A Fjeld JG Gjesdal O Edvardsen T Smiseth OA A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work.Eur Heart J. 2012; 33: 724-733Crossref PubMed Scopus (214) Google Scholar,9Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Gjesdal O Edvardsen T Smiseth OA Assessment of wasted myocardial work: a novel method to quantify energy loss due to uncoordinated left ventricular contractions.Am J Physiol Heart Circ Physiol. 2013; 305: H996-1003Crossref PubMed Scopus (124) Google Scholar,12Hubert A Le Rolle V Leclercq C Galli E Samset E Casset C Mabo P Hernandez A Donal E Estimation of myocardial work from pressure–strain loops analysis: an experimental evaluation.Eur Heart J Cardiovasc Imaging. 2018; 19: 1372-1379Crossref PubMed Scopus (77) Google Scholar, 13Boe E Russell K Eek C Eriksen M Remme EW Smiseth OA Skulstad H Non-invasive myocardial work index identifies acute coronary occlusion in patients with non-ST-segment elevation-acute coronary syndrome.Eur Heart J Cardiovasc Imaging. 2015; 16: 1247-1255Crossref PubMed Scopus (72) Google Scholar, 14El Mahdiui M van der Bijl P Abou R Ajmone Marsan N Delgado V Bax JJ Global left ventricular myocardial work efficiency in healthy individuals and patients with cardiovascular disease.J Am Soc Echocardiogr. 2019; 32: 1120-1127Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 15Manganaro R Marchetta S Dulgheru R Ilardi F Sugimoto T Robinet S Cimino S Go YY Bernard A Kacharava G Athanassopoulos GD Barone D Baroni M Cardim N Hagendorff A Hristova K Lopez-Fernandez T de la Morena G Popescu BA Penicka M Ozyigit T Rodrigo Carbonero JD van de Veire N Von Bardeleben RS Vinereanu D Zamorano JL Rosca M Calin A Moonen M Magne J Cosyns B Galli E Donal E Carerj S Zito C Santoro C Galderisi M Badano LP Lang RM Oury C Lancellotti P Echocardiographic reference ranges for normal non-invasive myocardial work indices: results from the EACVI NORRE study.Eur Heart J Cardiovasc Imaging. 2019; 20: 582-590Crossref PubMed Scopus (74) Google Scholar LV strain data were acquired using 2-dimensional speckle-tracking echocardiography by manually tracing the LV endo- and epicardial borders in the apical long-axis, 2- and 4-chamber views. The automatically generated region of interest was manually adjusted to the myocardial thickness, as required. The LV pressure was assumed to be equal to the arterial blood pressure measured from sphygmomanometric brachial artery cuff measurements. An LV pressure-strain curve was then constructed using a normalized reference curve provided by the software and adjusted to the different cardiac cycle phases using valvular event timing (mitral and aortic valve opening and closing). Strain rate was multiplied with LV pressure and integrated over time to produce segmental and global LV myocardial work.9Russell K Eriksen M Aaberge L Wilhelmsen N Skulstad H Gjesdal O Edvardsen T Smiseth OA Assessment of wasted myocardial work: a novel method to quantify energy loss due to uncoordinated left ventricular contractions.Am J Physiol Heart Circ Physiol. 2013; 305: H996-1003Crossref PubMed Scopus (124) Google Scholar,16van der Bijl P Kostyukevich M El Mahdiui M Hansen G Samset E Ajmone Marsan N Bax JJ Delgado V A roadmap to assess myocardial work: from theory to clinical practice.JACC Cardiovasc Imaging. 2019; 12: 2549-2554Crossref PubMed Scopus (10) Google Scholar Several global and segmental myocardial work indices can be derived from the construction of non-invasive LV pressure-strain loops: myocardial work index (MWI), constructive work (CW), wasted work (WW) and myocardial work efficiency (MWE). MWI is defined as the total LV work performed in a single cardiac cycle. CW is LV myocardial work performed during shortening of a myocardial segment in systole or during lengthening in isovolumic relaxation, thereby contributing to LV ejection. WW on the other hand, is LV myocardial work performed during lengthening of a myocardial segment in systole or during shortening in isovolumic relaxation, and which therefore does not contribute to LV ejection. MWE is defined as the ratio of CW, divided by the sum of CW and WW, expressed as a percentage. Patients were imaged on a 1.5-T Gyroscan ACS-NT/Intera MR system (Philips Medical Systems, Best, the Netherlands) or on a 3.0-T Ingenia MR system (Philips Medical Systems, Best, the Netherlands) using retrospective ECG gating. Cine steady-state free precession (SSFP) CMR images were acquired in the long-(2- and 4-chamber views) and short-axes of the LV. Typical imaging parameters were as follows for the 1.5-T Gyroscan ACS-NT/Intera MR system: field of view (FOV) 400×320 mm2; matrix, 256×206 pixels; slice thickness, 10 mm with no slice gap; flip angle (α), 35°; echo time (TE), 1.67 ms; and repetition time (TR), 3.3 ms.17Roes SD Borleffs CJ van der Geest RJ Westenberg JJ Marsan NA Kaandorp TA Reiber JH Zeppenfeld K Lamb HJ de Roos A Schalij MJ Bax JJ Infarct tissue heterogeneity assessed with contrast-enhanced MRI predicts spontaneous ventricular arrhythmia in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillator.Circ Cardiovasc Imaging. 2009; 2: 183-190Crossref PubMed Scopus (331) Google Scholar For the 3.0-T Ingenia MR system typical parameters were: FOV 400×350 mm; matrix, 232×192 pixels; slice thickness, 8 mm with no slice gap; α, 45°; TE, 1.5 ms and TR, 3.0 ms.18Tao Q van der Tol P Berendsen FF Paiman EHM Lamb HJ van der Geest RJ Robust motion correction for myocardial T1 and extracellular volume mapping by principle component analysis-based groupwise image registration.J Magn Reson Imaging. 2018; 47: 1397-1405Crossref PubMed Scopus (9) Google Scholar LGE images were acquired 15 minutes after a bolus injection of gadolinium diethylenetriamine pentaacetic acid (Magnevist, Schering, Berlin, Germany) or gadoterate meglumine (Dotarem, Guerbet, Villepinte, France) (0.15 mmol/kg) with an inversion-recovery 3-dimensional turbo-field echo sequence with parallel imaging. The heart was imaged in 1 or 2 breath-holds with short-axis slices at various levels dependent on the heart size. For the 1.5-T Gyroscan ACS-NT/Intera MR system, typical parameters were as follows: FOV 400×400 mm2; matrix, 256×206 pixels; slice thickness, 10 mm with 50% overlap; α, 10°; TE, 1.06 ms and TR, 3.7 ms.17Roes SD Borleffs CJ van der Geest RJ Westenberg JJ Marsan NA Kaandorp TA Reiber JH Zeppenfeld K Lamb HJ de Roos A Schalij MJ Bax JJ Infarct tissue heterogeneity assessed with contrast-enhanced MRI predicts spontaneous ventricular arrhythmia in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillator.Circ Cardiovasc Imaging. 2009; 2: 183-190Crossref PubMed Scopus (331) Google Scholar For the 3.0-T Ingenia MR system typical parameters were as follows: FOV 350 × 350 mm; matrix size 188 × 125 mm; acquired pixel size 1.86 × 2.8 mm; reconstructed pixel size 1.46 × 1.46 mm; slice thickness 10 mm with 50% overlap; α, 10°; SENSE factor 3; TE, 2.09 ms and TR, 4.31 ms.19Bizino MB Tao Q Amersfoort J Siebelink HJ van den Bogaard PJ van der Geest RJ Lamb HJ High spatial resolution free-breathing 3D late gadolinium enhancement cardiac magnetic resonance imaging in ischaemic and non-ischaemic cardiomyopathy: quantitative assessment of scar mass and image quality.Eur Radiol. 2018; 28: 4027-4035Crossref PubMed Scopus (11) Google Scholar Images were stored digitally for offline analysis. CMR data analysis was performed with dedicated software (MASS, Leiden University Medical Center, Leiden, the Netherlands). LV endocardial and epicardial borders were manually traced on short-axis SSFP cine images. Myocardial scar was assessed by using a previously reported method, based on the signal intensity (SI).17Roes SD Borleffs CJ van der Geest RJ Westenberg JJ Marsan NA Kaandorp TA Reiber JH Zeppenfeld K Lamb HJ de Roos A Schalij MJ Bax JJ Infarct tissue heterogeneity assessed with contrast-enhanced MRI predicts spontaneous ventricular arrhythmia in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillator.Circ Cardiovasc Imaging. 2009; 2: 183-190Crossref PubMed Scopus (331) Google Scholar The myocardial segment with the most dense scar was visually identified and a region of interest was placed in this segment to determine the maximum SI. Subsequently, any myocardium with a SI ≥ 35% of the maximum SI was defined as scar and automatically identified by the software.17Roes SD Borleffs CJ van der Geest RJ Westenberg JJ Marsan NA Kaandorp TA Reiber JH Zeppenfeld K Lamb HJ de Roos A Schalij MJ Bax JJ Infarct tissue heterogeneity assessed with contrast-enhanced MRI predicts spontaneous ventricular arrhythmia in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillator.Circ Cardiovasc Imaging. 2009; 2: 183-190Crossref PubMed Scopus (331) Google Scholar The LV was divided into a 13-segment model and each segment was scored based on the percentage of hyperenhancement of the LV myocardial wall: transmural infarcted segments (≥50%), non-transmural infarcted segments (1% to 50%) and non-infarcted segments (≤ 1%) (Figure 2). Thereafter, 2 specific regions of interest were defined in the LV myocardial wall according to the percentage of hyperenhancement: the core zone was defined as the segment with the largest extent of transmural hyperenhancement and the remote zone as the myocardial tissue opposite to the core zone, without any evidence of hyperenhancement (Figure 2). If there was evidence of any hyperenhancement in the segment diametrically opposing the core zone, the first adjacent segment without evidence of hyperenhancement was used as the remote zone. Defining these 2 regions of interest allowed meaningful comparison of echocardiography and CMR LGE data in STEMI patients (Figure 3).Figure 3Non-invasive pressure-strain loops and myocardial work efficiency of a patient after an ST-segment elevation myocardial infarction (STEMI). A 41 year old male patient presented with an inferior STEMI, due to complete occlusion of the right coronary artery. On late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) imaging the total scar burden was 11.9%. Panel A represents the core zone with 73% transmurality (A1) and the remote zone (A2) on LGE CMR. Panel B displays non-invasive pressure-strain loops from which myocardial work efficiency is derived (B1 core zone and B2 remote zone). The red pressure-strain loop represents the averaged loop for all left ventricular segments, whereas the green pressure-strain loop specifically represents the selected segment outlined in Panel C. Panel C shows parametric maps of left ventricular myocardial work efficiency (C1 core zone with myocardial work efficiency (MWE) of 89% and C2 remote zone MWE of 99%).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Normally distributed continuous variables are presented as mean ± standard deviation (SD) and non-normal continuous variables as median and interquartile range (IQR). Normality was assessed using the Shapiro-Wilk test and visual assessment of a histogram and Q-Q plots. Categorical variables are presented as frequencies and percentages. Continuous variables were compared using the Student's t-test if normally distributed and the Mann-Whitney U-test if not normally distributed. For comparison of related transmural, non-transmural and non-infarcted segments, linear mixed models were used for normally distributed variables (MWI and CW) and the Friedman's two-way ANOVA with post-hoc Wilcoxon signed-rank tests for non-normally distributed variables (WW and MWE). A p-value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 25.0 (SPSS, Armonk, NY). Fifty three patients (89% male, age 58 ± 9 years) were analyzed for the presence and distribution of segmental LGE. Patient clinical characteristics are shown in Table 1. Patients received appropriate, guideline-directed pharmacotherapy following STEMI.Table 1Patient characteristicsVariable(n = 53)Age (years)58 ± 9Men47 (89%)Height (cm)178.4 ± 6.7Weight (kg)87.6 ± 14.0BMI (kg/m²)27.5 ± 4.1BSA (m²)2.1 ± 0.2LAD culprit artery33 (62%)Peak creatine phosphokinase (U/L)2665 (1397-4661)Peak troponin T (µg/L)6.8 (4.0-11.3)Creatinine (µmol/L)81 (71-89)Hypertension24 (45%)Hypercholesterolemia13 (25%)Diabetes mellitus6 (11%)Current smoker26 (49%)Family history of CVD21 (40%)Medication at dischargeAspirin51 (96%)Thienopyridine53 (100%)β-blocker52 (98%)Statin53 (100%)ACE-I/ARB53 (100%)Values are mean ± standard deviation if normally distributed and median (interquartile range) if not normally distributed.ACE-I: angiotensin-converting enzyme inhibitor, ARB: angiotensin receptor blocker, BMI: body mass index, BSA: body surface area, CV: cardiovascular, CVD: cardiovascular disease, LAD: left anterior descending coronary artery. Open table in a new tab Values are mean ± standard deviation if normally distributed and median (interquartile range) if not normally distributed. ACE-I: angiotensin-converting enzyme inhibitor, ARB: angiotensin receptor blocker, BMI: body mass index, BSA: body surface area, CV: cardiovascular, CVD: cardiovascular disease, LAD: left anterior descending coronary artery. Conventional imaging variables, myocardial work indices and LGE burden on CMR are shown in Table 2. The median LVEF was 50% (IQR 44 to 55) and the median global LV MWE 93% (IQR 91 to 96). The mean scar burden was 14.0 ± 7.0% of the total LV mass.Table 2Imaging variablesVariable(n = 53)Conventional echocardiographic variables Left ventricular end-diastolic volume (ml)113 (89-142) Left ventricular end-systolic volume (ml)58 (42-84) Left ventricular ejection fraction (%)50 (44-55)Myocardial work indices Global myocardial work index (mmHg%)1446 ± 412 Global constructive work (mmHg%)1671 ± 474 Global wasted work (mmHg%)77 (58-127) Global left ventricular (LV) myocardial work efficiency (%)93 (91-96)LGE CMR Total LV mass (g)162 ± 41 Total scar burden (%)14.0 ± 7.0Values are mean ± standard deviation if normally distributed and median (interquartile range) if not normally distributed. Open table in a new tab Values are mean ± standard deviation if normally distributed and median (interquartile range) if not normally distributed. All segments (n = 689) could be analyzed for LGE and for myocardial work variables. A total of 76 segments (11%) demonstrated transmural hyperenhancement, 280 (41%) had non-transmural hyperenhancement and 333 (48%) segments showed no evidence for hyperenhancement on LGE CMR. An inverse relationship was observed between segmental MWI, CW and MWE and the extent of hyperenhancement transmurality on LGE CMR (p<0.05 for all comparisons) while a trend was observed between a greater amount of WW and transmural hyperenhancement (p = 0.086) (Figure 4). LV myocardial work indices of the infarct core and the remote zone are shown in Figure 5. Segmental MWI, CW and MWE were lower in the core zone (and WW was higher) compared to the remote zone (p<0.05 for all comparisons). The findings from our study can be summarized as follows: MWI, CW and MWE decreased significantly with increasing transmural myocardial hyperenhancement, whereas WW increased. Moreover, MWI, CW and MWE were significantly more impaired and WW significantly larger in the core zone compared to the remote zone. LV myocardial work, the product of force and distance, can be quantified using myocardial force-dimension loops and reflects myocardial oxygen consumption.20Hisano R Cooper Gt Correlation of force-length area with oxygen consumption in ferret papillary muscle.Circ Res. 1987; 61: 318-328Crossref PubMed Scopus (82) Google Scholar,21Delhaas
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