1 Echocardiographic Indices of Increased Left Ventricular Filling Pressure and Dilation After Acute Myocardial Infarction R2 Jungwook Kim Journal of the American Society of Echocardiography April 2006, 450~456 Graham S. Hillis, MB, ChB, PhD, Keiji Ujino, MD, PhD, Sharon L. Mulvagh, MD, Mary E. Hagen, RN, RDCS, and Jae K. Oh, MD, Rochester, Minnesota From the Division of Cardiovascular Disease, Mayo Clinic.

Introduction   LV dilatation   ⅓ : despite patency of the infarct-related coronary a.   LV remodeling : ↑ risk of progressive heart failure / death   Mechanism of LV remodeling   changes in LV diastolic properties (compliance & relaxation)   Secondary to scar formation   Compensatory hypertrophy of noninfarcted tissue   ⇒ increased LV filling pressure   Abbreviated Doppler-derived deceleration time (DT) of early tranmitral flow ⇔ ↑ risk of LV dilatation after AMI 2

Introduction   Elevated LV filling pressure   Transmitral flow velocities & DT + preload-independent indicators of diastolic function (Doppler tissue imaging of early mitral annulus velocity : e’ )   Ratio of early transmitral flow velocity(E) to e’ (E/e’) : well correlated LV filling pressure ( LV filling Pr ↑ ⇒ ↑ mortality after infarction )   Volume of LA indexed to BSA (LAVi) ⇔ chronic LV filling Pr   Aim to define whether E/e’ or LAVi predicted LV dilatation in Pts with successful reperfusion after AMI 3

Methods   47 patients   CAG (a patent infarct-related artery with thrombolysis in MI grade III flow) but, akinesia within the arterial territory on baseline Echo   Exclusion 1. required mechanical ventilation 2. receiving IV pressor 3. hemodynamic support with an intra-aortic balloon pump   Standard baseline   TTE + intravenous myocardial contrast echocardiography   f/u TTE (8 weeks later) 4

Methods   Wall mortion : Scored using a standard 16-seg. Model graded on a 4-point scale (1=normal, 2=hypokinetic, 3=akinetic, 4=dyskinetic)   Doppler tissue imaging of the septal mitral annulus : in the apical 4-chamber view ⇒ e’ was measured   LA volume (biplane area-length method) LV volume (modified biplane Simpson’s method)   Prospectively designed   Remodeling group : > 15% indexed LV end-diastolic volume   Non-remodeling group : < 15% indexed LV end-diastolic volume 5

Results 6

Results 7

Results 8

Results 9 Changes in indexed LV end-diastolic volume

Results 10 E/e’ : useful predictor of remodeling Area under the curve : % CI 0.65~1.00, p=0.002 Cut off : 15 ► sensitivity 70% ► specificity 91%

Results   Multivariable regression analysis   Site of infarction (anterior/non-anterior)   Requirement for rescue percutaneous coronary intervention   Receipt of a glycoprotein IIb/IIIa inhibitor   Basal wall-motion score index   Any degree of abnormal contrast opacification within the inf. Zone ⇒ strongest independent predictor of remodeling was E/e’ ratio 11

Conclusion  After acute MI, LV dilation may occur despite patency of the infarct-related artery and high use of evidence-based secondary prevention (ACEi and b-blockers)  E/e’ ratio ↑ ⇔ high LV filling pressure ⇒ associated with an ↑ likelihood of LV remodeling ⇒ associated with an ↑ likelihood of LV remodeling  May be of value in distinguishing a group of patients at highest risk. ⇒ identify potential therapies that might favorably modify ⇒ identify potential therapies that might favorably modify this response this response