Liam P. Ryan, MD, Kanji Matsuzaki, MD, PhD, Mio Noma, MD, Benjamin M

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Dermal Filler Injection: A Novel Approach for Limiting Infarct Expansion Liam P. Ryan, MD, Kanji Matsuzaki, MD, PhD, Mio Noma, MD, Benjamin M. Jackson, MD, Thomas J. Eperjesi, BS, Theodore J. Plappert, CVT, Martin G. St. John-Sutton, MBBS, Joseph H. Gorman, MD, Robert C. Gorman, MD The Annals of Thoracic Surgery Volume 87, Issue 1, Pages 148-155 (January 2009) DOI: 10.1016/j.athoracsur.2008.09.028 Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Sheep heart as seen through a left thoracotomy. (A) Immediately after coronary ligation. Note the discolored apical region in the area of the infarct. (B) Immediately after dermal filler injection. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 American Society of Echocardiography 17-segment left ventricle model. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Left ventricular global end-diastolic volumes (EDV) and end-systolic volumes (ESV) at baseline (medium gray bars), 30 minutes after infarction (Post-MI; dark gray bars), and 15 minutes after injection (Post-Injection; light gray bars) are plotted on common axes (A). The corresponding ejection fractions are illustrated in B. Data are presented as mean ± standard error of the mean. *p < 0.05 with respect to the corresponding value at baseline; †p < 0.05 with respect to the corresponding value after infarction. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Regional end-diastolic volume (EDV; A), end-systolic volume (ESV; B), and ejection fraction (C) for each of the three left ventricular regions are presented at baseline (medium gray bars), 30 minutes after infarction (Post-MI; dark gray bars), and 15 minutes after injection (Post-Injection; light gray bars). Data are presented as mean ± standard error of the mean. *p < 0.05 with respect to the corresponding value at baseline; †p < 0.05 with respect to the corresponding value after infarction. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Apical segmental end-diastolic volume (EDV; A), end-systolic volume (ESV; B), and ejection fraction (C) for each of the five left ventricular segments comprising the apical region are presented at baseline (medium gray bars), 30 minutes after infarction (Post-MI; dark gray bars), and 15 minutes after Radiesse injection (Post-Injection; light gray bars). Data are presented as mean ± standard error of the mean. *p < 0.05 with respect to the corresponding value at baseline; †p < 0.05 with respect to the corresponding value after infarction. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Apical anterior (A), apical septal (B), apical inferior (C), apical lateral (D), and apical cap (E) segmental volumes have been plotted as functions of normalized time at baseline (black lines), 30 minutes after infarction (Post-MI; red lines), and 15 minutes after Radiesse injection (Post-Injection; blue lines) for the 15-subject cohort on common axes. Data are presented as mean (solid line) ± standard error of the mean (dotted lines). End-diastole occurs at 0 ms and 800 ms, whereas end-systole occurs at 500 ms. Note in E that the apical cap segment is profoundly dyskinetic after infarction but becomes virtually akinetic after injection. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Mason trichrome stain of infarct tissue at ×2 and ×20 from untreated (A, C) 4-week-old ovine infarcts and infarcts of the same age injected with 1.3 mL of Radiesse (B, D). Untreated infarcts are thin and relatively acellular with occasional islands of residual vacuolated myocytes. Radiesse-treated infarcts are thicker with more extensive collagen deposition. The calcium hydroxyapatite microspheres are apparent. The carrier agent has been replaced by a dense cellular infiltrate. The Annals of Thoracic Surgery 2009 87, 148-155DOI: (10.1016/j.athoracsur.2008.09.028) Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions