European Journal of Heart Failure 2003 5(1):81-83; doi:10.1016/S1388-9842(02)00036-3
© 2002 European Society of Cardiology
Angioplasty of residual stenosis after severe anteroseptal myocardial infarction: is it able to improve systolic function and to prevent cardiac failure?
Marcel Toussainta,*,
Françoise Guyomarda,
Amine Meliania,
Xuan Tran-Thanha,
Christine Jouannona,
Florence Durupa and
Jean-Yves Devauxb
a Service de Cardiologie, Centre Hospitalier Général Longjumeau, France
b Service de Médecine Nucléaire, Hôpital Cochin Paris, France
* Corresponding author. Department of Cardiology, Centre Hospitalier Général, 159 rue du Président F. Mitterrand, F 91160 Longjumeau, France. Tel.: +11-33-64-54-31-62; fax: +11-33-64-54-30-89 E-mail address: marcel.toussaint{at}ch-longjumeau.fr
Key Words: Myocardial infarction • Left ventricular function • Coronary angioplasty
Received May 8, 2001; Revised October 17, 2001; Accepted December 14, 2001
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1. Background
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Left ventricular (LV) function is the major determinant of prognosis
in patients with myocardial infarction. Despite recent advances
in medical therapy of heart failure, mortality rates of patients
with poor ejection fraction (EF) remains high.
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2. Aims
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We hypothesised that systematic revascularisation of the stenosis
of the infarct-related artery would result in improved LV contractility.
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3. Methods
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From 1991 to 1997, 14 consecutive patients had severe Q wave
anteroseptal myocardial infarction with EF
36%. The mean age
of the 14 patients was 55±12 years (range 38–73
years). There were 12 men and 2 women. Forty-three percent had
a previous coronary history. Ten (71%) underwent thrombolytic
treatment 4.8±3.9 h after the onset of symptoms, 5 with
streptokinase and 5 with rt-PA. Four (28%) had heart failure
and 2 (14%) cardiogenic shock at the time of presentation. The
patients with heart failure received diuretics and angiotensin
converting enzyme inhibitors. They had no residual ischemia.
Coronary arteriography revealed a significant stenosis (
70%)
of the left anterior descending artery (LAD) in 11 patients
(79%) and a complete occlusion in 3 (21%). Associated lesions
were a stenosis of the second acute marginal artery in 1 patient,
a stenosis of the first marginal artery in 1 and a complete
occlusion of the right coronary artery in 4. Global LV EF was
assessed 5.2±4.3 days after the onset of symptoms; it
was measured by LV angiography in 12 patients and by gated blood
single-photon emission computed tomography (G-SPECT) in 2. The
EF was 31.4±5.8% (range 16–36%). Preoperative viability
studies were not used for patient selection. Coronary angioplasty
of LAD alone was performed 12.5±7.8 days after the onset
of infarction. Patients with heart failure clinically improved
at the time of intervention.
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4. Results
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Coronary angioplasty (PTCA) was successful in all patients.
The diameter stenosis, assessed by quantitative angiography,
decreased from 85.0±11.4 to 8.6±9.7% (
P<0.0001).
Follow-up averaged 7.2±5.1 months. Angina pectoris was
absent and exercise stress testing was negative. Eight patients
(58%) had no cardiac failure, 3 (21%) were in New York Heart
Association (NYHA) class II, 2 (14%) class III and 1 (7%) class
IV. EF was assessed by angiography in 5 patients and by G-SPECT
in 7. It was significantly increased from 31.4±5.8 to
45.6±10.4% (
P<0.001) (
Fig. 1).
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5. Discussion
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Few studies have been designed to analyse the improvement of
LV function after successful angioplasty of the residual stenosis
after myocardial infarction (
Table 1). In 1992, Montalescot
[1] and Ellis
[2] were not able to show that deferred angioplasty,
following fibrinolysis, would improve the EF and obtain clinical
benefits. However, three studies (Linderer
[3], Miketic
[4] and Meijer
[5]) have shown that deferred angioplasty following
fibrinolysis produced an improvement in EF, but this benefit
disappeared in the case of restenosis. It is worth noting that
in Linderer's
[3] and Miketic's
[4] studies, the EF prior to
angioplasty was only slightly altered. In Fath-Ordoubadi's
[6] study, the viability was evaluated by positron emission tomography
and the contractility evaluated by sonography. The EF increased
from 41±10 to 45±10% (
P=0.04) and the segment
contractility index improved. Danchin
[7] studied the effect
of unblocking completely occluded arteries using angioplasty,
on EFs. He noted an improved contractility in patients who retained
an open artery upon control; however, this benefit disappeared
in the case of reocclusion. Our study differs from the others
in that we selected the most severe patients, whose EF was very
low (<36%) and who were likely to develop severe cardiac
insufficiency. The limitations of this study are the small number
of patients and the lack of a control group. Moreover, two different
techniques were used to assess left EF. However, the values
obtained by the two methodologies are very well correlated in
our departments.
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6. Conclusion
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Despite its limitations, our study suggests that systematic
coronary angioplasty of the stenosis of the infarct-related
artery in patients with severely impaired LV function is able
to produce a significant improvement in systolic function. It
may avoid the development of severe cardiac failure in the majority
of patients.
Randomised controlled trials are now required to ensure that percutaneous revascularisation is of benefit in addition to medical therapy and that the risk is as low as observed in this patient series.
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References
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- Montalescot G., Faraggi M., Drobinski G., et al. Myocardial viability in patients with Q wave myocardial infarction and no residual ischemia. Circulation (1992) 86:47–55.[Abstract/Free Full Text]
- Ellis S.G., da Silva E.R., Heyndrickx G., et al. Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute anterior myocardial infarction. Circulation (1994) 90:2280–2284.[Abstract/Free Full Text]
- Linderer T., Guhl B., Spielberg C., Wunderlich W., Schnitzer L., Schroder R. Effect on global and regional left ventricular functions by percutaneous transluminal coronary angioplasty in the chronic stage after myocardial infarction. Am. J. Cardiol. (1992) 69:997–1002.[CrossRef][Web of Science][Medline]
- Miketic S., Carlsson J., Tebbe U. Improvement of global and regional left ventricular function by percutaneous transluminal coronary angioplasty after myocardial infarction. J. Am. Coll. Cardiol. (1995) 25:843–847.[Abstract]
- Meijer A., Verheugt F.W., van Eenige M.J., Werter C.J. Left ventricular function at 3 months after successful thrombolysis. Impact of reocclusion without reinfarction on ejection fraction, regional function, and remodeling. Circulation (1994) 90:1706–1714.[Abstract/Free Full Text]
- Fath-Ordoubadi F., Pagano D., Marinho N.V., Keogh B.E., Bonser R.S., Camici P.G. Coronary revascularizatic in the treatment of moderate and severe postischemic left ventricular dysfunction. Am. J. Cardiol. (1998) 82:26–31.[Web of Science][Medline]
- Danchin N., Angioi M., Cador R., Tricoche O., Dibon O., Juilliere Y., Cuilliere M., Cherrier F. Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion. Am. J. Cardiol. (1996) 78:729–735.[CrossRef][Web of Science][Medline]
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1. Background
2. Aims