Vers une nouvelle dfinition de lischmie myocardique Genevive - PowerPoint PPT Presentation

Vers une nouvelle définition de l’ischémie myocardique Geneviève Derumeaux Hôpital Louis Pradel, Lyon, France

Déclaration de Relations Professionnelles - Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Company Affiliation/Financial Relationship • • Grant/Research Support AstraZeneca • • Consulting Fees/Honoraria Toshiba, Servier

Characteristics of ischaemia Ischemic free cells (red) vs. normal free cells (blue)  no delay in onset of contraction  delay in Time to Peak (TTP) and prolonged Relaxation Half Time (RT 50 )  reduced peak contraction TTP TTP RT RT 50 50 RT RT TTP TTP 50 50 0 0 -0.02 -0.02 cell contraction cell contraction -0.04 -0.04 -0.06 -0.06 0 0 200 200 400 400 600 600 800 800 1000 1000 1200 1200 1400 1400 1600 1600 1800 1800 2000 2000 2200 2200 Time (ms) Time (ms)

Characteristics of ischaemia Theroux et al. Circ Res 1974 Circumferential segment length

Post-systolic shortening « Whether an ischemic myocardial segment is hypokinetic or dyskinetic depends on the balance between the stress imposed on that segment and the sum of the active and passive stresses within the segment » « Active contraction was defined as elevated LV pressure and stress during post-systolic shortening» Skulstad et al, Circulation 2002

Characteristics of ischaemia Contractile Force Loading Conditions Interaction with Adjacent Segments

Characteristics of ischaemia Lucats I et al; EHJ 2004

Rationale of deformation evaluation Several of the methods for global assessment concentrate only on radial function, ignoring longitudinal function, which in most cardiac pathology is altered before changes occur in radial indices. B Bijns et al; EJE (2010)

Myocardial function and ischemia Réant P et al; JACC 2008

Impact of ischemia on LV function Longitudinal and Circonferential Function Radial Function Réant P; J. Am. Coll. Cardiol. 2008;51;149-157

Validation of 4D speckle Tracking Imaging to quantify Regional Myocardial Deformation Parametric images of regional strain after MI Seo Y; Circ Cardiovasc Imaging 2009

The final infarct size following is predicted by: (i) the duration of ischaemia, (ii) the size of the area at risk, and (iii) the amount of collateral circulation Infarct size is the major determinant of prognosis after myocardial infarction Gibbons et al. JACC 2004 Ørn S, AJC 2007

Impact of MI on LV function -13% -13% Segmental strain differs with the level of transmural extension of MI Gjesdal O. Clin Sci 2007 Liebermann , Circulation 1981

4D-strain and assessment of MI extend Hayat D; Am J Cardiol 2011

Evidence for prognostic value of strain in ICM • Park YH, et al. « Prognostic value of longitudinal strain after primary reperfusion therapy in patients with anterior-wall acute myocardial infarction» J Am Soc Echocardiogr 2008 • Stanton T et al. « Prediction of All-Cause Mortality From Global Longitudinal Speckle Strain: Comparison With Ejection Fraction and Wall Motion Scoring” Circ Cardiovasc Imaging 2009 • Antoni Ml et al. « Prognostic importance of strain and strain rate after acute myocardial infarction” Eur Heart J 2010

Pronostic value of global longitudinal strain after reperfused MI All cause mortality  156 patients  Acute MI => primary PTCA  1st echo. 48h after MI; 2d echo at 1 year Prediction of recovery of LV Reinfarction, revascularisation, Heart failure function at 1-year follow-up. Combined endpoints Antoni M; European Heart J 2010;31 Mollema S; Circ Cardiovasc Imaging. 2010;3

BASELINE BASELINE 30 DAYS 30 DAYS Altman M, Euroecho 2012

Conclusion Rest DSE  sys  sys max. max. PSI PSI SR sys SR sys 5 s -1 60 % Normal 2 % Stunned Acute Ischemia Nontransmural MI Transmural MI Increase Biphasic response Higher compared to normal Decrease Lower compared to normal No response