Key result
In patients with anterior STEMI undergoing LV unloading, post-therapy infarct size ≤25% was associated with improved LV ejection fraction at 90 days (from 53.1% to 58.9%; P=0.001).
Why the study?
To determine the predictive value of CMR and echocardiographic parameters on LV remodeling in STEMI patients without cardiogenic shock treated with mechanical LV unloading and reperfusion.
Does early infarct size measured by CMR predict left ventricular remodeling at 90 days in patients with anterior STEMI treated with mechanical LV unloading and PCI?
RCT (n=50)
1:1
Yes
Does early infarct size measured by CMR predict left ventricular remodeling at 90 days in patients with anterior STEMI treated with mechanical LV unloading and PCI?
In anterior STEMI patients treated with mechanical LV unloading and PCI, early infarct size measured by CMR correlates with 90-day echocardiographic LVEF and adverse remodeling.
Answers are grounded in this paper and cite their sources.
Hypothesis-generating in pilot data; does not support practice change and requires larger randomized confirmation.
OBJECTIVES: To determine the predictive value of cardiac magnetic resonance (CMR) and echocardiographic parameters on left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients without cardiogenic shock and treated with mechanical LV unloading followed by immediate or delayed percutaneous coronary intervention (PCI)-mediated reperfusion. BACKGROUND: In STEMI, infarct size (IS) directly correlates with major cardiovascular outcomes. Preclinical models demonstrate mechanical LV unloading before reperfusion reduces IS. The door-to-unload (DTU)-STEMI pilot trial evaluated the safety and feasibility of LV unloading and delayed reperfusion in patients with STEMI. METHODS: This multicenter, prospective, randomized, safety and feasibility trial evaluated patients with anterior STEMI randomized 1:1 to LV unloading with the Impella CP (Abiomed) followed by immediate reperfusion vs delayed reperfusion after 30 minutes of unloading. Patients were assessed by CMR at 3-5 days and 30 days post PCI. Echocardiographic evaluations were performed at 3-5 and 90 days post PCI. At 3-5 days post PCI, patients were compared based on IS as percentage of LV mass (group 1 ≤25%, group 2 >25%). Selection of IS threshold was performed post hoc. RESULTS: Fifty patients were enrolled from April 2017 to May 2018. At 90 days, group 1 (IS ≤25%) exhibited improved LV ejection fraction (from 53.1% to 58.9%; P=.001) and group 2 (IS >25%) demonstrated no improvement (from 37.6% to 39.1%; P=.55). LV end-diastolic volume and end-systolic volume were unchanged in group 1 and worsened in group 2. There was correlation between 3-5 day and 30-day CMR measurements of IS and 90-day echocardiography-derived LV ejection fraction. CONCLUSIONS: Immediate 3-5 day post-therapy IS by CMR correlates with 90-day echocardiographic LVEF and indices of remodeling. Patients with post-therapy IS >25% demonstrated evidence of adverse remodeling. Larger studies are needed to corroborate these findings with implications on patient management and prognosis.
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O’Neill et al. (2022) conducted an RCT in anterior STEMI without cardiogenic shock (n=50). LV unloading with Impella CP followed by delayed reperfusion after 30 minutes vs. LV unloading with Impella CP followed by immediate reperfusion was evaluated on Safety and feasibility. In patients with anterior STEMI undergoing LV unloading, post-therapy infarct size ≤25% was associated with improved LV ejection fraction at 90 days (from 53.1% to 58.9%; P=0.001).
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