Clinical Investigations
Novel Roles for Ultrasound Enhancing Agents
The Impact of Sonothrombolysis on Left Ventricular Diastolic Function and Left Atrial Mechanics Preventing Left Atrial Remodeling in Patients With ST Elevation Acute Myocardial Infarction

https://doi.org/10.1016/j.echo.2022.12.010Get rights and content

Highlights

  • Sonothrombolysis is a new therapy in STEMI.

  • Sonothrombolysis improved diastolic function and LA strain in STEMI.

  • Sonothrombolysis reduced LA remodeling in STEMI.

  • Worse values of LA strain predicted LA remodeling.

Background

The diagnostic ultrasound-guided high mechanical index impulses during an intravenous microbubble infusion (sonothrombolysis) improve myocardial perfusion in acute ST segment elevation myocardial infarction, but its effect on left ventricular diastolic dysfunction (DD), left atrial (LA) mechanics and remodeling is unknown. We assessed the effect of sonothrombolysis on DD grade and LA mechanics.

Methods

One hundred patients (59 ± 10 years; 34% women) were randomized to receive either high mechanical index impulses plus percutaneous coronary intervention (PCI) (therapy group) or PCI only (control group) (n = 50 in each group). Diastolic dysfunction grade and LA mechanics were assessed immediately before and after PCI and at 48 to 72 hours, 1 month, and 6 months of follow-up. Diastolic dysfunction grades were classified as grades I, II, and III. The LA mechanics was obtained by two-dimensional speckle-tracking echocardiography–derived global longitudinal strain (GLS).

Results

As follow-up time progressed, increased DD grade was observed more frequently in the control group than in the therapy group at 1 month and 6 months of follow-up (all P < .05). The LA-GLS values were incrementally higher in the therapy group when compared with the control group at 48 to 72 hours, 24.0% ± 7.3% in the therapy group versus 19.6% ± 7.2% in the control group, P = .005; at 1 month, 25.3% ± 6.3% in the therapy group versus 21.5% ± 8.3% in the control group, P = .020; and at 6 months, 26.2% ± 8.7% in the therapy group versus 21.6% ± 8.5% in the control group, P = .015. The therapy group was less likely to experience LA remodeling (odds ratio, 2.91 [1.10-7.73]; P = .03). LA-GLS was the sole predictor of LA remodeling (odds ratio, 0.79 [0.67-0.94]; P = .006).

Conclusion

Sonothrombolysis is associated with better DD grade and LA mechanics, reducing LA remodeling.

Section snippets

Study Protocol

As previously described, the MRUSMI trial (ClinicalTrials.gov no. NCT02410330) was designed to assess the effect of sonothrombolysis to improve coronary angiographic and microvascular reflow in patients with first STEMI.10,11 From May 2014 through July 2018, 100 patients were randomized into 2 groups: a therapy group assigned to receive high MI (1.8 MHz; 1.1-1.3 MI; <5 μsec pulse duration) impulses during an intravenous microbubbles infusion (sonothrombolysis) before and after emergent PCI and

Baseline Characteristics

Between May 2014 and July 2018, a total of 100 prospectively enrolled patients included in the MRUSMI trial were randomized into the control or therapy group. Some patients died during the follow-up, and at the end of our study, we had 44 patients in each group with completed data during the follow-up. The numbers of patients in the control and therapy groups was, respectively, before PCI 50 versus 50, after PCI 49 versus 50, at 48 to 72 hours 47 versus 49, at 1 month 46 versus 44, and at

Discussion

The present study, based on the first randomized clinical trial in humans to evaluate the impact of sonothrombolysis on LV diastolic function (LVDF), LA mechanics and remodeling in patients with acute STEMI, identified several novel findings.

The reduction of STEMI complications, such as adverse cardiac remodeling that leads to heart failure, is intrinsically related to the restoration of coronary blood flow. In light of this, previous studies have shown the effects of sonothrombolysis on

Conclusion

In patients with acute STEMI treated with sonothrombolysis before and after emergent PCI, there was an early and persistent improvement in the LA-GLS and the LVDF and a decrease in LA remodeling, demonstrating the short- and long-term benefit of this emerging therapy. Further studies are needed to introduce this new therapy into clinical practice.

References (43)

  • Y.N.V. Reddy et al.

    Atrial dysfunction in patients with heart failure with preserved ejection fraction and atrial fibrillation

    J Am Coll Cardiol

    (2020)
  • R.M. Lang et al.

    Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

    J Am Soc Echocardiogr

    (2015)
  • S.F. Nagueh et al.

    Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American society of echocardiography and the European association of cardiovascular imaging

    J Am Soc Echocardiogr

    (2016)
  • K. Haji et al.

    Left atrial strain performance and its application in clinical practice

    JACC Cardiovasc Imaging

    (2019)
  • L. Thomas et al.

    Left atrial reverse remodeling: mechanisms, evaluation, and clinical significance

    JACC Cardiovasc Imaging

    (2017)
  • M.T. Corban et al.

    Non-infarct related artery microvascular obstruction is associated with worse persistent diastolic dysfunction in patients with revascularized ST elevation myocardial infarction

    Int J Cardiol

    (2020)
  • S.J. Reinstadler et al.

    Microvascular obstruction and diastolic dysfunction after STEMI: an important link?

    Int J Cardiol

    (2020)
  • W.C. Levy et al.

    Early patency of the infarct-related artery after myocardial infarction preserves diastolic filling

    Am J Cardiol

    (2001)
  • C.M. Bianco et al.

    Myocardial mechanics in patients with normal LVEF and diastolic dysfunction

    JACC Cardiovasc Imaging

    (2020)
  • M.L. Antoni et al.

    Comprehensive assessment of changes in left atrial volumes and function after ST-segment elevation acute myocardial infarction: role of two-dimensional speckle-tracking strain imaging

    J Am Soc Echocardiogr

    (2011)
  • S.B. Prasad et al.

    Echocardiographic predictors of all-cause mortality in patients with left ventricular ejection fraction >35%: value of guideline based assessment of diastolic dysfunction

    Int J Cardiol Heart Vasc

    (2019)
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    Conflicts of Interest: None.

    This work was supported by a grant from “Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), São Paulo, Brazil.” The funding for study coordinators was provided by the Theodore F. Hubbard Foundation from the University of Nebraska Medical Center. The funding resources played no role in the design, conduct, or reporting of the present study.

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