Combined assessment of microvascular integrity and contractile reserve improves differentiation of stunning and necrosis after acute anterior wall myocardial infarction
Michael L. Main, MD, FACC*,*,
Anthony Magalski, MD, FACC*,
Becky A. Morris, RDCS*,
Michael M. Coen, MA*,
David G. Skolnick, MD, FACC* and
Thomas H. Good, MD, FACC*
* Mid America Heart Institute, Kansas City, Missouri, USA
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Figure 1 These myocardial contrast echocardiography (MCE) images were obtained in a 52-year-old man, two days after he presented with an anterior myocardial infarction. (a) Apical long-axis perfusion image revealing a normally perfused posterior wall (white arrow) and an anteroseptal and apical transmural perfusion defect (yellow arrow). In these power pulse inversion MCE images, the left ventricular (LV) cavity appears yellow, whereas the perfused myocardium appears orange. (b) "Flash" imaging with a high mechanical index (see text for details). (c) The image immediately after "flash" or destruction frames. Note a lack of contrast effect throughout the myocardium, with residual LV cavity opacification. (d) Several cardiac cycles later after microbubble replenishment, perfusion is again noted in the posterior wall, with a perfusion defect in the left anterior descending coronary artery distribution. As predicted by MCE, follow-up echocardiography nearly two months later revealed continued akinesia throughout the infarct zone.
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Figure 2 Comparison of mean wall motion scores at follow-up in initially akinetic segments, stratified by the myocardial contrast echocardiography result. Perfused segments demonstrated a significantly lower (better) wall motion score index at follow-up (p < 0.0001). Solid line = perfused segments; dashed line = segments with a perfusion defect.
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Figure 3 Comparison of mean wall motion scores at follow-up in initially akinetic segments, stratified by the low-dose dobutamine echocardiography result. Segments with contractile reserve demonstrated a significantly lower (better) wall motion score index at follow-up (p < 0.0001). Solid line = contractile reserve; dashed line = lack of contractile reserve.
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Figure 4 Diagnostic accuracy of low-dose dobutamine echocardiography (LDDE), myocardial contrast echocardiography (MCE), and concordant test results. For each measure of diagnostic utility, MCE performed at least as well as LDDE, with the former having a higher sensitivity. Concordant test results occurred in 74% of segments and, when present, further enhanced the overall accuracy. White bars = LDDE; lined bars = MCE; black bars = concordant test results. NPV = negative predictive value; PPV = positive predictive value.
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