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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 189-196

Evaluation of the effect of elective percutaneous intervention to left coronary artery disease on left ventricular functions: an echocardiography and tissue Doppler study


Department of Cardiology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission08-Jun-2018
Date of Acceptance12-Aug-2018
Date of Web Publication27-Feb-2019

Correspondence Address:
Mohamed Mahmoud
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Assiut, 71511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_50_18

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  Abstract 

Background and Aim Coronary artery disease (CAD) is the leading cause of death worldwide. After acute myocardial infarction (AMI), CAD is a serious and common ailment that can influence a patient’s prognosis and quality of life.
Aim of the study The aim of this study was to assess the effect of elective percutaneous coronary intervention (PCI) on left ventricular (LV) functions after 3 months in patient with significant chronic left coronary system lesions by echo and tissue doppler imaging (TDI).
Patients and methods The study was conducted on 30 patients with chronic significant (more than 70%) left coronary system stenosis as proved by diagnostic coronary angiography with or without other coronary artery affections.
Resuts Left ventricular ejection fraction (EF) was statistically significant different between the patient’s pre-& post-PCI (mean ± SD was = 0.4893 ± 0.06963 pre-PCI, 0.4550 ± 0.05158 post-PCI with P value of 0.0341. twenty two of patients (73.3%) were males and 8 (26.7%) were females, with age ranged from 40 to 67 years and mean age or 55.92 years.
Conclusion PCI for a significant coronary lesion has a beneficial effect on LV functions, improvement in regional and global LV functions & myocardial contractility after revascularization that can be predicted by conventional echo and TDI.

Keywords: assessment of left ventricular function; coronary artery intervention; drug-eluting stent; echo and tissue Doppler imaging; elective percutaneous intervention


How to cite this article:
Mahmoud M, Abd Elbaset MA, Yousof W. Evaluation of the effect of elective percutaneous intervention to left coronary artery disease on left ventricular functions: an echocardiography and tissue Doppler study. Al-Azhar Assiut Med J 2018;16:189-96

How to cite this URL:
Mahmoud M, Abd Elbaset MA, Yousof W. Evaluation of the effect of elective percutaneous intervention to left coronary artery disease on left ventricular functions: an echocardiography and tissue Doppler study. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:189-96. Available from: http://www.azmj.eg.net/text.asp?2018/16/2/189/253089




  Introduction Top


Coronary artery disease (CAD) is a serious and common ailment that can influence a patient’s prognosis and quality of life [1]. CAD is the leading cause of death worldwide. Following an acute myocardial infarction (MI), early and successful myocardial reperfusion with the use of thrombolytic therapy or primary percutaneous coronary intervention (PCI) is the most effective strategy for reducing the size of MI and improving the clinical outcome [2]. Stable CAD is classified into two types depending on the lesion site and the number of affected vessels: one type is high risk, which includes three-vessel disease, left main trunk lesions, and ostial left anterior descending (LAD) and carries a high risk of death, and the other type is low risk, involves 1-vessel disease or 2-vessel disease other than those associated with high-risk type. This type accounts for most patients and carries a low risk of death [1]. PCI coupled with improved technology has made it possible to treat increasingly complex lesions and patients with a history of clinically significant cardiac disease, risk factors for CAD, coexisting conditions, or anatomical risk factors [3]. Justification for performing PCI on patients with stable and low-risk CAD is the reduction of anginal pain and the prevention of cardiac events, such as acute coronary syndrome and cardiac death [4]. Management of proximal CAD is important owing to the large areas of myocardium that lie downstream of the stenosis. The proximal LAD stenosis represents the most important proximal site for obstructive coronary artery after left main stem lesion, as it supplies 40–50% of the left ventricular (LV) myocardium and could result in ischemia to a large area of myocardium. This leads to adverse effects of MI and, therefore, require a safe and long-term effective method of treatment [3]. Several methods have been developed over the years to assess both qualitatively and quantitatively the different parameters of LV functions. Echocardiography (echo) has been the most popular as it is a noninvasive technique that can provide information on the structure of the heart as well as on its functions [5]. Tissue Doppler image (TDI) echocardiography, a variation of conventional pulse wave Doppler echo, measures myocardial motion and velocity. During conventional pulse wave Doppler, a filter eliminates the lower velocities generated by cardiac tissue, allowing the system to concentrate on higher velocities scattered from the moving red blood cells. This filter is inactive during TDI, allowing measurement of the higher amplitude lower velocity signals generated by tissue motion [6].


  Aim Top


The aim of this study to assess the effect of elective PCI on LV functions after 3 months in patient with significant chronic left coronary system lesions by echo and TDI.


  Patients and methods Top


The study was conducted through the period from October 2014 to August 2016 and included 30 patients, comprising 22 (73.3%) males and eight (26.7%) females. The study is approved by Al-Azhar Assiut Faculty of Meidcine ethical committee. and informed consent was obtained from each patient. Their age ranged from 40 to 67 years old, with mean age of 55.92 years. They were selected from patients admitted to Cardiology Department in Assiut and Assiut Al-Azhar University Hospital.

Inclusion criteria

Patients with chronic significant left coronary system stenosis (>70%) as proved by diagnostic coronary angiography with or without other coronary artery affection were included in the study.

Exclusion criteria

The following were the exclusion criteria: (a) patients with rheumatic heart disease, (b) patients with end-stage renal disease, (c) patients with end-stage liver disease, (d) hemodynamically unstable patients, (e) patients with acute coronary syndrome, and (f) patients with New york heart association (NYHA) class III or IV heart failure.

All patients underwent the following: (a) informed written medical consent, (b) full history taking, (c) complete clinical examination including general and local examination, (d) resting surface 12-lead ECG, which was performed in the supine position using Cardiomax Fukuda Denshi model FX 7102 (Tokyo, Japan), (e) PCI of significant left coronary system stenosis. Left and right coronary angiography in multiple planes was done to diagnose coronary lesions and assess severity of these lesions. The types of lesions were classified according to the American colleague of cardiology (ACC)/American heart association (AHA) classification, and then PCI for significant left coronary system stenosis was done. (f) Transthoracic echo was performed with Vivid 7 Dimensions echo using 3–7 MHz transducer, with the patients breathing quietly and lying in the left lateral position. All parameters of echo were done according to the American Society of Echocardiography. (g) TDI: by activating the doppler tissue imaging (DTI) function in the echo machine, the mitral annular velocities were recorded using the pulsed-wave (pw) TDI. A variable frequency phased array transducer (2.0–4.0 MHz) was used. The following were calculated: the longitudinal mitral annular velocities: these were calculated from the septal, lateral, anterior, and inferior LV sites. (a) The positive peak systolic velocity was measured when the mitral ring moved toward the cardiac apex owing to longitudinal contraction of the LV (S’ wave). (b) Two negative diastolic velocities were measured when the mitral annulus moved toward the base away from the apex, one during the early phase of diastole (E’) and the other in the late phase of diastole (A’). Average S wave: the mitral annular positive peak systolic velocities were recorded from septal, lateral, anterior, and inferior LV sites. A mean value for the above four sites was used to assess global systolic function. Left ventricular diastolic function (LVDF): this was done as follows: the Doppler beam was aligned to the direction of flow, and a 1–2-mm sample volume was placed between the tips of the mitral leaflets during diastole, in the apical four-chamber view, for detecting the transmitral early velocity wave (E wave); transmitral late velocity wave (A wave); deceleration time (DT), measured along the descending slope of mitral flow A wave; E/A ratio (normally >0.8); isovolumic relaxation time, measured by TDI-PWD at LV basal lateral wall from the end of systolic velocity wave (S wave) to the onset of early diastolic wave (E’ wave); MV E/E’ ratio, measured by TDI-PWD to obtain mitral inflow early diastolic velocity wave E’ then calculating E/E’ ratio; and MV Em/Am ratio, which was measured by TDI-PWD to obtain mitral inflow early diastolic velocity wave (E’) and the late diastolic velocity wave (A’) to calculate the ratio.

Patients were grouped according to the following grading of left ventricular systolic function (LVSF) and LVDF: (a) left ventricular ejection fraction (LVEF) by M mode and 2D, where normal is more than or equal to 50%, mild impairment is 45 to less than 50%, moderate impairment is 30 to less than 45%, and (d) severe impairment is less than 30% [7]; (b) LVEF by conventional myocardial performance index (MPI) (Tei index), where normal value is 0.45±0.05 and measured by LV MPI=Interventricular contraction time (IVCT)+Interventricular Relaxation Time (IVRT)/Left ventricular Ejection Time (LVET) [8]; (c) LVSF by TDI, where normal=average S wave more than 8.25 cm/s and impaired=average S wave less than 8.25 cm/s [9]; (d) LVDF by pulsed Doppler over mitral flow, where normal or pseudonormal E/A ratio=0.8–1.5, impaired relaxation E/A ratio less than 0.8, and restrictive pattern E/A more than 2. A normal IVRT is about 73–101 ms. In abnormal relaxation, IVRT is usually in excess of 100 ms. A normal DT is about 143–219 ms. In abnormal relaxation, DT is usually in excess of 220 ms; and (e) LVDF by TDI, where Em wave normal more than 12 cm/s, and Am wave normal more than 5.05 cm/s. LVDF impaired Em/Am ratio is less than 1 [10]. In E/e’ ratio, a ratio of 8 is usually associated with normal LV filling pressures (normal diastolic function), whereas a ratio of 15 is associated with increased filling pressures (diastolic dysfunction). When the value is between 8 and 15, it is a gray zone [11].

Statistical analysis

The clinical and investigating data were collected and transferred to statistical program ‘SPSS’ (IBM SPSS Inc., Chicago, US) for Windows, version 6.12, to obtain minimum, maximum, mean±SD, number and percentage (from quantitative data). For analytic statistics, t test was used to compare more than two groups. P values indicated the level of significance as follows: P value more than 0.05=not significant, P value less than 0.05=significant, and P value less than 0.001=highly significant.


  Results Top


A total of 60 patients are involved in this study.

First, comparison was done for all patients according to patients’ demographic characteristics and risk factors ([Table 1]).
Table 1 Comparison of basic characteristics of the patients

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Second, comparison between all patient’s according to echo characteristics (LVSF) before and after PCI was as follows:
  1. Regarding EF by modified Simpson’s method before and after PCI, there was a statistically significant difference between the patients before and after PCI (mean±SD was 52.417±7.354% before PCI, 58.173±8.061% after PCI; P≤0.0054).
  2. Regarding EF by M mode method before and after PCI, there was a statistically significant difference between the patients before and after PCI (mean±SD was 53.863±9.469% before PCI and 60.793±10.236% after PCI; P≤0.0085) ([Table 2]).
    Table 2 EF by M mode before and after percutaneous coronary intervention

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  3. Regarding EF by MPI by conventional echo before and after PCI, there was a statistically significant difference between the patients before and after PCI (mean±SD was=0.4893±0.06963 before PCI and 0.4550±0.05158 after PCI; P≤0.0341).
  4. EF by TDI method ‘S wave’ before and after PCI: regarding EF by TDI ‘S wave,’ there was a statistically significant difference between the patients before and after PCI (mean±SD was 9.222±2.811% before PCI and 11.618±2.753 after PCI; P≤0.0015) ([Table 3]).
    Table 3 Comparison between patients’ regarding S wave before and after percutaneous coronary intervention

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LVDF
  1. LVDF by pulsed wave doppler (PWD) over mitral inflow ‘E/A’ before and after PCI: regarding LVDF by PWD over mitral inflow there was a statistically very significant difference between the patients before and after PCI (mean±SD was 0.6757±0.1298 before PCI and 0.9693±0.1612 after PCI; P<0.0001).
  2. LVDF by DT: regarding LVDF by PWD over mitral inflow, there was a statistically very significant difference between the patients before and after PCI (mean±SD was 239.37±20.523 before PCI and 201.37±21.394 after PCI; P<0.0001).
  3. LVDF by IVRT: regarding LVDF by PWD over mitral inflow, there was a statistically very significant difference between the patients before and after PCI (mean±SD was 119.87±15.878 before PCI and 91.600±12.255 after PCI; P<0.0001) ([Table 4] and [Table 5]).
    Table 4 IVRT before and after percutaneous coronary intervention

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    Table 5 Em/Am before and after percutaneous coronary intervention

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LVDF by Em/Am TDI before and after PCI: regarding LVDF by TDI over mitral inflow, there was a very statistically significant difference between the patient’s before and after PCI (mean±SD was 0.6857±0.08500 before PCI and 1.168±0.1703 after PCI; P<0.0001).

LVDF by E/E’ TDI before and after PCI: regarding LVDF by TDI over mitral inflow, there was a very statistically significant difference between the patient’s before and after PCI (mean±SD was 16.483±0.8714 before PCI and 6.910±2.651 after PCI; P< 0.0001) ([Table 6]).
Table 6 E/E’ before and after percutaneous coronary intervention

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The aforementioned results could be summarized as follows:
  1. There is a statistically significant difference between patients (before and after PCI) regarding EF by modified Simpson method, EF by M Mode, EF by MPI by conventional Echo, and EF by TDI ‘S wave.’
  2. There is a statistically very significant difference between patients (before and after PCI) regarding E/A ratio by pulsed wave mitral inflow, IVRT by pulsed wave mitral inflow, DT by pulsed wave mitral inflow, E/E’ by PWD over the mitral annulus, and Em/Am by PWD over the mitral annulus.



  Discussion Top


TDI can be used to study both longitudinal and radial myocardial function. However, it is better suited for the assessment of long-axis ventricular shortening and lengthening because longitudinal motion has higher amplitude and is less affected by rotational and translational cardiac activity, making the velocities less prone to error and, therefore, more reproducible. Pulsed TDI measuring LV function can quantify the velocity of the myocardial wall and valve annulus motions. The most common structure examined by pulsed TDI is the MV annulus, because the apex remains relatively stationary throughout the cardiac cycle; mitral annular motion is an appropriate surrogate measurement of overall longitudinal LV contraction and relaxation [12]. Mitral annular motion, unlike mitral inflow velocity, is relatively unaffected by changes in preload. Thus, the Em/Am ratio typically remains less than 1 even with advanced myocardial dysfunction [13]. Peak Em velocity is a reliable marker of diastolic dysfunction. It has a linear reverse relationship with LVDF, whereas peak E velocity does not. Therefore, TDI is more sensitive than conventional transmitral Doppler flow in patients with CAD [14]. The Tei index is used as a reasonable index of global LV function because it simultaneously reflects systolic and diastolic LV function and also allows prediction of prognosis of post-MI conditions [15]. Many studies have shown that this index could be measured at mitral annulus using TDI and that it correlated well with the conventional Tei index. Moreover, measurement of the TDI-Tei index is simple and provides a reliable indicator of overall LV function [16]. The primary aim of reperfusion therapy is not only the restoration of blood flow in the epicardial coronary artery but also the complete and sustained reperfusion of myocardial tissue, thus limiting the extension of myocardial necrosis [14]. The basis of pathophysiologic benefit of revascularization is improving the function of viable myocardium [17]. Early coronary recanalization helps to survive the viable myocardium and improves global LV function. According to the studies in patients with CAD and LV dysfunction, the outcome can be improved with PCI or surgical revascularization (CABG, coronary artery bypass graft) [18]. Intervals between MI and PCI, basic LVEF before PCI, and global condition of the patients affect the result of PCI; many studies have been done to study the effect of PCI on cardiac function [19]. Many trials including Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) have shown no significant difference in outcomes in the treatment of patients with stable angina with revascularization versus OMT alone [20]. Several reviews and meta-analyses have been conducted to determine the role of PCI in patients with stable CAD, with some suggesting a greater relief of angina symptoms (odds ratio, 1.69; 95% confidence interval, 1.24–2.30), and others showing no improvement in death, MI, or need for subsequent revascularization using the invasive strategy [21]. From this study, the following data were obtained regarding LVSF: according to changes in LVEF by M mode in patients before and after PCI, there was a significant improvement in LVEF in 22 (73.3%) patients, unchanged in three (10%) patients and changed but still abnormal in five (16.7%) patients, with mean±SD of 53.863±9.469 before PCI and 60.793±10.236 after PCI (P=0.0085). According to changes in LVEF by 2D in patients before and after PCI, there was an improvement in LVEF in 23 (76.6%) patients, unchanged in three (10%) patients, and changed but still abnormal in four (13.4%), with mean±SD of 52.417±7.354 before PCI and 58.173±8.061 after PCI (P=0.0054). According to the changes in LVEF by MPI in patients before and after PCI, there was improvement in LVEF in 24 (80%) patients, unchanged in four (13.3%) patients, and changed but still abnormal in two (6.7%) patients, with mean±SD of 0.4893±0.06963 before PCI and 0.4550±0.05158 after PCI, with P value of 0.0341. According to the changes in LVSF by TDI in patients before and after PCI, there was a very significant improvement in LVEF in 25 (83.4%) patients, unchanged in two (6.6%) patients, and changed but still abnormal in three (10%) patients, with mean±SD of 9.222±2.811 before PCI and 11.618±2.753 after PCI, with P value of 0.0015. From the aforementioned statistics, we can find that there was an improvement in LVSF by either means of M mode EF, modified Simpson’s EF method, or by TDI ‘Average S wave’ in patients’ post-PCI LT coronary system lesion. This came in agreement with previous studies such as the TOMIIS study, which showed that patients with a patent culprit coronary artery 4 months after PCI (n=12) had a significant improvement in EF, in comparison with patients with an occluded artery (n=25). Similar to our results, Dzavik et al. [22] studied 244 patients and showed that the restoration of coronary patency of nonacute occluded coronary arteries is associated with a small but significant improvement in regional and global LV function, especially in patients with depressed LV function. Dudek et al. [23] studied patients with LVEF less than 45% undergoing PCI. A total of 29 patients (mean age, 54.4±11 years) were analyzed before and after PCI. They assessed the duration and grade of symptoms of heart failure (HF), angina class, and echo parameters of LVSF. After 6-month follow-up, LVEF was obtained again. In the whole group of patients, they found a significant increase in EF (38.4±6 vs. 50.4±15%; P=0.005) at follow-up examination. There was a significant improvement of EF in patients with NYHA class I or II (from 40.4±5 to 58.1±9%; P<0.0001) as compared with NYHA class III or IV (from 31.4±9 to 31.8±11%; P=NS). In multivariate regression analysis, correlation between NYHA class and LVEF at control examination (beta=−0.54; P=0.03) was independent from epidemiological variables and baseline LVEF. There was a significant increase in LVEF in patients with severe angina (CCS III or IV) as compared with patients without angina (DEF 21.3±5 vs. 7.9±10%; P=0.009). There was also a higher increase in LVEF in patients with chest pain during balloon inflation (delta EF 17.4±9 vs. 5.7±9%; P=0.01). Rashid et al. [24] determined the effect of PCI on myocardial function assessed by TDI in patients with chronic stable angina and found that systolic myocardial peak velocities improved significantly after PCI of left coronary system lesion in the septal, lateral, anterior, posterior, and inferior walls (P<0.001 for each) by TDI, whereas nondetected by conventional echo. There was a significant increase of E’/A’ ratio at anterior angle of mitral valve annulus and lateral angle of tricuspid valve annulus (P=0.02 for both). You et al. [25] studied the effect of PCIs on heart function in patients with left coronary heart disease and HF disease. After PCI, the systolic and diastolic functions in patients with coronary heart disease with HF were significantly improved. LVEF, FS, left ventricular End systolic dimension (LVESD), left ventricular End diastolic dimension (LVEDD), E, A, and E/A were significantly improved (P<0.05, 0.01) 6 months after operation compared with before operation. LVEF and FS were improved (P<0.05) 1 week after the operation compared with before the operation. LVEF, FS, LVESD, and LVEDD were improved (P<0.05) 6 months after the operation compared with 1 week after the operation. This comes in disagreement with previous studies performed, such as by Yousef et al. [26], who in the TOAT study found a worse LV dilatation by echo, in the PCI group, in comparison with no-PCI. The authors pointed out that these results could be related to the occurrence of microembolization to the microvasculature in the PCI group, reducing the perfusion and resulting in adverse ventricular remodeling. However, the biochemical markers of myocardial necrosis were not measured routinely, making the evidence of this possibility less obvious. An alternative explanation for these negative results could be related to restenosis and reocclusion rates that were higher than expected, with a subsequent high rate of late events, as observed in the PCI group. Sattarzadeh et al. [27] evaluated the early effects of successful elective PCI on systolic and diastolic function and found that Tei index and systolic indices (LVEF, regional wall motion abnormality score, tricuspid annular plane systolic excursion, and peak systolic velocity of mitral and tricuspid annulus) did not change significantly. Among the diastolic indices, only velocity propagation improved significantly following PCI. Diastolic velocities, E/A ratio, DT, early and late diastolic velocities of mitral annulus in TDI, pulmonary vein systolic, and diastolic flow velocity did not show significant improvement. The diastolic pw-TDI parameters taken from both subepicardial (circumferential contraction) and subendocardial layers (longitudinal contraction) improved after PCI. After PCI, it was shown that although Ea velocity (P=0.012) taken from the subendocardial layer increased, IVRa velocity (P<0.001) taken from the subepicardial layer decreased. Surucu et al. [28] evaluated subepicardial and subendocardial LV functions in patient with single coronary artery lesion at early stage after PCI and stated that LV, LA, and Ao diameter increased in patients with CAD. The systolic and diastolic functions were impaired at subendocardial and subepicardial layers. These dysfunctions can be easily presented with pw-TDI. Although systolic dysfunction persists, diastolic dysfunction improves at early stage after PCI. According to changes in LVDF by pulsed Doppler over mitral flow in patients before and after PCI, there was a significant improvement in LVDF by measuring E/A ratio, with normal or pseudonormal (E/A ratio 0.8–2) in four (13.3%) patients, and impaired relaxation (E/A ratio<0.8) in 26 (86.7%) patients before PCI, and normal or pseudonormal (E/A ratio 0.8–2) in 26 (86.7%) patients, and impaired relaxation (E/A ratio<0.8) in four (13.3%) patients after PCI (mean±SD=0.6757±0.1298 before PCI and 0.9693±0.1612 after PCI, with P<0.0001). There was a significant improvement in LVDF by measuring DT, with normal DT less than 220 ms in two (6.6%) patients and impaired relaxation DT more than 220 ms in 28 (93.4%) before PCI and normal DT less than 220 ms in 26 (86.7%) patients and impaired relaxation DT more than 220 ms in four (13.3%) patients after PCI (mean±SD=239.37±20.523 before PCI and 201.37±21.394 after PCI, with P<0.0001). There was a significant improvement in LVDF by measuring IVRT, with normal IVRT less than 100 ms in three (10%) patients and impaired relaxation IVRT more than 100 ms in 27 (90%) patients before PCI and normal IVRT less than 100 ms in 26 (86.7%) patients and impaired relaxation IVRT more than 100 ms in four (13.3%) patients after PCI (mean±SD=119.87±15.878 before PCI and 91.600±12.255 after PCI, with P<0.0001). According to the changes in LVDF by TDI in patients before and after PCI, there was a very significant improvement in LVDF by TDI and measuring average Em/average Am ratio, which was normal (Em/Am ratio 1–2) in 0 (0%) patients, and impaired relaxation (Em/Am ratio<1) in 30 (100%) patients before PCI, and normal (Em/Am ratio 1–2) in 29 (96.6%) patients, and impaired relaxation (Em/Am ratio<1) in one (3.4%) patients after PCI (mean±SD=0.6857±0.08500 before PCI and 1.168±0.1703 after PCI, with P<0.0001). There was a very significant improvement in LVDF by TDI and measuring E/E’ ratio, with a normal E/E’ ratio less than 8 in 1 (3.4%) patient, and impaired relaxation E/E’ ratio more than 15 in 29 (96.6%) patients before PCI and a normal E/E’ ratio less than 8 in 28 (93.3%) patients and impaired relaxation E/E’ ratio more than 15 in 2 (6.7%) patients after PCI (mean±SD=16.483±0.8714 before PCI and 6.910±2.651 after PCI, with P<0.0001).

This came in agreement with previous studies performed by Hashemi et al. [29], who assessed improvement in diastolic function after elective PCI in patients with CAD and compared the results with those previously published in the medical literature from other countries. Improvement in diastolic function was detected especially 3 months after elective PCI to LT coronaries. The study showed a significant decrease of late diastolic A’ wave velocity of the septal angle of mitral valve annulus after PCI (P<0.05). This is because they did select only the patients with LAD disease, whereas our study was done on single-vessel and also two-vessel disease. The increase in some of the values related to diastolic function by this method suggests that PCI can be employed to enhance diastolic function in patients with CAD. All the study patients exhibited abnormal diastolic filling patterns before PCI characterized by prolonged mitral DT, decreased E/A peak velocity ratio and increased mitral A wave. At 48 h after PCI, mitral DT were significantly shortened. Concomitantly, E/A ratio increased significantly and mitral A wave significantly decreased in all the study patients. The early diastolic mitral E2 wave was significantly improved after PCI in all patients with CAD, and mitral E wave velocity to early diastolic mitral annular velocity in the medial annulus (E/E2 ratio) exhibited significant difference after PCI, in the entire CAD group. The peak systolic (S) shortening velocity and the early diastolic (E2) lengthening velocities are considered to be sensitive measures of LVSF or LVDF. Especially, the ratio of early mitral valve flow velocity (E) divided by E2 correlates closely with LV filling pressures. Dzavik et al. [22] determined the effect of PCI on myocardial function assessed by tissue Doppler echo in patients with chronic stable angina and found that there was a significant increase of E’/A’ ratio at anterior angle of mitral valve annulus and lateral angle of tricuspid valve annulus (P=0.02 for both). Carluccio et al. [30] in the June issue of the European Heart Journal found significant improvement in LV diastolic filling on TDI and in LVEF on conventional echo in 26 patients who underwent PCI serving hibernating, hypomyocardium, or akinetic myocardium, which was demonstrated by dobutamine-echo viability imaging. These results support the tenet that in IHD, systolic and diastolic functions go hand-in-glove, and directly demonstrate that revascularizing chronically viable, dyssynergic myocardium may also beneficially affect diastolic function [23]. Moreover, the results came in disagreement with previous studies performed by Carluccio et al. [30], who evaluated the early effects of successful elective PCI to left coronary lesion on diastolic function and found that among the diastolic indices, only velocity propagation improved significantly following PCI. Diastolic velocities, E/A ratio, DT, early and late diastolic velocities of mitral annulus in TDI, pulmonary vein systolic and diastolic flow velocity did not show significant improvement. Discrepancy between various studies may be owing to the interval between MI and PCI, basic LVEF before PCI, global condition of the patients, degree of coronary artery stenosis, and presence or absence of affection of other coronaries. Some studies have included patients with a shorter duration of the occlusion also, and PCI was undertaken without the contemporary specialized technologies. It seems likely that the selection process of coronary lesion with more favorable characteristics for PCI success used in these studies was associated with the selection of patients with a better baseline cardiac risk profile when compared with other studies, and so the results of these studies were better.[31]


  Conclusion Top


PCI for a significant coronary lesion has a beneficial effect on LV functions and improvement in regional and global LV functions and myocardial contractility after revascularization, which can be predicted by conventional echo and TDI.

Recommendations

PCI to CAD has beneficial effect on LV function parameters, so early intervention and perfusion will save the myocardium and its functions. Angiographic detection of stentable coronary lesions should be done as early as possible when optimal medical therapy is failed. In patient with stable angina, risk factor control is the goal of therapy. Assessment of LV functions before and after PCI is better done by conventional echocardiography, and more accurate and more details can be obtained by tissue Doppler study.

Further studies are recommended to assess the rest of coronaries PCI and their beneficial effect on LV functions, myocardial contractility, and patient outcome.

Limitations

  1. These data from an assessment of the benefits of successful left CAD patient group.
  2. The number of patients was small, and the duration of coronary lesion was not known for the entire group.
  3. Only patients with normal LV dimensions were included.
  4. Other coronary affections were not examined.
  5. No medical therapy patient group for comparison was included.
  6. No failed coronary lesion PCI patient group for comparison was included.
  7. Cardiac troponin and creatine phosphokinase data were not collected following PCI during the study period.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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