MYOCARDIAL STUNNING AND HIBERNATION. Dr Binjo J Vazhappilly . SR , Cardiology Dept. Calicut Medical College. Stunning. Definition : Prolonged and fully reversible dysfunction of the ischemic heart that persists despite the normalization of blood flow.
Dr Binjo J Vazhappilly.
SR , Cardiology Dept.
Calicut Medical College
Prolonged and fully reversible dysfunction of the ischemic heart that persists despite the normalization of blood flow.
1stdescribed by Heyndrickx et al in 1975 in conscious dogs undergoing brief coronary occlusions.
Stunning occurs in a wide variety of settings that differ from one another in several aspects
1. Single , completely reversible episode of
regional ischemia (< 20 min )
2. Multiple, completely reversible episodes of
3. Partly reversible plus partly irreversible
ischemia in vivo ( > 20 min & < 3 hrs)
5. After global ischemia in vivo (cardioplegic arrest)
6. After exercise-induced ischemia
1. Brief period of total coronary occlusion:
pts with angina due to spasm
2. Global ischemia after cardiopulmonary bypass.
3. In combination : Subendocardium is infarcted and
overlying subepicardium reversibly injured in MI
4. Following exercise in presence of a flow limiting
5. Ischemic bout that is induced by PCI
Oxyradical hypothesis : oxidant stress secondary
to the generation of ROS.
Calcium hypothesis : results from disturbance of
cellular calcium homeostasis.
Term hibernation is borrowed from zoology and implies an adaptive reduction of energy expenditure through reduced activity in situation of reduced energy supply.
Diamond et al. in 1978 1st used the word hibernation in ischemic dog myocardium.
Myocardial metabolism and function are reduced to match concomitant reduction in coronary blood flow which prevents necrosis.
Repetitive episodes of ischemia results in
sustained depression of contractile function.
Maintained viability in hibernation suggests possibility of genomic adaptation.
Major survival genes (antiapoptotic, cytoprotective & growth-promoting genes) and their corresponding proteins are up regulated in hibernating myocardium.
No clear correlation between Q waves on ECG and presence of viability.
Pts with preserved QT dispersion are likely to have viable myocardium.
Pts with high QT dispersion have predominantly non-viable scar tissue.
Safety , low cost , widespread availability of equipment .
Spatial resolution is relatively low.
High interobserver variability.
Diagnostic accuracy is reduced in pts with poor
Early uptake is proportional to regional blood flow & delayed uptake indicates preserved Na+ K+ pump and an intact cell membrane.
Defects on initial images that improve later are viable.
lipophilic molecules and their intracellular retention requires intact mitochondrial function.
Gating allow simultaneous assessment of myocardial perfusion & contractile function.
1.Resting MRI to measure end diastolic wall thickness.
2. Dobutamine MRI to evaluate contractile reserve
3. Contrast enhanced MRI to detect extent
and transmurality of scar tissue.
End diastolic wall thickness < 6 mm represent
Evaluate contractile reserve.
Increased resolution of MRI avoid subjective
variation of echo.
Has sensitivity of 89% & specificity of 94% to predict improvement after revascularization.
Allows precise detection of scar tissue.
Extent & transmurality of scar can be assessed.
Can detect subendocardial scar.
Similar to FDG PET in detecting scar.
In dyskinetic and akinetic segments, absence of scar or a transmural extension of scar of <25% have PPV of 88% and NPV 89% for functional recovery.
Hibernating Myocardium : PHYSIOLOGICAL REVIEWS Vol. 78, No. 4, October 1998