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Microvascular perfusion in infarcted and remote myocardium after successful primary PCI: angiographic and CMR findings

  • Anne Bethke
  • Limalanathan Shanmuganathan
  • Geir Øystein Andersen
  • Jan Eritsland
  • David Swanson
  • Nils Einar Kløw
  • Pavel Hoffmann
Cardiac

Abstract

Objectives

The aim of this study was to investigate the association between TIMI myocardial perfusion (TMP) grading acute and cardiac magnetic resonance (CMR) first-pass perfusion early and at 4 months in patients with ST-segment-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI).

Material and methods

One hundred ninety-eight STEMI patients were recruited from the POSTEMI study. TMP grade was assessed after PCI; CMR was performed at day 2 and after 4 months. Signal intensity was measured on first-pass perfusion images, and a maximum contrast enhancement index (MCE) was calculated.

Results

Patients with TMP grade 2-3 (n = 108) after PCI had significantly better EF (59 ± 10 vs. 51 ± 13, p < 0.001) and smaller infarct volume (12 ± 8 vs. 19 ± 12 %, p < 0.001) at 4 months compared with patients with TMP grade 0-1 (n = 81). MCE in the infarcted (MCEi) and remote myocardium (MCEr) improved from early to follow-up CMR, MCEi from 94 ± 56 to 126 ± 59, p < 0.001, and MCEr from 112 ± 51 to 127 ± 50, p < 0.001. In patients with the lowest CMR perfusion early, perfusion at 4 months remained decreased compared with the other groups, MCEi 108 ± 75 vs. 133 ± 51, p = 0.01, and MCEr 115 ± 41 vs. 131 ± 52, p = 0.047.

Conclusion

TMP grade and early CMR first-pass perfusion were associated with CMR outcomes at 4 months. First-pass perfusion improved after 4 months in the infarcted and remote myocardium. However, in patients with the lowest CMR perfusion early, perfusion was still reduced after 4 months.

Key Points

• Cardiac magnetic resonance myocardial first-pass perfusion and TMP grading after successful PCI helps to assess risk in patients with ST elevation myocardial infarction.

• Cardiac magnetic resonance myocardial first-pass perfusion shows that microvascular perfusion after ST elevation myocardial infarction can be impaired in both infarcted and non-infarcted myocardium.

• Microvascular perfusion improves over time in patients with ST elevation myocardial infarction treated with primary PCI.

Keywords

ST elevation myocardial infarction Magnetic resonance imaging Myocardial reperfusion Percutaneous coronary intervention 

Abbreviations

AaR

Area at risk

CMR

Cardiac magnetic resonance

ECG

Electrocardiography

EDV

End-diastolic volume

EF

Ejection fraction

ESV

End-systolic volume

IRA

Infarct related artery

LGE

Late gadolinium enhancement

MBG

Myocardial “blush” grade

MCE

Maximum contrast enhancement index

MCEi

MCE in the infarcted myocardium

MCEr

MCE in the remote myocardium

PCI

Percutaneous coronary intervention

POSTEMI

Postconditioning in STEMI study

SI

Signal intensity

TIMI

Thrombolysis in myocardial infarction

TMP

TIMI myocardial perfusion

TTP

Time to peak contrast enhancement

Notes

Acknowledgments

The authors thank the radiographers and staff of the Department of Cardiology and Radiology at the Oslo University Hospital, Ullevål.

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Pavel Hoffmann.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors, David Swanson, has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Several articles on the cohort of patients included in the POSTEMI trial have been published [1-5]. The results reported were mainly clinical and biochemical endpoints. CMR results reported were infarct size, left ventricular function, microvascular obstruction, area at risk and myocardial salvage. Data on CMR first-pass perfusion have not been published yet.

1. Limalanathan S, Eritsland J, Andersen GO, Klow NE, Abdelnoor M, Hoffmann P (2013) Myocardial salvage is reduced in primary PCI-treated STEMI patients with microvascular obstruction, demonstrated by early and late CMR. PLoS One 8 (8):e71780. doi:10.1371/journal.pone.0071780

2. Limalanathan S, Andersen GO, Klow NE, Abdelnoor M, Hoffmann P, Eritsland J (2014) Effect of ischemic postconditioning on infarct size in patients with ST-elevation myocardial infarction treated by primary PCI results of the POSTEMI (POstconditioning in ST-Elevation Myocardial Infarction) randomized trial. J Am Heart Assoc 3 (2):e000679. doi:10.1161/JAHA.113.000679

3. Limalanathan S, Eritsland J, Klow NE, Abdelnoor M, Hoffmann P, Andersen GO (2015) Influence of ischemic postconditioning on myocardial dysfunction measured by speckle tracking echocardiography in patients with ST-elevation myocardial infarction. Int J Cardiol 187:459-461. doi:10.1016/j.ijcard.2015.03.192

4. Shetelig C, Limalanathan S, Eritsland J, Hoffmann P, Seljeflot I, Gran JM, Aukrust P, Ueland T, Andersen GO (2017) Osteoprotegerin levels in ST-elevation myocardial infarction: Temporal profile and association with myocardial injury and left ventricular function. PLoS One 12 (3):e0173034. doi:10.1371/journal.pone.0173034

5. Ritschel V, Shetelig C, Seljeflot I, Limalanathan S, Hoffmann P, Halvorsen S, Arnesen H, Eritsland J, Andersen GO (2017) Evaluation of circulating levels of CCN2/connective tissue growth factor in patients with ST-elevation myocardial infarction. Sci Rep 7 (1):11945. doi:10.1038/s41598-017-12372-w

Methodology

• prospective

• randomized controlled trial

• performed at one institution

References

  1. 1.
    Costantini CO, Stone GW, Mehran R et al (2004) Frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty and stenting, with and without glycoprotein IIb/IIIa inhibition, in acute myocardial infarction. J Am Coll Cardiol 44:305–312CrossRefPubMedGoogle Scholar
  2. 2.
    Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB (2002) Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol 39:591–597CrossRefPubMedGoogle Scholar
  3. 3.
    Nijveldt R, Beek AM, Hirsch A et al (2008) Functional recovery after acute myocardial infarction: comparison between angiography, electrocardiography, and cardiovascular magnetic resonance measures of microvascular injury. J Am Coll Cardiol 52:181–189CrossRefPubMedGoogle Scholar
  4. 4.
    Wu KC, Zerhouni EA, Judd RM et al (1998) Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 97:765–772CrossRefPubMedGoogle Scholar
  5. 5.
    Hoffmann P, Halvorsen S, Stensaeth KH et al (2006) Myocardial perfusion in ST-elevation myocardial infarction treated successfully with primary angioplasty. Scand Cardiovasc J 40:96–104CrossRefPubMedGoogle Scholar
  6. 6.
    Gibson CM, Cannon CP, Murphy SA et al (2002) Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 105:1909–1913CrossRefPubMedGoogle Scholar
  7. 7.
    van’t Hof AWJ, Liem A, Suryapranata H, Hoorntje JCA, de Boer MJ, Zijlstra F (1998) Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction : myocardial blush grade. Circulation 97:2302–2306CrossRefGoogle Scholar
  8. 8.
    Abraham JM, Gibson CM, Pena G et al (2009) Association of angiographic perfusion score following percutaneous coronary intervention for ST-elevation myocardial infarction with left ventricular remodeling at 6 weeks in GRACIA-2. J Thromb Thrombolysis 27:253–258CrossRefPubMedGoogle Scholar
  9. 9.
    Bethke A, Halvorsen S, Bohmer E, Abdelnoor M, Arnesen H, Hoffmann P (2015) Myocardial perfusion grade predicts final infarct size and left ventricular function in patients with ST-elevation myocardial infarction treated with a pharmaco-invasive strategy (thrombolysis and early angioplasty). EuroIntervention 11:518–524CrossRefPubMedGoogle Scholar
  10. 10.
    Hopp E, Bjornerud A, Lunde K et al (2013) Perfusion MRI at rest in subacute and chronic myocardial infarct. Acta Radiol 54:401–411CrossRefPubMedGoogle Scholar
  11. 11.
    Yan AT, Gibson CM, Larose E et al (2006) Characterization of microvascular dysfunction after acute myocardial infarction by cardiovascular magnetic resonance first-pass perfusion and late gadolinium enhancement imaging. J Cardiovasc Magn Reson 8:831–837CrossRefPubMedGoogle Scholar
  12. 12.
    Bogaert J, Kalantzi M, Rademakers FE, Dymarkowski S, Janssens S (2007) Determinants and impact of microvascular obstruction in successfully reperfused ST-segment elevation myocardial infarction. Assessment by magnetic resonance imaging. Eur Radiol 17:2572–2580CrossRefPubMedGoogle Scholar
  13. 13.
    Mayr A, Pedarnig K, Klug G et al (2012) Regional functional recovery after acute myocardial infarction: a cardiac magnetic resonance long-term study. Int J Cardiovasc Imaging 28:1445–1453CrossRefPubMedGoogle Scholar
  14. 14.
    Baks T, van Geuns RJ, Biagini E et al (2005) Recovery of left ventricular function after primary angioplasty for acute myocardial infarction. Eur Heart J 26:1070–1077CrossRefPubMedGoogle Scholar
  15. 15.
    Nijveldt R, Hofman MB, Hirsch A et al (2009) Assessment of microvascular obstruction and prediction of short-term remodeling after acute myocardial infarction: cardiac MR imaging study. Radiology 250:363–370CrossRefPubMedGoogle Scholar
  16. 16.
    Limalanathan S, Andersen GO, Hoffmann P, Klow NE, Abdelnoor M, Eritsland J (2010) Rationale and design of the POSTEMI (postconditioning in ST-elevation myocardial infarction) study. Cardiology 116:103–109CrossRefPubMedGoogle Scholar
  17. 17.
    Limalanathan S, Andersen GO, Klow NE, Abdelnoor M, Hoffmann P, Eritsland J (2014) Effect of ischemic postconditioning on infarct size in patients with ST-elevation myocardial infarction treated by primary PCI results of the POSTEMI (POstconditioning in ST-Elevation Myocardial Infarction) randomized trial. J Am Heart Assoc 3:e000679CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Gibson CM, Cannon CP, Murphy SA et al (2000) Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation 101:125–130CrossRefPubMedGoogle Scholar
  19. 19.
    Schulz-Menger J, Bluemke DA, Bremerich J et al (2013) Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on standardized post processing. J Cardiovasc Magn Reson 15(35)Google Scholar
  20. 20.
    Taylor AJ, Al-Saadi N, Abdel-Aty H, Schulz-Menger J, Messroghli DR, Friedrich MG (2004) Detection of acutely impaired microvascular reperfusion after infarct angioplasty with magnetic resonance imaging. Circulation 109:2080–2085CrossRefPubMedGoogle Scholar
  21. 21.
    Orn S, Manhenke C, Greve OJ et al (2009) Microvascular obstruction is a major determinant of infarct healing and subsequent left ventricular remodelling following primary percutaneous coronary intervention. Eur Heart J 30:1978–1985CrossRefPubMedGoogle Scholar
  22. 22.
    Noel B, Morice MC, Garot J et al (2005) CMR assessment of AMI patients treated by PCI shows delays in myocardial reperfusion despite initial achievement of TIMI 3 flow. EuroIntervention 1:214–218PubMedGoogle Scholar
  23. 23.
    Gregorini L, Marco J, Kozakova M et al (1999) Alpha-adrenergic blockade improves recovery of myocardial perfusion and function after coronary stenting in patients with acute myocardial infarction. Circulation 99:482–490CrossRefPubMedGoogle Scholar
  24. 24.
    Eeckhout E, Kern MJ (2001) The coronary no-reflow phenomenon: a review of mechanisms and therapies. Eur Heart J 22:729–739CrossRefPubMedGoogle Scholar
  25. 25.
    Lee WW, Marinelli B, van der Laan AM et al (2012) PET/MRI of inflammation in myocardial infarction. J Am Coll Cardiol 59:153–163CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Olivetti G, Quaini F, Sala R et al (1996) Acute myocardial infarction in humans is associated with activation of programmed myocyte cell death in the surviving portion of the heart. J Mol Cell Cardiol 28:2005–2016CrossRefPubMedGoogle Scholar
  27. 27.
    Corday E, Kaplan L, Meerbaum S et al (1975) Consequences of coronary arterial occlusion on remote myocardium: effects of occlusion and reperfusion. Am J Cardiol 36:385–394CrossRefPubMedGoogle Scholar
  28. 28.
    Oskarsson HJ, Coppey L, Weiss RM, Li WG (2000) Antioxidants attenuate myocyte apoptosis in the remote non-infarcted myocardium following large myocardial infarction. Cardiovasc Res 45:679–687CrossRefPubMedGoogle Scholar
  29. 29.
    Wang S, Fei K, Xu YW, Wang LX, Chen YQ (2009) Dihydroxyflavonol reduces post-infarction left ventricular remodeling by preventing myocyte apoptosis in the non-infarcted zone in goats. Chin Med J (Engl) 122:61–67Google Scholar
  30. 30.
    Carberry J, Carrick D, Haig C et al (2016) Remote zone extracellular volume and left ventricular remodeling in survivors of ST-elevation myocardial infarction. Hypertension 68:385–391CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Reinstadler SJ, Stiermaier T, Liebetrau J et al (2018) Prognostic significance of remote myocardium alterations assessed by quantitative noncontrast T1 mapping in ST-segment elevation myocardial infarction. JACC Cardiovasc Imaging 11:411–419CrossRefPubMedGoogle Scholar
  32. 32.
    Fearon WF, Low AF, Yong AS et al (2013) Prognostic value of the Index of Microcirculatory Resistance measured after primary percutaneous coronary intervention. Circulation 127:2436–2441CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Joost A, Stiermaier T, Eitel C et al (2016) Impact of initial culprit vessel flow on infarct size, microvascular obstruction, and myocardial salvage in acute reperfused ST-elevation myocardial infarction. Am J Cardiol 118:1316–1322CrossRefPubMedGoogle Scholar
  34. 34.
    Dibra A, Mehilli J, Dirschinger J et al (2003) Thrombolysis in myocardial infarction myocardial perfusion grade in angiography correlates with myocardial salvage in patients with acute myocardial infarction treated with stenting or thrombolysis. J Am Coll Cardiol 41:925–929CrossRefPubMedGoogle Scholar
  35. 35.
    Appelbaum E, Abraham JM, Pride YB et al (2009) Association of thrombolysis in myocardial infarction myocardial perfusion grade with cardiovascular magnetic resonance measures of infarct architecture after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am Heart J 158:84–91CrossRefPubMedGoogle Scholar
  36. 36.
    Brener SJ, Cristea E, Mehran R, Dressler O, Lansky AJ, Stone GW (2011) Relationship between angiographic dynamic and densitometric assessment of myocardial reperfusion and survival in patients with acute myocardial infarction treated with primary percutaneous coronary intervention: the harmonizing outcomes with revascularization and stents in AMI (HORIZONS-AMI) trial. Am Heart J 162:1044–1051CrossRefPubMedGoogle Scholar
  37. 37.
    Angeja BG, Gunda M, Murphy SA et al (2002) TIMI myocardial perfusion grade and ST segment resolution: association with infarct size as assessed by single photon emission computed tomography imaging. Circulation 105:282–285CrossRefPubMedGoogle Scholar
  38. 38.
    Porto I, Burzotta F, Brancati M et al (2007) Relation of myocardial blush grade to microvascular perfusion and myocardial infarct size after primary or rescue percutaneous coronary intervention. Am J Cardiol 99:1671–1673CrossRefPubMedGoogle Scholar
  39. 39.
    Wong DT, Leung MC, Richardson JD et al (2012) Cardiac magnetic resonance derived late microvascular obstruction assessment post ST-segment elevation myocardial infarction is the best predictor of left ventricular function: a comparison of angiographic and cardiac magnetic resonance derived measurements. Int J Cardiovasc Imaging 28:1971–1981CrossRefPubMedGoogle Scholar
  40. 40.
    Niccoli G, Cosentino N, Lombardo A et al (2011) Angiographic patterns of myocardial reperfusion after primary angioplasty and ventricular remodeling. Coron Artery Dis 22:507–514PubMedGoogle Scholar
  41. 41.
    Steigen TK, Buller CE, Mancini GB et al (2010) Myocardial perfusion grade after late infarct artery recanalization is associated with global and regional left ventricular function at one year: analysis from the Total Occlusion Study of Canada-2. Circ Cardiovasc Interv 3:549–555CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Zalewski J, Nycz K, Przewlocki T et al (2011) Evolution of myocardial perfusion during primary angioplasty in spontaneously reperfused infarct-related artery: impact on long-term clinical outcomes and left ventricular function recovery. Int J Cardiol 147:25–31CrossRefPubMedGoogle Scholar
  43. 43.
    Rochitte CE, Lima JA, Bluemke DA et al (1998) Magnitude and time course of microvascular obstruction and tissue injury after acute myocardial infarction. Circulation 98:1006–1014CrossRefPubMedGoogle Scholar
  44. 44.
    Mather AN, Lockie T, Nagel E et al (2009) Appearance of microvascular obstruction on high resolution first-pass perfusion, early and late gadolinium enhancement CMR in patients with acute myocardial infarction. J Cardiovasc Magn Reson 11(33)Google Scholar
  45. 45.
    O'Gara PT, Kushner FG, Ascheim DD et al (2013) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 127:e362–e425CrossRefPubMedGoogle Scholar
  46. 46.
    Robbers LF, Nijveldt R, Beek AM et al (2014) Cell therapy in reperfused acute myocardial infarction does not improve the recovery of perfusion in the infarcted myocardium: a cardiac MR imaging study. Radiology 272:113–122CrossRefPubMedGoogle Scholar
  47. 47.
    Nagao M, Higashino H, Matsuoka H et al (2008) Clinical importance of microvascular obstruction on contrast-enhanced MRI in reperfused acute myocardial infarction. Circ J 72:200–204CrossRefPubMedGoogle Scholar
  48. 48.
    Wald DS, Morris JK, Wald NJ et al (2013) Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med 369:1115–1123CrossRefPubMedGoogle Scholar
  49. 49.
    Doost Hosseiny A, Moloi S, Chandrasekhar J, Farshid A (2016) Mortality pattern and cause of death in a long-term follow-up of patients with STEMI treated with primary PCI. Open Heart 3:e000405CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of Radiology and Nuclear MedicineDivision of Diagnostics and InterventionOsloNorway
  2. 2.Institute for Clinical MedicineUniversity of OsloOsloNorway
  3. 3.Feiring Heart ClinicFeiringNorway
  4. 4.Department of CardiologyOslo University HospitalUllevålNorway
  5. 5.Institute of Basic Medical Sciences, Department of BiostatisticsUniversity of OsloOsloNorway
  6. 6.Department of Cardiology, Section for Interventional CardiologyOslo University HospitalUllevålNorway

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