Francone M, Bucciarelli-Ducci C*, Carbone I, Canali E, Scardala R, Calabrese F, Sardella G, Mancone M, Catalano C, Fedele F, Passariello R, Bogaert J** and Agati L
Impact Of Primary Coronary Angioplasty Delay On Myocardial Salvage, Infarct Size And Microvascular Damage
in Patients with ST-Elevation Myocardial Infarction: Insight From Cardiovascular Magnetic Resonance
*Royal Brompton Hospital, National Heart and Lung Institute, Imperial College *Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, United KingdomLondon, United Kingdom
**Leuven University, Belgium**Leuven University, Belgium
Umberto I Hospital, University “La Sapienza”, Rome, ItalyUmberto I Hospital, University “La Sapienza”, Rome, Italy
Time is muscle
De Luca, Circulation 2004
Background
Challenges
Background
What happens to the muscle?
How to recognize salvageable myocardium?
How much salvageable myocardium is there?
Background
Kim RJ et al, Circulation 1999
Aletras AH et al, Circulation 2006Rochitte C et al, Circulation 1998
MICROVASCULAR DAMAGE
MYOCARDIAL NECROSIS
MYOCARDIUM AT RISK
Aims of the Study
1. To investigate the correlation between the extent and the
nature of myocardial damage in relation to different time-to-
reperfusion intervals
2. To investigate the relationship between time-to-reperfusion
intervals, myocardial damage and subsequent LV remodeling
Study Protocol
n=70 STEMI, primary PCI
≤90min
n=19
>90-150min
n=17
>150-360min
n=17
>360min
n=17
Time-to-reperfusion
CMR Protocol
Cine
6 months3±2 days
CMR Protocol
3±2 days
T2 w T1 w gadolinium T1 w gadolinium
increased signal intensity (myocardial edema)
Myocardium at risk
increased signal intensity reduced signal intensity
Infarct Size Microvascular Obstruction
Results: Myocardium at Risk
Myocardial Edema(% LV)
Time to reperfusion (min)
p=0.37
Results: Infarct Size
Infarct Size(% LV)
Time to reperfusion (min)
p=0.005
*
* p=0.002
Myocardium at Risk – Infarct size
Time to reperfusion (min)
Myocardial Salvage
Myocardial Salvage(%)
Time to reperfusion (min)
p=0.003
*
*
p=0.001
Microvascular Obstruction
MVO(% LV)
Time to reperfusion (min)
p=0.04
*
*
p=0.001
EDV: Baseline
90
110
130
150
170
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
EDV(ml)
p=0.03
EDV: Baseline vs 6 Months
90
110
130
150
170
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
EDV(ml)
p=0.002
p=0.005
p=0.05p=0.003
Baseline
6 months
ESV: Baseline
40
60
80
100
120
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
ESV(ml)
p=0.02
ESV: Baseline vs 6 Months
40
60
80
100
120
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
ESV(ml)
p=0.003
p=0.006
p=0.001p=0.06
Baseline
6 months
EF: Baseline
25
35
45
55
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
EF(%)
p=0.06
EF: Baseline vs 6 Months
25
35
45
55
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)
EF(%)
p=0.04
p=nsp= ns
p=0.04Baseline
6 months
LAD Infarctions
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)* MVO
Myocardiumat Risk
InfarctSize
Non-LAD Infarctions
≤90 min >90-150 min >150-360 min >360 min
Time to reperfusion (min)* MVO
Myocardiumat Risk
InfarctSize
Conclusions-1
First in-vivo, clinical, non invasive evaluation of the consequences of early and delayed coronary reperfusion on myocardial damage
Conclusions-2
Time is muscle
Longer time-to-reperfusion(>360min) Less salvaged myocardium
Larger infarct size and more MVO
LV remodeling
Myocardial salvage, infarct size and MVO by CMRsurrogate endpoints for clinical trials assessing the
efficacy of reperfusion strategies
