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