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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Impact of Primary Coronary Angioplasty Delay on Myocardial Salvage, Infarct Size, and Microvascular Damage in Patients With ST-Segment Elevation Myocardial Infarction

Insight From Cardiovascular Magnetic Resonance

Marco Francone, MD, PhD, MSc^_*, Chiara Bucciarelli-Ducci, MD^,, Iacopo Carbone, MD^_*, Emanuele Canali, MD, Raffaele Scardala, MD, Francesca A. Calabrese, MD^_*, Gennaro Sardella, MD, Massimo Mancone, MD, Carlo Catalano, MD^_*, Francesco Fedele, MD, Roberto Passariello, MD^_*, Jan Bogaert, MD, PhD^|| and Luciano Agati, MD^,_*

^_* Cardiovascular Magnetic Resonance Unit, Department of Radiology Sciences, "Sapienza" University of Rome, Rome, Italy
Cardiac Imaging Unit and Cardiovascular Division, "Sapienza" University of Rome, Rome, Italy
Catheterization Laboratory, Department of Cardiology Sciences, "Sapienza" University of Rome, Rome, Italy
Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
^|| Department of Medical Imaging, Gasthuisberg University Hospital, Leuven, Belgium

Manuscript received May 3, 2009; revised manuscript received August 13, 2009, accepted August 30, 2009.

^_* Reprint requests and correspondence: Dr. Luciano Agati, Professor of Cardiology, Head of Cardiac Imaging Unit, Department of Cardiology, "Sapienza" University of Rome, Viale del Policlinico 155, 00161 Roma, Italy (Email: luciano.agati{at}uniroma1.it).

Objectives: We investigated the extent and nature of myocardial damage by using cardiovascular magnetic resonance (CMR) in relation to different time-to-reperfusion intervals.

Background: Previous studies evaluating the influence of time to reperfusion on infarct size (IS) and myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) have yielded conflicting results.

Methods: Seventy patients with STEMI successfully treated with primary percutaneous coronary intervention within 12 h from symptom onset underwent CMR 3 ± 2 days after hospital admission. Patients were subcategorized into 4 time-to-reperfusion (symptom onset to balloon) quartiles: 90 min (group I, n = 19), >90 to 150 min (group II, n = 17), >150 to 360 min (group III, n = 17), and >360 min (group IV, n = 17). T2-weighted short tau inversion recovery and late gadolinium enhancement CMR were used to characterize reversible and irreversible myocardial injury (area at risk and IS, respectively); salvaged myocardium was defined as the normalized difference between extent of T2-weighted short tau inversion recovery and late gadolinium enhancement.

Results: Shorter time-to-reperfusion (group I) was associated with smaller IS and microvascular obstruction and larger salvaged myocardium. Mean IS progressively increased overtime: 8% (group I), 11.7% (group II), 12.7% (group III), and 17.9% (group IV), p = 0.017; similarly, MVO was larger in patients reperfused later (0.5%, 1.5%, 3.7%, and 6.6%, respectively, p = 0.047). Accordingly, salvaged myocardium markedly decreased when reperfusion occurred >90 min of coronary occlusion (8.5%, 3.2%, 2.4%, and 2.1%, respectively, p = 0.004).

Conclusions: In patients with STEMI treated with primary percutaneous coronary intervention, time to reperfusion determines the extent of reversible and irreversible myocardial injury assessed by CMR. In particular, salvaged myocardium is markedly reduced when reperfusion occurs >90 min of coronary occlusion.

Key Words: myocardial salvage • myocardial infarction • microvascular injury • cardiovascular magnetic resonance • time to reperfusion

Abbreviations and Acronyms   CMR = cardiovascular magnetic resonance   IRA = infarct-related artery   IS = infarct size   LAD = left anterior descending artery   LGE = late gadolinium enhancement   LV = left ventricle/ventricular   LVEDV = left ventricular end-diastolic volume   LVEF = left ventricular ejection fraction   LVESV = left ventricular end-systolic volume   MVO = microvascular obstruction   PCI = percutaneous coronary intervention   PPCI = primary percutaneous coronary intervention   SSFP = steady-state free precession   STEMI = ST-segment elevation myocardial infarction   T2w-STIR = T2-weighted short tau inversion recovery   TE = echo time   TR = repetition time

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