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Angiographic Estimates of Myocardium at Risk During Acute Myocardial Infarction: a Validation Study Using Cardiac MRI PowerPoint Presentation
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Angiographic Estimates of Myocardium at Risk During Acute Myocardial Infarction: a Validation Study Using Cardiac MRI. José T. Ortiz, Sheridan N. Meyers, Daniel C. Lee, Preeti Kansal, Thomas A. Holly, Francis J. Klocke, Charles J. Davidson, Robert O. Bonow, Edwin Wu.

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Angiographic Estimates of Myocardium at Risk During Acute Myocardial Infarction: a Validation Study Using Cardiac MRI

José T. Ortiz, Sheridan N. Meyers, Daniel C. Lee, Preeti Kansal, Thomas A. Holly, Francis J. Klocke, Charles J. Davidson, Robert O. Bonow, Edwin Wu

Feinberg Cardiovascular Research InstituteChicago, Illinois

slide2

Background

Determinants of infarct size

  • Duration of coronary occlusion
  • Residual flow in the territory at risk

Collaterals

Antegrade flow in the IRA

  • Hemodynamic factors: Blood pressure, HR.
  • Area at risk
slide3

Background

The “Wavefront Phenomenon” of Myocardial Ischemic Cell Death

Myocardium at risk

Final infarct

3 hours

96 hours

40 minutes

Duration of coronary occlusion

Reimer K, Jennings R et al. Lab Inv 1979;40:633-44

slide4

Background

SPECT-Tc99m

Area at risk = Perfusion defect before reperfusion

Infarct size = Perfusion defect 2 weeks later

Myocardial salvage = area at risk - infarct size

Christian T et al. Circulation 1992;86:81-90Gibbons RJ et al. NEJM 1993;328:685-91Kastrati A et al. Lancet 2002;359:920-25

slide5

Background

Limitations of SPECT for assessment of area at risk

  • Requires imaging within 6 hours post-PCI.
  • Not available during off-hours.
  • Low spatial resolution.
  • Redistribution.
  • Requires to separate studies to compute myocardial salvage.
slide6

Aims of the study

  • To assess the clinical usefulness of coronary angiography to retrospectively quantify the area at risk of infarction.
  • To study the relationship between the anatomic area at risk by angiography and the infarct endocardial surface area on DE-CMR images.
slide7

Methods

APPROACH-modified score

slide8

BARI-score

1

1

1

1

1

2

3

1

3

1

1

2

1

3

3

1

Methods

PatentLAD

Occluded LAD

Area at risk calculation

Area at risk: 11 pointsTotal LV: 26 points

BARI (%LV) = 42.3%

slide9

Methods

Infarct Endocardial Surface Area (i-ESA) calculation

Infarct = 34.12 cm2

Non-infarct = 51.18 cm2

Total = 85.3 cm2

i-ESA = 40 % LV

slide10

First STEMI

No prior history of MI

CMR done within the first week

23 subjects with TIMI flow >0

121 subjects

12 subjects.Time not available

98 subjects

1 IRA not identified

2 previous CABG

86 subjects

83 subjects

Methods

slide11

Results

Patient characteristics

slide12

Results

Area at risk by angiography vs infarct size by CMR

  • Among subjects with transmural infarct, the anatomic area at risk matched the infarct size on ce-CMR. Bland-Altman analysis showed a bias of 2.42 % LV myocardial wall (95%CI: 3.98-0.85) and 1.14% (95%CI: 2.67- -0.38) for BARI and APPROACH scores when compared to infarct size.
  • In patients with non-transmural infarcts, infarct size by ce-CMR (17.3 ±8% LV) was significantly smaller than the anatomic area at risk by BARI (30.5±10% LV) and APPROACH score (29.6±10% LV)
slide13

Results

Area at risk by angiography vs i-ESA

  • In the whole group, the infarct-ESA highly correlated with the anatomical area at risk by both BARI and APPROACH scores.
  • Bland-Altman analysis showed a bias of -1.66% LV (95% CI: -2.61 - -0.70) and -2.81% of the left ventricle (95% CI: -3.88 - -1.75) between infarct-ESA and anatomical area at risk by BARI and APPROACH-scores, respectively.

Ortiz-Pérez JT et al. EHJ 2007:28;1750-58.

slide14

Results

Area at risk by angiography (P = 0.8 for the trend)

Infarct size (P < 0.001 for the trend)

BARI

APPROACH

Ortiz-Pérez JT et al. EHJ 2007:28;1750-58.

slide15

Results

Effect of collaterals and time to reperfusion

Myocardial salvage by BARI

Myocardial salvage by APPROACH

Infarct transmurality score

slide16

Conclusions

  • The myocardium at risk can be estimated by coronary angiography and by measuring the endocardial extent of the infarct on DE-CMR images, independently of the presence of collaterals and the time to reperfusion.
  • This combined angiographic and CMR method permits prediction of potential infarct size and therefore allows quantification of myocardial salvage provided by reperfusion therapies.
slide17

Conclusions

  • The benefits of collateral flow and early reperfusion occurs by means of reduction in infarct transmural extent.
  • These findings confirm in humans the wavefrront phenomenon of evolving myocardial infarction described by Reimer and Jennings 30 years ago.