Bruder Oliver, Breuckmann Frank, Jensen Christoph, Jochims Markus, Naber Christoph K, Barkhausen Jörg, Erbel Raimund, Sabin Georg V
Department of Cardiology and Angiology, Elisabeth Hospital Essen, Essen, Germany.
Herz. 2008 Mar;33(2):136-42. doi: 10.1007/s00059-008-3102-8.
In acute ST segment elevation myocardial infarction (STEMI), rapid restoration of epicardial coronary blood flow and myocardial perfusion limits infarct size and improves survival. Primary percutaneous coronary intervention (PCI) is superior to systemic fibrinolysis when instantly performed by experienced operators. The "Herzinfarktverbund Essen" (HIVE) is an urban STEMI network supporting direct patient transfer for primary PCI to four PCI centers covering a city area of 600,000 inhabitants. Integrated health care is an optional part of the HIVE allowing for reimbursement of medical innovations such as the evaluation of infarct size and the presence and extent of microvascular obstruction by contrast-enhanced cardiac magnetic resonance (CMR). The aim of this study was to assess the prognostic impact of contrast-enhanced CMR in the patient cohort of a regional STEMI network.
Within the 1st year (09/2004 to 08/2005) of the HIVE registry, 489 patients with acute myocardial infarction were treated in the four primary PCI centers. In one of the centers, including 143 patients, early CMR imaging using a standardized MR protocol for infarct quantification was performed whenever possible. Patients with hemodynamic instability, emergency coronary artery bypass grafting, resuscitation or death prior to CMR, claustrophobia, and other general contraindications to MRI had to be excluded, leaving 67 patients (54 male; mean age 61 +/- 12 years) for final evaluation. CMR was performed 4.5 +/- 2.5 days after admission on a 1.5-T MR scanner (Sonata, Siemens Medical Solutions, Erlangen, Germany) including steady-state free precession (SSFP) cine imaging for left ventricular function and single-shot inversion-recovery SSFP imaging for delayed enhancement (DE) and no-reflow (NR) evaluation following injection of 0.2 mmol/kg body weight gadodiamide (Omniscan, GE Healthcare Buchler, Munich, Germany). NR and DE volumes were calculated from single-shot short-axis stacks taken within the 1st minute following gadodiamide infusion by manual planimetry and summation of disks. 1-year follow-up data (telephone interview) for major adverse cardiac events (MACE: cardiac death, myocardial infarction, and rehospitalization for congestive heart failure, angina pectoris, or revascularization) were available for all patients.
DE as a measure of infarct size was 9% +/- 7% (range 0-33%) of left ventricular mass (LVM), and mean volume of microvascular obstruction was 2% +/- 3% (range 0-17%). Microvascular obstruction was present in 61% of patients. 16 MACE (one cardiac death, one myocardial infarction, and 14 rehospitalizations for congestive heart failure or unstable angina pectoris with PCI in six cases) occurred within the follow-up period of 430 +/- 63 days. Patients with MACE had larger infarcts (14% +/- 10% vs. 8% +/- 6% DE), lower left ventricular ejection fraction (LVEF 44% +/- 17% vs. 48% +/- 14%) and larger NR (3% +/- 5% vs. 2% +/- 3%). Using a stepwise logistic regression model, only NR > 0.5% of LVM was independently related to outcome (odds ratio = 3.9, confidence interval 1.1-13.9).
NR as a correlate of microvascular obstruction remains independently related to prognosis in patients with acute myocardial infarction treated by PCI.
在急性ST段抬高型心肌梗死（STEMI）中，迅速恢复心外膜冠状动脉血流和心肌灌注可限制梗死面积并提高生存率。由经验丰富的术者即刻进行的直接经皮冠状动脉介入治疗（PCI）优于全身纤溶治疗。“埃森心肌梗死联盟”（HIVE）是一个城市STEMI网络，支持将患者直接转运至四个PCI中心进行直接PCI，这四个中心覆盖了一个有60万居民的城市区域。综合医疗保健是HIVE的一个可选部分，允许对医学创新进行报销，如通过对比增强心脏磁共振（CMR）评估梗死面积以及微血管阻塞的存在和程度。本研究的目的是评估对比增强CMR对一个地区STEMI网络患者队列的预后影响。
在HIVE注册研究的第1年（2004年9月至2005年8月），489例急性心肌梗死患者在四个直接PCI中心接受治疗。在其中一个中心，包括143例患者，只要有可能，就使用标准化的MR方案进行早期CMR成像以进行梗死定量。血流动力学不稳定、紧急冠状动脉旁路移植术、CMR前复苏或死亡、幽闭恐惧症以及其他MRI一般禁忌证的患者必须排除，最终有67例患者（54例男性；平均年龄61±12岁）可供评估。入院后4.5±2.5天在1.5-T MR扫描仪（Sonata，西门子医疗解决方案公司，德国埃尔兰根）上进行CMR检查，包括用于评估左心室功能的稳态自由进动（SSFP）电影成像以及注射0.2 mmol/kg体重钆双胺（欧乃影，通用电气医疗集团布赫勒公司，德国慕尼黑）后用于延迟强化（DE）和无复流（NR）评估的单次激发反转恢复SSFP成像。NR和DE体积通过钆双胺注入后第1分钟内获取的单次激发短轴图像堆栈，采用手动面积测量法和圆盘求和法计算。所有患者均有1年随访数据（电话访谈），记录主要不良心脏事件（MACE：心源性死亡、心肌梗死以及因充血性心力衰竭、心绞痛或血运重建再次住院）。
作为梗死面积指标的DE为左心室质量（LVM）的9%±7%（范围0 - 33%），微血管阻塞的平均体积为2%±3%（范围0 - 17%）。61%的患者存在微血管阻塞。在430±63天的随访期内发生了16例MACE（1例心源性死亡、1例心肌梗死以及14例因充血性心力衰竭或不稳定型心绞痛再次住院，其中6例行PCI）。发生MACE的患者梗死面积更大（DE为14%±10% vs. 8%±6%），左心室射血分数更低（左心室射血分数[LVEF]为44%±17% vs. 48%±14%）且NR更大（3%±5% vs. 2%±3%）。使用逐步逻辑回归模型，仅NR>左心室质量的0.5%与预后独立相关（比值比 = 3.9，置信区间1.1 - 13.9）。
作为微血管阻塞相关指标的NR在接受PCI治疗的急性心肌梗死患者中仍与预后独立相关。
