Durante Alessandro, Laricchia Alessandra, Benedetti Giulia, Esposito Antonio, Margonato Alberto, Rimoldi Ornella, De Cobelli Francesco, Colombo Antonio, Camici Paolo G
From the Vita-Salute University and San Raffaele Hospital, Milan, Italy (A.D., A.L., G.B., A.E., A.M., F.D., A.C., P.G.C.); CNR-IBFM, Segrate, Italy (O.R.).
Circ Cardiovasc Imaging. 2017 Jun;10(6):e005841. doi: 10.1161/CIRCIMAGING.116.005841.
The incidence of angiographic no reflow (NR) and microvascular obstruction (MVO) at cardiac magnetic resonance is significantly different. The aim of this study was to investigate the occurrence of NR and MVO in a cohort of consecutive patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary interventions.
In this prospective study, 88 consecutive ST-segment-elevation myocardial infarction patients were enrolled within 12 hours from symptoms onset. All patients underwent cardiac magnetic resonance between 2 and 5 days after primary percutaneous coronary interventions. NR was defined as thrombolysis in myocardial infarction flow grade ≤2 and as myocardial blush grade <2. Presence of early or late MVO was assessed 4 and 10 to 15 minutes after gadolinium injection. Thirty-one patients (36%) had evidence of NR, whereas 58 (67%) had MVO. One NR patient did not have MVO. In contrast, NR was present in 30 of 58 MVO patients. MVO patients had higher troponin T peak (<0.0001), larger late gadolinium enhancement area (<0.0001), and lower left ventricular ejection fraction (<0.001) because of an increased end-systolic volume (=0.015). In contrast, patients with NR had higher troponin T peak (=0.006) but similar late gadolinium enhancement area (=0.24) compared with those without NR. Major cardiovascular adverse events-free survival was worse in patients with MVO (=0.014), although it was similar in patients with and without NR (=0.33). The independent predictors of major cardiovascular adverse events were MVO (hazard ratio, 3.418; =0.046) and ischemic time (hazard ratio, 1.016; <0.001). MVO was a strong predictor of target lesion revascularization occurrence (=0.017 for log-rank test).
Compared with coronary angiography performed soon after recanalization of the culprit artery, cardiac magnetic resonance performed during index hospitalization provides better prognostic stratification of ST-segment-elevation myocardial infarction patients treated with primary percutaneous coronary interventions. Another novel finding of our study is a significantly increased rate of clinically driven target lesion revascularization in the index event culprit vessel in patients with MVO.
心脏磁共振成像时血管造影无复流（NR）和微血管阻塞（MVO）的发生率有显著差异。本研究旨在调查接受直接经皮冠状动脉介入治疗的连续性ST段抬高型心肌梗死患者中NR和MVO的发生情况。
在这项前瞻性研究中，88例连续性ST段抬高型心肌梗死患者在症状发作后12小时内入组。所有患者在直接经皮冠状动脉介入治疗后2至5天接受心脏磁共振成像检查。NR定义为心肌梗死溶栓血流分级≤2级和心肌 blush分级<2级。在注射钆剂后4分钟以及10至15分钟评估早期或晚期MVO的存在情况。31例患者（36%）有NR证据，而58例（67%）有MVO。1例有NR的患者没有MVO。相反，58例有MVO的患者中有30例存在NR。由于收缩末期容积增加（=0.015），MVO患者肌钙蛋白T峰值更高（<0.0001）、晚期钆增强面积更大（<0.0001）且左心室射血分数更低（<0.001）。相比之下，与无NR的患者相比，有NR的患者肌钙蛋白T峰值更高（=0.006）但晚期钆增强面积相似（=0.24）。有MVO的患者无主要心血管不良事件生存情况更差（=0.014），尽管有和无NR的患者情况相似（=0.33）。主要心血管不良事件的独立预测因素是MVO（风险比，3.418；=0.046）和缺血时间（风险比，1.016；<0.001）。MVO是靶病变血运重建发生的有力预测因素（对数秩检验=0.017）。
与罪犯血管再通后不久进行的冠状动脉造影相比，在首次住院期间进行的心脏磁共振成像能为接受直接经皮冠状动脉介入治疗的ST段抬高型心肌梗死患者提供更好的预后分层。我们研究的另一个新发现是，MVO患者在首次事件罪犯血管中临床驱动的靶病变血运重建率显著增加。
