Incidence, predictors, and prognostic value of intramyocardial hemorrhage lesions in ST elevation myocardial infarction.

Intra myocardial hemorrhage lesions (IMH) are underdiagnosed complication of ST elevation myocardial infarction (STEMI). We sought to determine the incidence, predictors and the prognostic value of IMH in STEMI using cardiac MR imaging (CMR) techniques. We screened for inclusion consecutive patients with STEMI treated by percutaneous coronary intervention (PCI) within the first 12 hr of evolution. IMH lesions were identified on T2-weighted sequences on CMR between days 4 and 8 after PCI. Adverse cardiac events were defined as a composite of death + severe ventricular arrhythmias + acute coronary syndrome + acute heart failure. N = 114 patients were included and n = 11 patients (10%) presented IMH lesions. Patients with IMH lesions had a larger myocardial infarction extent (25.6 ± 1.8 vs. 13.5 ± 1.0 % LV mass, P < 0.01), microvascular obstructive lesions extent (4.6 ± 1.0 vs. 1.3 ± 0.3% LV mass, P < 0.01) and lower LV ejection fraction (40.7 ± 2.3% vs. 50.7 ± 1.3%, P < 0.01). The value of glycemia at admission was an independent predictor of IMH development (Odd ratio 1.8 [1.1-2.8] per mmol l(-1), P = 0.01). The incidence of adverse cardiac events was higher in the IMH group than in the non-IMH group during the first year following STEMI (P = 0.01, log-rank analysis). Cox regression analysis identified the presence of IMH lesions as an independent predictor of adverse clinical outcome (Hazard Ratio = 2.8 [1.2-6.8], P = 0.02). Our study indicates that IMH is a rare but severe finding in STEMI, associated with a larger myocardial infarction and a worse clinical outcome. Per-PCI glycemia might influence IMH development.

Amabile N ，Jacquier A ，Shuhab A ，Gaudart J ，Bartoli JM ，Paganelli F ，Moulin G ... -  《-》

Extent of RV dysfunction and myocardial infarction assessed by CMR are independent outcome predictors early after STEMI treated with primary angioplasty.

The aim of this study was to assess the prognostic value of right ventricular (RV) involvement diagnosed by cardiac magnetic resonance (CMR) early after ST-elevation myocardial infarction (STEMI). CMR allows accurate and reproducible RV assessment. However, there is a paucity of data regarding the prognostic value of RV involvement detected by CMR early after STEMI. Ninety-nine patients (77 men, mean age 57 ± 11 years) who underwent CMR 3 to 5 days after STEMI treated with primary angioplasty were followed for 1,150 ± 337 days for cardiac events (cardiac death, nonfatal myocardial infarction [MI], and hospitalizations due to decompensated heart failure). Cox proportional hazards model was applied in stepwise forward fashion to identify outcome predictors. Event-free survival was estimated by Kaplan-Meier method and compared between groups by the log-rank test. Cardiac events occurred in 34 patients (7 cardiac deaths, 8 MIs, 26 hospitalizations). By multivariable analysis, the independent outcome predictors were left ventricular (LV) MI transmurality index (hazard ratio: 1.03 per 1%; 95% confidence interval: 1.01 to 1.04; p = 0.001), RV ejection fraction (RVEF) (hazard ratio: 1.46 per 10% decrease; 95% confidence interval: 1.05 to 2.02; p = 0.03), and RVMI extent (hazard ratio: 1.50 per each infarcted RV segment; 95% confidence interval: 1.11 to 2.01; p = 0.007). Compared with clinical data (global chi-square = 5.2), LV ejection fraction [LVEF] (global chi-square = 11.1), RVEF (global chi-square = 17.1), LVMI transmural extent (global chi-square = 26.0), and RVMI extent (global chi-square = 34.9) improved outcome prediction in sequential Cox model analysis (p < 0.05 for all steps). RVEF stratified risk in patients with LVEF <40% in whom the 4-year event-free survival was 66.7% for RVEF ≥40% and 40.0% for RVEF <40% (p < 0.05). The extent of RVMI and RV dysfunction assessed early after STEMI are independent outcome predictors, which provide incremental prognostic value to clinical data, LV systolic function, and infarct burden. Measurement of RVEF may be particularly useful to stratify risk in patients with depressed LV function after STEMI.

Miszalski-Jamka T ，Klimeczek P ，Tomala M ，Krupiński M ，Zawadowski G ，Noelting J ，Lada M ，Sip K ，Banyś R ，Mazur W ，Kereiakes DJ ，Zmudka K ，Pasowicz M ... -  《-》

Cardiovascular magnetic resonance-derived intramyocardial hemorrhage after STEMI: Influence on long-term prognosis, adverse left ventricular remodeling and relationship with microvascular obstruction.

T2 weighted cardiovascular magnetic resonance (CMR) can detect intramyocardial hemorrhage (IMH) after ST-elevation myocardial infarction (STEMI). The long-term prognostic value of IMH beyond a comprehensive CMR assessment with late enhancement (LE) imaging including microvascular obstruction (MVO) is unclear. The value of CMR-derived IMH for predicting major adverse cardiac events (MACE) and adverse cardiac remodeling after STEMI and its relationship with MVO was analyzed. CMR including LE and T2 sequences was performed in 304 patients 1 week after STEMI. Adverse remodeling was defined as dilated left ventricular end-systolic volume indexes (dLVESV) at 6 months CMR. During a median follow-up of 140 weeks, 47 MACE (10 cardiac deaths, 16 myocardial infarctions, 21 heart failure episodes) occurred. Predictors of MACE were ejection fraction (HR .95 95% CI [.93-.97], p=.001, per %) and IMH (HR 1.17 95% CI [1.03-1.33], p=.01, per segment). The extent of MVO and IMH significantly correlated (r=.951, p<.0001). dLVESV was present in 40% of patients. CMR predictors of dLVESV were: LVESV (OR 1.11 95% CI [1.07-1.15], p<.0001, per ml/m(2)), infarct size (OR 1.05 95% CI [1.01-1.09], p=.02, per %) and IMH (OR 1.54 95% CI [1.15-2.07], p=.004, per segment). Addition of T2 information did not improve the LE and cine CMR-model for predicting MACE (.744 95% CI [.659-.829] vs. .734 95% CI [.650-.818], p=.6) or dLVESV (.914 95% CI [.875-.952] vs. .913 95% CI [.875-.952], p=.9). IMH after STEMI predicts MACE and adverse remodeling. Nevertheless, with a strong interrelation with MVO, the addition of T2 imaging does not improve the predictive value of LE-CMR.

Husser O ，Monmeneu JV ，Sanchis J ，Nunez J ，Lopez-Lereu MP ，Bonanad C ，Chaustre F ，Gomez C ，Bosch MJ ，Hinarejos R ，Chorro FJ ，Riegger GA ，Llacer A ，Bodi V ... -  《-》

Prognostic impact of contrast-enhanced CMR early after acute ST segment elevation myocardial infarction (STEMI) in a regional STEMI network: results of the "Herzinfarktverbund Essen".

Bruder O ，Breuckmann F ，Jensen C ，Jochims M ，Naber CK ，Barkhausen J ，Erbel R ，Sabin GV ，Herzinfarktverbund Essen ... -  《HERZ》

Delayed versus immediate stenting for the treatment of ST-elevation acute myocardial infarction with a high thrombus burden.

High thrombus burden (HTB) is an independent predictor of no flow or low reflow during a primary percutaneous coronary intervention. This study aimed to compare immediate versus delayed stenting in ST-elevation myocardial infarction (STEMI) patients with HTB. In this retrospective, nonrandomized study, a total of 103 consecutive STEMI patients with HTB (thrombus burden score, TBS≥3) were assigned to immediate stenting (IS group, n=50) or delayed stenting (DS group, n=53), a decision that was made at the discretion of the operators. The IS group received stent placement immediately, whereas the DS group was given enhanced antithrombotic therapies and deferred for stenting at least 7 days later. Thrombolysis in myocardial infarction (TIMI) flow score (TIMIs) and myocardial blush grade (MBG) were assessed angiographically and the left ventricular ejection fraction (LVEF) was measured echocardiographically. The major adverse cardiac event (MACE) was the composite of cardiac death, reinfarction, target vessel revascularization, heart failure, and major bleeding. The DS group had better immediate MBG (P<0.001), higher LVEF at 6 months (P=0.044), and lower MACE rate at 1 year (log-rank P=0.008). Multiple logistic regression identified immediate stenting (odds ratio 7.4, 95% confidence interval 2.1-26.6; P=0.002) and high TBS (odds ratio 2.6, 95% confidence interval 1.1-6.5, P=0.034) as the independent predictors of poor myocardial perfusion. Delayed stenting benefited the male patients, those who were of a younger age, and those who had a larger infarction-related artery, higher TBS, or lower TIMIs in terms of MBG or MACE. Delayed stenting avoided stent implantation of the infarct-related artery in 12/53 (22.6%) patients particularly in the younger patients. For STEMI patients with HTB who have undergone initial thrombectomy, delayed stenting is safe and feasible, and may be associated with better immediate myocardial perfusion, more LV function recovery, and less occurrence of MACE at the 1-year follow-up.

Ke D ，Zhong W ，Fan L ，Chen L ... -  《-》