Coronary interventions - Mini focus on STEMI

Pressure-bounded coronary flow reserve to assess the extent of microvascular dysfunction in patients with ST-elevation acute myocardial infarction

EuroIntervention 2021;16:1434-1443. DOI: 10.4244/EIJ-D-19-00674

Roberto Scarsini
Roberto Scarsini1,2, MD; Giovanni Luigi De Maria1, MD, PhD; Mayooran Shanmuganathan1,3, MD; Rafail A. Kotronias1,4, MD; Dimitrios Terentes-Printzios1, MD, PhD; Jeremy Langrish1, MD, PhD, FRCP; Andrew J. Lucking1, MD, PhD; Flavio L. Ribichini2, MD; Robin Choudhury1,5, MD, FRCP; Rajesh K. Kharbanda1,4, MD, PhD; Vanessa Ferreira1,3, MD, DPhil; Keith M. Channon1,4, MD, FRCP; Adrian P. Banning1,4, MD, FRCP
1. Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; 2. Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy; 3. Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; 4. Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; 5. Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom

Aims: Assessment of microvascular function in patients with ST-elevation acute myocardial infarction (STEMI) may be useful to determine treatment strategy. The possible role of pressure-bounded coronary flow reserve (pb-CFR) in this setting has not been determined. In this study we aimed to compare pb-CFR with thermodilution-derived physiology including the index of microcirculatory resistance (IMR) and CFRthermo in a consecutive series of patients enrolled in the OxAMI study. Moreover, we aimed to assess the presence of microvascular obstruction (MVO) and myocardial injury on cardiovascular magnetic resonance (CMR) imaging performed at 48 hours and six months in STEMI patients stratified according to pb-CFR.

Methods and results: Thermodilution-pressure-wire assessment of the infarct-related artery was performed in 148 STEMI patients before stenting and/or at completion of primary percutaneous coronary intervention (PPCI). The extent of the myocardial injury was assessed with CMR imaging at 48 hours and six months after STEMI. Post-PPCI pb-CFR was impaired (<2) and normal (>2) in 69.9% and 9.0% of the cases, respectively. In the remaining 21.1% of the patients, pb-CFR was “indeterminate”. In this cohort, pb-CFR correlated poorly with thermodilution-derived coronary flow reserve (k=0.03, p=0.39). The IMR was significantly different across the pb-CFR subgroups. Similarly, significant differences were observed in MVO, myocardium area at risk and 48-hour infarct size (IS). A trend towards lower six-month IS was observed in patients with high (>2) post-PPCI pb-CFR. Nevertheless, pb-CFR was inferior to IMR in predicting MVO and the extent of IS.

Conclusions: Pb-CFR can identify microvascular dysfunction in patients after STEMI. It provided superior diagnostic performance compared to thermodilution-derived CFR in predicting MVO. However, IMR was superior to both pb-CFR and thermodilution-derived CFR and, consequently, IMR was the most accurate in predicting all of the studied CMR endpoints of myocardial injury after PPCI.

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fractional flow reservemrinon-invasive imagingother imaging modalitiesstemi
Coronary interventionsSTEMI
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