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Vora KP, Kumar A, Krishnam MS, Prato FS, Raman SV, Dharmakumar R. Microvascular Obstruction and Intramyocardial Hemorrhage in Reperfused Myocardial Infarctions: Pathophysiology and Clinical Insights From Imaging. JACC Cardiovasc Imaging 2024; 17:795-810. [PMID: 38613553 DOI: 10.1016/j.jcmg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/10/2024] [Accepted: 02/01/2024] [Indexed: 04/15/2024]
Abstract
Microvascular injury immediately following reperfusion therapy in acute myocardial infarction (MI) has emerged as a driving force behind major adverse cardiovascular events in the postinfarction period. Although postmortem investigations and animal models have aided in developing early understanding of microvascular injury following reperfusion, imaging, particularly serial noninvasive imaging, has played a central role in cultivating critical knowledge of progressive damage to the myocardium from the onset of microvascular injury to months and years after in acute MI patients. This review summarizes the pathophysiological features of microvascular injury and downstream consequences, and the contributions noninvasive imaging has imparted in the development of this understanding. It also highlights the interventional trials that aim to mitigate the adverse consequences of microvascular injury based on imaging, identifies potential future directions of investigations to enable improved detection of disease, and demonstrates how imaging stands to play a major role in the development of novel therapies for improved management of acute MI patients.
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Affiliation(s)
- Keyur P Vora
- Krannert Cardiovascular Research Center, Indiana University School of Medicine/IUHealth, Indianapolis, Indiana, USA. https://twitter.com/KeyurVoraMD
| | - Andreas Kumar
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada. https://twitter.com/AndreasKumarMD
| | | | | | | | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine/IUHealth, Indianapolis, Indiana, USA.
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Yang YX, Zhou F, Wen T, Li WJ. Deciphering the Enigma of Intramyocardial Hemorrhage Following Reperfusion Therapy in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Exploration from Mechanisms to Therapeutic Strategies. Cardiol Rev 2024:00045415-990000000-00274. [PMID: 38780252 DOI: 10.1097/crd.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Acute ST-segment elevation myocardial infarction (STEMI) is a formidable challenge in cardiovascular medicine, demanding advanced reperfusion strategies such as emergency percutaneous coronary intervention. While successful revascularization is pivotal, the persistent "no-reflow" phenomenon remains a clinical hurdle, often intertwined with microvascular dysfunction. Within this intricate scenario, the emergence of intramyocardial hemorrhage (IMH) has garnered attention as a significant contributor. This review offers a detailed exploration of the multifaceted relationship between IMH and the "no-reflow" phenomenon, delving into the mechanisms governing IMH occurrence, state-of-the-art diagnostic modalities, predictive factors, clinical implications, and the evolving landscape of preventive and therapeutic strategies. The nuanced examination aims to deepen our comprehension of IMH, providing a foundation for the identification of innovative therapeutic avenues and enhanced clinical outcomes for STEMI patients.
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Affiliation(s)
- Yong Xin Yang
- From the Department of Cardiology, Yichang Central People's Hospital/The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Disease, China Three Gorges University, Yichang, Hubei, China
| | - Fei Zhou
- From the Department of Cardiology, Yichang Central People's Hospital/The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Disease, China Three Gorges University, Yichang, Hubei, China
- Department of Cardiology, Institute of Cardiovascular Disease, Yichang Central People's Hospital/The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
| | - Te Wen
- From the Department of Cardiology, Yichang Central People's Hospital/The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Disease, China Three Gorges University, Yichang, Hubei, China
| | - Wen Jing Li
- From the Department of Cardiology, Yichang Central People's Hospital/The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Disease, China Three Gorges University, Yichang, Hubei, China
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Yang YS, Xi DY, Duan Y, Yu M, Liu K, Meng YK, Hu CF, Han SG, Xu K. A nomogram model for predicting intramyocardial hemorrhage post-PCI based on SYNTAX score and clinical features. BMC Cardiovasc Disord 2024; 24:179. [PMID: 38528469 DOI: 10.1186/s12872-024-03847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/15/2024] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVE The aim of this study is to develop a nomogram model for predicting the occurrence of intramyocardial hemorrhage (IMH) in patients with Acute Myocardial Infarction (AMI) following Percutaneous Coronary Intervention (PCI). The model is constructed utilizing clinical data and the SYNTAX Score (SS), and its predictive value is thoroughly evaluated. METHODS A retrospective study was conducted, including 216 patients with AMI who underwent Cardiac Magnetic Resonance (CMR) within a week post-PCI. Clinical data were collected for all patients, and their SS were calculated based on coronary angiography results. Based on the presence or absence of IMH as indicated by CMR, patients were categorized into two groups: the IMH group (109 patients) and the non-IMH group (107 patients). The patients were randomly divided in a 7:3 ratio into a training set (151 patients) and a validation set (65 patients). A nomogram model was constructed using univariate and multivariate logistic regression analyses. The predictive capability of the model was assessed using Receiver Operating Characteristic (ROC) curve analysis, comparing the predictive value based on the area under the ROC curve (AUC). RESULTS In the training set, IMH post-PCI was observed in 78 AMI patients on CMR, while 73 did not show IMH. Variables with a significance level of P < 0.05 were screened using univariate logistic regression analysis. Twelve indicators were selected for multivariate logistic regression analysis: heart rate, diastolic blood pressure, ST segment elevation on electrocardiogram, culprit vessel, symptom onset to reperfusion time, C-reactive protein, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, creatine kinase-MB, high-sensitivity troponin T (HS-TnT), and SYNTAX Score. Based on multivariate logistic regression results, two independent predictive factors were identified: HS-TnT (Odds Ratio [OR] = 1.61, 95% Confidence Interval [CI]: 1.21-2.25, P = 0.003) and SS (OR = 2.54, 95% CI: 1.42-4.90, P = 0.003). Consequently, a nomogram model was constructed based on these findings. The AUC of the nomogram model in the training set was 0.893 (95% CI: 0.840-0.946), and in the validation set, it was 0.910 (95% CI: 0.823-0.970). Good consistency and accuracy of the model were demonstrated by calibration and decision curve analysis. CONCLUSION The nomogram model, constructed utilizing HS-TnT and SS, demonstrates accurate predictive capability for the risk of IMH post-PCI in patients with AMI. This model offers significant guidance and theoretical support for the clinical diagnosis and treatment of these patients.
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Affiliation(s)
| | - De-Yang Xi
- Xuzhou Medical University, Jiangsu, 221004, China
| | - Yang Duan
- Department of Cardiac Care Unit, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China
| | - Miao Yu
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China
| | - Kai Liu
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China
| | - Yan-Kai Meng
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China
| | - Chun-Feng Hu
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China
| | - Shu-Guang Han
- Xuzhou Medical University, Jiangsu, 221004, China.
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China.
| | - Kai Xu
- Xuzhou Medical University, Jiangsu, 221004, China.
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, 221006, China.
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Zhang Y, Zou Z, Xu B, Chen B, Ge H, Ding S, Pu J. Impact of Bivalirudin on Ischemia/Reperfusion Injury in Patients with Reperfused STEMI Assessed by Cardiac Magnetic Resonance. Pharmaceuticals (Basel) 2024; 17:196. [PMID: 38399411 PMCID: PMC10893429 DOI: 10.3390/ph17020196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/25/2024] Open
Abstract
Thrombin is an important ischemia/reperfusion injury (IRI) mediator in patients with ST-elevation myocardial infarction (STEMI). This study examines the use of bivalirudin, a direct thrombin inhibitor, in reducing IRI in STEMI patients. STEMI patients (n = 21) were treated with bivalirudin and compared to 21 patients treated with unfractionated heparin (UFH) from the EARLY Assessment of Myocardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). Infarct size (IS) and left ventricular ejection fraction (LVEF) were comparable between the two groups at follow up. During the first cardiac magnetic resonance (CMR) scan within the first week after percutaneous coronary intervention (PCI), all patients in both the bivalirudin and UFH groups exhibited myocardial edema. However, the myocardium edema volume was significantly less in the bivalirudin group (p < 0.05). At the one-month follow-up, a smaller proportion of patients in the bivalirudin group than in the UFH group exhibited myocardial edema (4.7% vs. 33.3%, p < 0.05). At the three-month follow-up, myocardial edema had completely resolved in the bivalirudin group, while it persisted in two patients in the UFH group. The incidence and volume of microvascular obstruction (MVO) were significantly lower in the bivalirudin group during the acute phase. Additionally, the incidence of intramyocardial hemorrhage (IMH) was significantly lower in the bivalirudin group during both the acute and follow up (p < 0.05). These findings were corroborated by T2 and T1 mapping results. The study concluded that the use of bivalirudin for anticoagulation is associated with attenuated IRI in STEMI patients who receive primary PCI.
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Affiliation(s)
- Yizhi Zhang
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Zhiguo Zou
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Bihe Xu
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Binghua Chen
- Department of Radiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China;
| | - Heng Ge
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Song Ding
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
- Department of Cardiology, Punan Branch of Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Jun Pu
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
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Guan X, Zhang X, Yang HJ, Dharmakumar R. On the loss of image contrast in double-inversion-recovery prepared T2* MRI of Intramyocardial hemorrhage. Magn Reson Imaging 2024; 105:125-132. [PMID: 37993042 DOI: 10.1016/j.mri.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/08/2023] [Accepted: 11/17/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Studies have shown that double-inversion-recovery (DIR) prepared dark-blood T2*-weighted images result in lower SNR, CNR and diagnostic accuracy for intramyocardial hemorrhage (IMH) detection compared to non-DIR-prepared (bright-blood) T2*-weighted images; however, the mechanism contributing to this observation has not been investigated and explained in detail. This work tests the hypothesis that the loss of SNR on dark-blood cardiac T2*-weighted images of IMH stems from spin-relaxation during the long RF pulses in double inversion preparation, as a result, compromising image contrast for intramyocardial hemorrhage detection. METHODS Phantom and in-vivo animal studies were performed to test the hypothesis of the study. An agar phantom was imaged with multi-gradient-echo T2* imaging protocols with and without double-inversion-recovery (DIR) preparation. Image acquisitions were placed at different delay times (TD) after DIR preparation. SNR, T2* and Coefficient of Variation (COV) were measured and compared between DIR-prepared and non-DIR-prepared images. Canines with hemorrhagic myocardial infarctions were scanned at 3.0 T with DIR-prepared (dark-blood) and non-DIR-prepared (bright-blood) T2* imaging protocols. DIR-prepared T2* images were acquired with short, medium, and long delay times (TD). SNR, CNR, intramyocardial hemorrhage (IMH) extent, T2* and COV were measured and compared between DIR-prepared T2* images with short, medium, and long delay times (TD) to non-DIR-prepared bright-blood T2* images. RESULTS Phantom studies confirmed the hypothesis that the SNR loss on DIR-prepared T2* images originated from signal loss during DIR preparation. SNR followed T1 recovery curve with increased delay times (TD) indicating that SNR can be recovered with longer time delay between DIR and image acquisition. Myocardial T2* values were not affected by DIR preparation but COV of T2* was elevated. Animal studies supported the hypothesis and showed that DIR-prepared T2* images with insufficient delay time (TD) had impaired sensitivity for IMH detection due to lower SNR and CNR, and higher COV. CONCLUSION We conclude that lower SNR and CNR on DIR-prepared T2* images originate from signal loss during DIR preparation and insufficient recovery between DIR preparation and image acquisition. Although, the impaired sensitivity can be recovered by extending delay time (TD), it will extend the scan time. Bright-blood T2* imaging protocols should remain the optimal choice for assessment of intramyocardial hemorrhage. DIR-prepared dark-blood T2* imaging protocols should be performed with extra attention on image signal-to-noise ratio when used for intramyocardial hemorrhage detection.
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Affiliation(s)
- Xingmin Guan
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Xinheng Zhang
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Bioengineering, University of California, Los Angeles, CA, USA
| | - Hsin-Jung Yang
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, IN, USA.
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Chen YC, Zheng G, Donner DG, Wright DK, Greenwood JP, Marwick TH, McMullen JR. Cardiovascular magnetic resonance imaging for sequential assessment of cardiac fibrosis in mice: technical advancements and reverse translation. Am J Physiol Heart Circ Physiol 2024; 326:H1-H24. [PMID: 37921664 PMCID: PMC11213480 DOI: 10.1152/ajpheart.00437.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
Cardiovascular magnetic resonance (CMR) imaging has become an essential technique for the assessment of cardiac function and morphology, and is now routinely used to monitor disease progression and intervention efficacy in the clinic. Cardiac fibrosis is a common characteristic of numerous cardiovascular diseases and often precedes cardiac dysfunction and heart failure. Hence, the detection of cardiac fibrosis is important for both early diagnosis and the provision of guidance for interventions/therapies. Experimental mouse models with genetically and/or surgically induced disease have been widely used to understand mechanisms underlying cardiac fibrosis and to assess new treatment strategies. Improving the appropriate applications of CMR to mouse studies of cardiac fibrosis has the potential to generate new knowledge, and more accurately examine the safety and efficacy of antifibrotic therapies. In this review, we provide 1) a brief overview of different types of cardiac fibrosis, 2) general background on magnetic resonance imaging (MRI), 3) a summary of different CMR techniques used in mice for the assessment of cardiac fibrosis including experimental and technical considerations (contrast agents and pulse sequences), and 4) provide an overview of mouse studies that have serially monitored cardiac fibrosis during disease progression and/or therapeutic interventions. Clinically established CMR protocols have advanced mouse CMR for the detection of cardiac fibrosis, and there is hope that discovery studies in mice will identify new antifibrotic therapies for patients, highlighting the value of both reverse translation and bench-to-bedside research.
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Affiliation(s)
- Yi Ching Chen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Gang Zheng
- Monash Biomedical Imaging, Monash University, Melbourne, Victoria, Australia
| | - Daniel G Donner
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David K Wright
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John P Greenwood
- Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Julie R McMullen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Baker Department of Cardiometabolic Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia
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Kumar A, Dharmakumar R. Editorial for "Detection of Intramyocardial Iron in Patients Following ST-Elevation Myocardial Infarction Using Diffusion Tensor Imaging". J Magn Reson Imaging 2022; 56:1182-1183. [PMID: 35143087 DOI: 10.1002/jmri.28099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Andreas Kumar
- Department of Cardiology, Health Sciences North, Sudbury, Ontario, Canada.,Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
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