1
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Zuccarelli V, Andreaggi S, Walsh JL, Kotronias RA, Chu M, Vibhishanan J, Banning AP, De Maria GL. Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention? J Clin Med 2024; 13:2923. [PMID: 38792463 PMCID: PMC11122374 DOI: 10.3390/jcm13102923] [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: 04/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.
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Affiliation(s)
- Vittorio Zuccarelli
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Jason L. Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Miao Chu
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Jonathan Vibhishanan
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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2
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Satti Z, Omari M, Bawamia B, Cartlidge T, Egred M, Farag M, Alkhalil M. The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice. J Clin Med 2024; 13:2291. [PMID: 38673564 PMCID: PMC11050836 DOI: 10.3390/jcm13082291] [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: 03/06/2024] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.
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Affiliation(s)
- Zahir Satti
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Muntaser Omari
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Bilal Bawamia
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Timothy Cartlidge
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohamed Farag
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohammad Alkhalil
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
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3
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Dawkins S, Digby JE, Belgard TG, Lee R, De Maria GL, Banning AP, Kharbanda RK, Mayr M, Choudhury RP, Channon KM. Stratification of acute myocardial and endothelial cell injury, salvage index and final infarct size by systematic microRNA profiling in acute ST-elevation myocardial infarction. Coron Artery Dis 2024; 35:122-134. [PMID: 38009375 DOI: 10.1097/mca.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
AIM Acute injury and subsequent remodelling responses to ST-segment elevation myocardial infarction (STEMI) are major determinants of clinical outcome. Current imaging and plasma biomarkers provide delayed readouts of myocardial injury and recovery. Here, we sought to systematically characterize all microRNAs (miRs) released during the acute phase of STEMI and relate miR release to magnetic resonance imaging (MRI) findings to predict acute and late responses to STEMI, from a single early blood sample. METHODS AND RESULTS miRs were quantified in blood samples obtained from patients after primary PCI (PPCI) for STEMI. Cardiac MRI (cMRI) was performed to quantify myocardial edema, infarct size and salvage index. Regression models were constructed to predict these outcomes measures, which were then tested with a validation cohort. Transcoronary miR release was quantified from paired measurements of coronary artery and coronary sinus samples. A cell culture model was used to identify endothelial cell-derived miRs.A total of 72 patients undergoing PPCI for acute STEMI underwent miR analysis and cMRI. About >200 miRs were detectable in plasma after STEMI, from which 128 miRs were selected for quantification in all patients. Known myocardial miRs demonstrated a linear correlation with troponin release, and these increased across the transcoronary gradient. We identified novel miRs associated with microvascular injury and myocardial salvage. Regression models were constructed using a training cohort, then tested in a validation cohort, and predicted myocardial oedema, infarct size and salvage index. CONCLUSION Analysis of miR release after STEMI identifies biomarkers that predict both acute and late outcomes after STEMI. A novel miR-based biomarker score enables the estimation of area at risk, late infarct size and salvage index from a single blood sample 6 hours after PPCI, providing a simple and rapid alternative to serial cMRI characterization of STEMI outcome.
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Affiliation(s)
- Sam Dawkins
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Janet E Digby
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Regent Lee
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, National Institute for Health (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Adrian P Banning
- Oxford Heart Centre, National Institute for Health (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Rajesh K Kharbanda
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Oxford Heart Centre, National Institute for Health (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Manuel Mayr
- King's British Heart Foundation Centre, King's College London, London, UK
| | - Robin P Choudhury
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Oxford Heart Centre, National Institute for Health (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Keith M Channon
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Oxford Heart Centre, National Institute for Health (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
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4
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Groenland FT, Ziedses des Plantes AC, Scoccia A, Neleman T, Masdjedi K, Kardys I, Diletti R, Van Mieghem NM, Daemen J. Post percutaneous coronary intervention physiology in patients presenting with ST-segment elevation myocardial infarction. IJC HEART & VASCULATURE 2023; 49:101319. [PMID: 38143782 PMCID: PMC10746447 DOI: 10.1016/j.ijcha.2023.101319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Frederik T.W. Groenland
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Alessandra Scoccia
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Cardiology, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Isabella Kardys
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M. Van Mieghem
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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5
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Ghobrial M, Bawamia B, Cartlidge T, Spyridopoulos I, Kunadian V, Zaman A, Egred M, McDiarmid A, Williams M, Farag M, Alkhalil M. Microvascular Obstruction in Acute Myocardial Infarction, a Potential Therapeutic Target. J Clin Med 2023; 12:5934. [PMID: 37762875 PMCID: PMC10532390 DOI: 10.3390/jcm12185934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Microvascular obstruction (MVO) is a recognised phenomenon following mechanical reperfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI). Invasive and non-invasive modalities to detect and measure the extent of MVO vary in their accuracy, suggesting that this phenomenon may reflect a spectrum of pathophysiological changes at the level of coronary microcirculation. The importance of detecting MVO lies in the observation that its presence adds incremental risk to patients following STEMI treatment. This increased risk is associated with adverse cardiac remodelling seen on cardiac imaging, increased infarct size, and worse patient outcomes. This review provides an outline of the pathophysiology, clinical implications, and prognosis of MVO in STEMI. It describes historic and novel pharmacological and non-pharmacological therapies to address this phenomenon in conjunction with primary PCI.
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Affiliation(s)
- Mina Ghobrial
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Bilal Bawamia
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Timothy Cartlidge
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Ioakim Spyridopoulos
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Mohaned Egred
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Adam McDiarmid
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Matthew Williams
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
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6
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Alkhalil M, De Maria GL, Akbar N, Ruparelia N, Choudhury RP. Prospects for Precision Medicine in Acute Myocardial Infarction: Patient-Level Insights into Myocardial Injury and Repair. J Clin Med 2023; 12:4668. [PMID: 37510783 PMCID: PMC10380764 DOI: 10.3390/jcm12144668] [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: 06/07/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
The past decade has seen a marked expansion in the understanding of the pathobiology of acute myocardial infarction and the systemic inflammatory response that it elicits. At the same time, a portfolio of tools has emerged to characterise some of these processes in vivo. However, in clinical practice, key decision making still largely relies on assessment built around the timing of the onset of chest pain, features on electrocardiograms and measurements of plasma troponin. Better understanding the heterogeneity of myocardial injury and patient-level responses should provide new opportunities for diagnostic stratification to enable the delivery of more rational therapies. Characterisation of the myocardium using emerging imaging techniques such as the T1, T2 and T2* mapping techniques can provide enhanced assessments of myocardial statuses. Physiological measures, which include microcirculatory resistance and coronary flow reserve, have been shown to predict outcomes in AMI and can be used to inform treatment selection. Functionally informative blood biomarkers, including cellular transcriptomics; microRNAs; extracellular vesicle analyses and soluble markers, all give insights into the nature and timing of the innate immune response and its regulation in acute MI. The integration of these and other emerging tools will be key to developing a fuller understanding of the patient-level processes of myocardial injury and repair and should fuel new possibilities for rational therapeutic intervention.
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Affiliation(s)
- Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | | | - Naveed Akbar
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Neil Ruparelia
- Cardiology Department, Hammersmith Hospital, Imperial College London, London W12 0HS, UK
| | - Robin P Choudhury
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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7
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Alkhalil M, Kuzemczak M, Zhao R, Kavvouras C, Cantor WJ, Overgaard CB, Lavi S, Sharma V, Chowdhary S, Stanković G, Kedev S, Bernat I, Bhindi R, Sheth T, Niemela K, Jolly SS, Džavík V. Prognostic Role of Residual Thrombus Burden Following Thrombectomy: Insights From the TOTAL Trial. Circ Cardiovasc Interv 2022; 15:e011336. [PMID: 35580203 DOI: 10.1161/circinterventions.121.011336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone). METHODS This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days. RESULTS Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34-2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13-2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08-3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02-2.96]) but not myocardial infarction or stroke. CONCLUSIONS Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01149044.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.).,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom (M.A.).,Translational and Clinical Research Institute, Newcastle University, United Kingdom (M.A.)
| | - Michał Kuzemczak
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.).,Division of Emergency Medicine, Poznan University of Medical Sciences, Poland (M.K.).,Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland (M.K.)
| | - Robin Zhao
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | - Charalampos Kavvouras
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.)
| | - Warren J Cantor
- Division of Cardiology, University of Toronto and Southlake Regional Health Centre, Canada (W.J.C., C.B.O.)
| | - Christopher B Overgaard
- Division of Cardiology, University of Toronto and Southlake Regional Health Centre, Canada (W.J.C., C.B.O.)
| | - Shahar Lavi
- London Health Sciences Centre, Canada (S.L.)
| | - Vinoda Sharma
- Cardiology Department, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom (V.S.)
| | - Saqib Chowdhary
- Cardiology Department, Wythenshawe Hospital, Manchester, United Kingdom (S.C.)
| | - Goran Stanković
- Department of Cardiology, University of Belgrade, Serbia (G.S.)
| | - Saško Kedev
- University Clinic of Cardiology, Ss. Cyril and Methodius University, Skopje, Macedonia (S.K.)
| | - Ivo Bernat
- University Hospital and Faculty of Medicine Pilsen, Czech Republic (I.B.)
| | - Ravinay Bhindi
- Royal North Shore Hospital, University of Sydney, Australia (R.B.)
| | - Tej Sheth
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | | | - Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.)
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8
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Scarsini R, Terentes-Printzios D, Shanmuganathan M, Kotronias RA, Borlotti A, Marin F, Langrish J, Lucking A, Ribichini F, Kharbanda R, Ferreira VM, Channon KM, De Maria GL, Banning AP. Pressure-controlled intermittent coronary sinus occlusion improves the vasodilatory microvascular capacity and reduces myocardial injury in patients with STEMI. Catheter Cardiovasc Interv 2022; 99:329-339. [PMID: 34051133 DOI: 10.1002/ccd.29793] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/17/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preliminary data suggest that pressure-controlled intermittent coronary sinus occlusion (PICSO) might reduce the infarct size (IS) in patients with anterior ST-elevation myocardial infarction (STEMI). However, the applicability of this therapy to patients with inferior STEMI and its exact mechanism of action is uncertain. METHODS AND RESULTS Thirty-six patients (27 anterior and 9 inferior) with STEMI underwent PICSO-assisted-primary percutaneous intervention (PPCI) and were compared with matched controls who underwent standard PCI (n = 72). Median age was 63 (55-70) years and 82% were male. Coronary microvascular status was assessed using thermodilution-derived index of microcirculatory resistance (IMR) and the vasodilatory capacity was assessed using the resistive reserve ratio (RRR). IS and microvascular obstruction (MVO) were assessed using cardiovascular magnetic resonance imaging (CMR) within 48 h and 6 months of follow-up. At completion of PPCI, IMR improved significantly in PICSO-treated patients compared with controls in patients with either anterior (63.7 [49.8-74.6] vs. 35.9 [27.9-47.6], p < 0.001) or inferior STEMI (60.0 [47.6-67.1] vs. 22.7 [18.4-35.0], p < 0.001). RRR significantly improved after PICSO treatment for anterior (1.21 [1.01-1.42] vs. 1.73 [1.51-2.16], p = 0.002) or inferior STEMI (1.39 [1.05-1.90] vs. 2.87 [2.17-3.78], p = 0.001), whereas it did not change in controls compared with baseline. Patients treated with PICSO presented significantly less frequently with MVO (66.6% vs. 86.1%, p = 0.024) and smaller 6-month IS compared with controls (26% [17%-30%] vs. 30% [21%-37%], p = 0.045). CONCLUSION PICSO therapy may improve microvascular function and vasodilatory capacity, which contributes to reducing IS in patients with STEMI undergoing PPCI.
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Affiliation(s)
- Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Mayooran Shanmuganathan
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Rafail A Kotronias
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Alessandra Borlotti
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Federico Marin
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Jeremy Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Andrew Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Rajesh Kharbanda
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Vanessa M Ferreira
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Keith M Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
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9
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Marin F, Scarsini R, Terentes-Printzios D, Kotronias RA, Ribichini F, Banning AP, De Maria GL. The Role of Coronary Physiology in Contemporary Percutaneous Coronary Interventions. Curr Cardiol Rev 2022; 18:e080921196264. [PMID: 34521331 PMCID: PMC9241117 DOI: 10.2174/1573403x17666210908114154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/21/2021] [Accepted: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
Invasive assessment of coronary physiology has radically changed the paradigm of myocardial revascularization in patients with coronary artery disease. Despite the prognostic improvement associated with ischemia-driven revascularization strategy, functional assessment of angiographic intermediate epicardial stenosis remains largely underused in clinical practice. Multiple tools have been developed or are under development in order to reduce the invasiveness, cost, and extra procedural time associated with the invasive assessment of coronary physiology. Besides epicardial stenosis, a growing body of evidence highlights the role of coronary microcirculation in regulating coronary flow with consequent pathophysiological and clinical and prognostic implications. Adequate assessment of coronary microcirculation function and integrity has then become another component of the decision-making algorithm for optimal diagnosis and treatment of coronary syndromes. This review aims at providing a comprehensive description of tools and techniques currently available in the catheterization laboratory to obtain a thorough and complete functional assessment of the entire coronary tree (both for the epicardial and microvascular compartments).
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Affiliation(s)
- Federico Marin
- Division of Cardiology, University of Verona, Verona, Italy.,Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | | | - Rafail A Kotronias
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom
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10
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Alkhalil M. Novel Applications for Invasive and Non-invasive Tools in the Era of Contemporary Percutaneous Coronary Revascularisation. Curr Cardiol Rev 2022; 18:e190122191004. [PMID: 33530910 PMCID: PMC9241120 DOI: 10.2174/1573403x17666210202102549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/08/2020] [Accepted: 11/24/2020] [Indexed: 11/22/2022] Open
Abstract
Percutaneous coronary intervention (PCI) is an expanding treatment option for patients with coronary artery disease (CAD). It is considered the default strategy for the unstable presentation of CAD. PCI techniques have evolved over the last 4 decades with significant improvements in stent design, an increase in functional assessment of coronary lesions, and the use of intra-vascular imaging. Nonetheless, the morbidity and mortality related to CAD remain significant. Advances in technology have allowed a better understanding of the nature and progression of CAD. New tools are now available that reflect the pathophysiological changes at the level of the myocardium and coronary atherosclerotic plaque. Certain changes within the plaque would render it more prone to rupture leading to acute vascular events. These changes are potentially detected using novel tools invasively, such as near infra-red spectroscopy, or non-invasively using T2 mapping cardiovascular magnetic resonance imaging (CMR) and 18F-Sodium Fluoride positron emission tomography/ computed tomography. Similarly, changes at the level of the injured myocardium are feasibly assessed invasively using index microcirculatory resistance or non-invasively using T1 mapping CMR. Importantly, these changes could be detected immediately with the opportunity to tailor treatment to those considered at high risk. Concurrently, novel therapeutic options have demonstrated promising results in reducing future cardiovascular risks in patients with CAD. This Review article will discuss the role of these novel tools and their applicability in employing a mechanical and pharmacological treatment to mitigate cardiovascular risk in patients with CAD.
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Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman hospital, Newcastle-upon-Tyne UK.,Department of Cardiology, Toronto General Hospital, Toronto Canada
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11
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Montalto C, Kotronias RA, Marin F, Terentes-Printzios D, Shanmuganathan M, Emfietzoglou M, Scalamera R, Porto I, Langrish J, Lucking A, Choudhury R, Kharbanda R, Channon KM, De Maria GL, Banning A. Pre-procedural ATI score (age-thrombus burden-index of microcirculatory resistance) predicts long-term clinical outcomes in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention. Int J Cardiol 2021; 339:1-6. [PMID: 34311009 DOI: 10.1016/j.ijcard.2021.07.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The ATI (Age-Thrombus burden-Index of Microvascular Resistance [IMR]) score was developed to predict suboptimal myocardial reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI). When applied in the early phases of revascularization (e.g. before stent insertion), it predicts which patients are most likely to have a larger infarct size. In this study, we assessed the score's utility in determining which STEMI patients are at highest risk of clinical events during follow-up. METHODS The ATI-score was calculated prospectively in 254 STEMI patients using age (>50 years = 1 point), pre-stenting IMR (>40 U and < 100 U = 1 point; ≥100 U = 2 points) and angiographic thrombus score (4 = 1 point, 5 = 3 points); the cohort was stratified in high vs. low-intermediate ATI-score strata (≥4 vs. < 4, respectively). RESULTS After 3 years of follow-up, patients with high ATI-score presented a higher rate of Major Adverse Cardiac Events (MACE) defined as the composite of all-cause mortality, resuscitated cardiac arrest and new heart failure diagnosis (Hazard Ratio [HR]: 3.07; 95% Confidence Interval [CI]: 1.19-7.93; p = 0.02). The ATI-score showed a moderate discriminative power (c-stat: 0.69), not significantly different from that of other risk scores used in the STEMI setting. A high ATI-score was an independent predictor of MACE (HR: 3.24; 95% CI: 1.22-8.58; p = 0.018). CONCLUSIONS The ATI-score can discriminate patients at higher risk of long-term adverse events. The score allows predication of subsequent events even before coronary stenting, and consequently it may allow the option of individualized therapy in the early stages of the clinical care-pathway.
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Affiliation(s)
- Claudio Montalto
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Rafail A Kotronias
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Federico Marin
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | | | - Mayooran Shanmuganathan
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Maria Emfietzoglou
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Riccardo Scalamera
- Division of Cardiovascular Medicine, Policlinico San Martino, University of Genova, Genova, Italy
| | - Italo Porto
- Division of Cardiovascular Medicine, Policlinico San Martino, University of Genova, Genova, Italy
| | - Jeremy Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Andrew Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Robin Choudhury
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Rajesh Kharbanda
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Keith M Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
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12
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Xiao Y, Chen H, Liu D, Wang Y, Wang W, Zhang Q, Han Y, Fu X. The Comparison between Two Risk Scores as for the Prediction of Coronary Microvascular Obstruction during Primary Percutaneous Intervention. Arq Bras Cardiol 2021; 116:959-967. [PMID: 34008822 PMCID: PMC8121479 DOI: 10.36660/abc.20200115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
Fundamento: Para pacientes com infarto do miocárdio com elevação do segmento ST (IAMCST) que sofrem de obstrução coronariana microvascular funcional e estrutural (OCM) subsequente, nenhuma abordagem terapêutica específica e definitiva de atenuação foi comprovada como válida em testes de larga escala atuais, o que destaca a necessidade de abordar seu reconhecimento precoce. Objetivos: Este estudo teve como objetivo comparar o desempenho de dois escores de risco clínico com uma medida objetiva de OCM durante intervenção coronária percutânea (ICP) em casos de IAMCST Métodos: A medição do índice de resistência microcirculatória (IRM) foi realizada e os parâmetros clínicos e angiográficos basais também foram registrados. Os pacientes foram divididos em entre os grupos OM (obstrução microvascular) e NOM (não-obstrução microvascular), de acordo com o valor de IRM pós-procedimento. O risco de OCM foi avaliado para todos os participantes pelos escores preditivos SAK e ATI, respectivamente. Cada sistema foi calculado somando-se as pontuações de todas as variáveis. As curvas de características do operador receptor (ROC) e a área sob a curva (AUC) de dois modelos de risco foram utilizadas para avaliar o desempenho discriminatório. Um ecocardiograma foi realizado sete dias após o procedimento para avaliar a fração de ejeção do ventrículo esquerdo (FEVE). Um valor P bicaudal de <0,05 foi considerado estatisticamente significativo. Resultados: Entre os 65 pacientes elegíveis com IAMCST, 48 foram alocados no grupo NOM e 17 no grupo OM, com uma incidência de OCM de 26,15%. Não houve diferença significativa na AUC entre os dois escores. A FEVE avaliada para o grupo NOM foi maior do que para o grupo OM. Conclusão: Os escores SAK e ATI tiveram bom desempenho para estimar o risco de OCM após ICP primário para pacientes com IAMCST.
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Affiliation(s)
- Yuyang Xiao
- Hebei General Hospital - Department of Cardiology, Shijiazhuang, Hebei - China.,Second Hospital of Hebei Medical University - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Hua Chen
- Hebei General Hospital - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Dongxia Liu
- Hebei General Hospital - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Yanbo Wang
- Second Hospital of Hebei Medical University - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Wenlu Wang
- Second Hospital of Hebei Medical University - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Qian Zhang
- Second Hospital of Hebei Medical University - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Yuping Han
- Hebei General Hospital - Department of Cardiology, Shijiazhuang, Hebei - China
| | - Xianghua Fu
- Second Hospital of Hebei Medical University - Department of Cardiology, Shijiazhuang, Hebei - China
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13
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Ciofani JL, Allahwala UK, Scarsini R, Ekmejian A, Banning AP, Bhindi R, De Maria GL. No-reflow phenomenon in ST-segment elevation myocardial infarction: still the Achilles' heel of the interventionalist. Future Cardiol 2020; 17:383-397. [PMID: 32915083 DOI: 10.2217/fca-2020-0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Improvements in systems, technology and pharmacotherapy have significantly changed the prognosis over recent decades in patients presenting with ST-segment elevation myocardial infarction. These clinical achievements have, however, begun to plateau and it is becoming increasingly necessary to consider novel strategies to further improve outcomes. Approximately a third of patients treated by primary percutaneous coronary intervention for ST-segment elevation myocardial infarction will suffer from coronary no-reflow (NR), a condition characterized by poor myocardial perfusion despite patent epicardial arteries. The presence of NR impacts significantly on clinical outcomes including left ventricular dysfunction, heart failure and death, yet conventional management algorithms neither assess the risk of NR nor treat NR. This review will provide a contemporary overview on the pathogenesis, diagnosis and treatment of NR.
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Affiliation(s)
- Jonathan L Ciofani
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia.,Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiology, University of Verona, Verona, Italy
| | - Avedis Ekmejian
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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14
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De Maria GL, Scarsini R, Shanmuganathan M, Kotronias RA, Terentes-Printzios D, Borlotti A, Langrish JP, Lucking AJ, Choudhury RP, Kharbanda R, Ferreira VM, Channon KM, Garcia-Garcia HM, Banning AP. Angiography-derived index of microcirculatory resistance as a novel, pressure-wire-free tool to assess coronary microcirculation in ST elevation myocardial infarction. Int J Cardiovasc Imaging 2020; 36:1395-1406. [PMID: 32409977 PMCID: PMC7381481 DOI: 10.1007/s10554-020-01831-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/28/2020] [Indexed: 11/30/2022]
Abstract
Immediate assessment of coronary microcirculation during treatment of ST elevation myocardial infarction (STEMI) may facilitate patient stratification for targeted treatment algorithms. Use of pressure-wire to measure the index of microcirculatory resistance (IMR) is possible but has inevitable practical restrictions. We aimed to develop and validate angiography-derived index of microcirculatory resistance (IMRangio) as a novel and pressure-wire-free index to facilitate assessment of the coronary microcirculation. 45 STEMI patients treated with primary percutaneous coronary intervention (pPCI) were enrolled. Immediately before stenting and at completion of pPCI, IMR was measured within the infarct related artery (IRA). At the same time points, 2 angiographic views were acquired during hyperaemia to measure quantitative flow ratio (QFR) from which IMRangio was derived. In a subset of 15 patients both IMR and IMRangio were also measured in the non-IRA. Patients underwent cardiovascular magnetic resonance imaging (CMR) at 48 h for assessment of microvascular obstruction (MVO). IMRangio and IMR were significantly correlated (ρ: 0.85, p < 0.001). Both IMR and IMRangio were higher in the IRA rather than in the non-IRA (p = 0.01 and p = 0.006, respectively) and were higher in patients with evidence of clinically significant MVO (> 1.55% of left ventricular mass) (p = 0.03 and p = 0.005, respectively). Post-pPCI IMRangio presented and area under the curve (AUC) of 0.96 (CI95% 0.92–1.00, p < 0.001) for prediction of post-pPCI IMR > 40U and of 0.81 (CI95% 0.65–0.97, p < 0.001) for MVO > 1.55%. IMRangio is a promising tool for the assessment of coronary microcirculation. Assessment of IMR without the use of a pressure-wire may enable more rapid, convenient and cost-effective assessment of coronary microvascular function.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Mayooran Shanmuganathan
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.,Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Oxford, UK
| | - Rafail A Kotronias
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Dimitrios Terentes-Printzios
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Alessandra Borlotti
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Jeremy P Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Andrew J Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Robin P Choudhury
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Rajesh Kharbanda
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | - Vanessa M Ferreira
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.,Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Oxford, UK
| | | | - Keith M Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK
| | | | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.
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15
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De Maria GL, Lee R, Alkhalil M, Borlotti A, Kotronias R, Langrish J, Lucking A, Dawkins S, Choudhury RP, Kharbanda R, Banning AP, Vallance C, Channon KM. Reflectance spectral analysis for novel characterization and clinical assessment of aspirated coronary thrombi in patients with ST elevation myocardial infarction. Physiol Meas 2020; 41:045001. [PMID: 32197256 DOI: 10.1088/1361-6579/ab81de] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The visual appearance of coronary thrombi may be clinically informative in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). However, subjective assessment is poorly reproducible and cannot provide an objective basis for treatment decisions or patient stratification. We have assessed the feasibility of a novel reflectance spectroscopy technique to systematically characterize coronary artery thrombi retrieved by aspiration during pPCI in patients with STEMI, and the clinical utility for predicting distal microvascular obstruction. APPROACH Patients with STEMI treated with pPCI and thrombus aspiration (n = 288) were recruited from the Oxford Acute Myocardial Infarction (OxAMI) Study. Of these, 158 patients underwent cardiac magnetic resonance imaging within 48 h for assessment of microvascular obstruction (MVO). Coronary thrombi were imaged by reflectance spectroscopy across wavelengths 500-800 nm. MAIN RESULTS Spectral data were analysed using function fitting and multivariate models. The coefficient 'c red' determined from the fitting procedure correlated with the visually-assessed colour of thrombi ('red' or 'white') and with MVO. When applied to a reduced data set, consisting of spectra from 20 patients with the largest MVO and from 20 propensity-score-matched patients with no MVO, three multivariate analysis methods were able to discriminate spectra of thrombi from patients without MVO and with the largest MVO. SIGNIFICANCE Reflectance spectral analysis of coronary thrombus provides new insights into the pathology of STEMI, with potential clinical implications for emergency patient care. Further studies are warranted for validation as a point-of-care stratification tool in predicting the degree of microvascular injury and clinical outcomes in STEMI.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, John Radcliffe Hospital, Oxford, United Kingdom
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16
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Alkhalil M, Borlotti A, De Maria GL, Wolfrum M, Dawkins S, Fahrni G, Gaughran L, Langrish JP, Lucking A, Ferreira VM, Kharbanda RK, Banning AP, Dall'Armellina E, Channon KM, Choudhury RP. Hyper-acute cardiovascular magnetic resonance T1 mapping predicts infarct characteristics in patients with ST elevation myocardial infarction. J Cardiovasc Magn Reson 2020; 22:3. [PMID: 31915031 PMCID: PMC6951001 DOI: 10.1186/s12968-019-0593-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Myocardial recovery after primary percutaneous coronary intervention in acute myocardial infarction is variable and the extent and severity of injury are difficult to predict. We sought to investigate the role of cardiovascular magnetic resonance T1 mapping in the determination of myocardial injury very early after treatment of ST-segment elevation myocardial infarction (STEMI). METHODS STEMI patients underwent 3 T cardiovascular magnetic resonance (CMR), within 3 h of primary percutaneous intervention (PPCI). T1 mapping determined the extent (area-at-risk as %left ventricle, AAR) and severity (average T1 values of AAR) of acute myocardial injury, and related these to late gadolinium enhancement (LGE), and microvascular obstruction (MVO). The characteristics of myocardial injury within 3 h was compared with changes at 24-h to predict final infarct size. RESULTS Forty patients were included in this study. Patients with average T1 values of AAR ≥1400 ms within 3 h of PPCI had larger LGE at 24-h (33% ±14 vs. 18% ±10, P = 0.003) and at 6-months (27% ±9 vs. 12% ±9; P < 0.001), higher incidence and larger extent of MVO (85% vs. 40%, P = 0.016) & [4.0 (0.5-9.5)% vs. 0 (0-3.0)%, P = 0.025]. The average T1 value was an independent predictor of acute LGE (β 0.61, 95%CI 0.13 to 1.09; P = 0.015), extent of MVO (β 0.22, 95%CI 0.03 to 0.41, P = 0.028) and final infarct size (β 0.63, 95%CI 0.21 to 1.05; P = 0.005). Receiver-operating-characteristic analysis showed that T1 value of AAR obtained within 3-h, but not at 24-h, predicted large infarct size (LGE > 9.5%) with 100% positive predictive value at the optimal cut-off of 1400 ms (area-under-the-curve, AUC 0.88, P = 0.006). CONCLUSION Hyper-acute T1 values of the AAR (within 3 h post PPCI, but not 24 h) predict a larger extent of MVO and infarct size at both 24 h and 6 months follow-up. Delayed CMR scanning for 24 h could not substitute the significant value of hyper-acute average T1 in determining infarct characteristics.
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Affiliation(s)
- Mohammad Alkhalil
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alessandra Borlotti
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Sam Dawkins
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Gregor Fahrni
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Lisa Gaughran
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jeremy P Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Andrew Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Vanessa M Ferreira
- Division of Cardiovascular Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Oxford, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Erica Dall'Armellina
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, Department of Biomedical Imaging Sciences, University of Leeds, Leeds, UK
| | - Keith M Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Robin P Choudhury
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
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17
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Xaplanteris P, Fournier S, Keulards DCJ, Adjedj J, Ciccarelli G, Milkas A, Pellicano M, Van't Veer M, Barbato E, Pijls NHJ, De Bruyne B. Catheter-Based Measurements of Absolute Coronary Blood Flow and Microvascular Resistance: Feasibility, Safety, and Reproducibility in Humans. Circ Cardiovasc Interv 2019; 11:e006194. [PMID: 29870386 DOI: 10.1161/circinterventions.117.006194] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/29/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The principle of continuous thermodilution can be used to calculate absolute coronary blood flow and microvascular resistance (R). The aim of the study is to explore the safety, feasibility, and reproducibility of coronary blood flow and R measurements as measured by continuous thermodilution in humans. METHODS AND RESULTS Absolute coronary flow and R can be calculated by thermodilution by infusing saline at room temperature through a dedicated monorail catheter. The temperature of saline as it enters the vessel, the temperature of blood and saline mixed in the distal part of the vessel, and the distal coronary pressure were measured by a pressure/temperature sensor-tipped guidewire. The feasibility and safety of the method were tested in 135 patients who were referred for coronary angiography. No significant adverse events were observed; in 11 (8.1%) patients, bradycardia and concomitant atrioventricular block appeared transiently and were reversed immediately on interruption of the infusion. The reproducibility of measurements was tested in a subgroup of 80 patients (129 arteries). Duplicate measurements had a strong correlation both for coronary blood flow (ρ=0.841, P<0.001; intraclass correlation coefficient=0.89, P<0.001) and R (ρ=0.780, P<0.001; intraclass correlation coefficient=0.89, P<0.001). In Bland-Altman plots, there was no significant bias or asymmetry. CONCLUSIONS Absolute coronary blood flow (in L/min) and R (in mm Hg/L/min or Wood units) can be safely and reproducibly measured with continuous thermodilution. This approach constitutes a new opportunity for the study of the coronary microcirculation.
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Affiliation(s)
- Panagiotis Xaplanteris
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Stephane Fournier
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Daniëlle C J Keulards
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Julien Adjedj
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Giovanni Ciccarelli
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Anastasios Milkas
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Mariano Pellicano
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Marcel Van't Veer
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Emanuele Barbato
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Nico H J Pijls
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Bernard De Bruyne
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.).
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De Maria GL, Alkhalil M, Wolfrum M, Fahrni G, Borlotti A, Gaughran L, Dawkins S, Langrish JP, Lucking AJ, Choudhury RP, Porto I, Crea F, Dall'Armellina E, Channon KM, Kharbanda RK, Banning AP. Index of Microcirculatory Resistance as a Tool to Characterize Microvascular Obstruction and to Predict Infarct Size Regression in Patients With STEMI Undergoing Primary PCI. JACC Cardiovasc Imaging 2019; 12:837-848. [PMID: 29680355 DOI: 10.1016/j.jcmg.2018.02.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This study aimed to compare the value of the index of microcirculatory resistance (IMR) and microvascular obstruction (MVO) measured by cardiac magnetic resonance (CMR) in patients treated for and recovering from ST-segment elevation myocardial infarction. BACKGROUND IMR can identify patients with microvascular dysfunction acutely after primary percutaneous coronary intervention (pPCI), and a threshold of >40 has been shown to be associated with an adverse clinical outcome. Similarly, MVO is recognized as an adverse feature in patients with ST-segment elevation myocardial infarction. Even though both IMR and MVO reflect coronary microvascular status, the interaction between these 2 parameters is uncertain. METHODS A total of 110 patients treated with pPCI were included, and IMR was measured immediately at completion of pPCI. Infarct size (IS) as a percentage of left ventricular mass was quantified at 48 h (38.4 ± 12.0 h) and 6 months (194.0 ± 20.0 days) using CMR. MVO was identified and quantified at 48 h by CMR. RESULTS Overall, a discordance between IMR and MVO was observed in 36.7% of cases, with 31 patients having MVO and IMR ≤40. Compared with patients with MVO and IMR ≤40, patients with both MVO and IMR >40 had an 11.9-fold increased risk of final IS >25% at 6 months (p = 0.001). Patients with MVO and IMR ≤40 had a significantly smaller IS at 6 months (p = 0.001), with significant regression in IS over time (34.4% [interquartile range (IQR): 27.3% to 41.0%] vs. 22.3% [IQR: 16.0% to 30.0%]; p = 0.001). CONCLUSIONS Discordant prognostic information was obtained from IMR and MVO in nearly one-third of cases; however, IMR can be helpful in grading the degree and severity of MVO.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mohammad Alkhalil
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Mathias Wolfrum
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Gregor Fahrni
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Alessandra Borlotti
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Lisa Gaughran
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Sam Dawkins
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Jeremy P Langrish
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrew J Lucking
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Robin P Choudhury
- Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Department of Cardiology, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Italo Porto
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Filippo Crea
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Erica Dall'Armellina
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Keith M Channon
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Rajesh K Kharbanda
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Adrian P Banning
- Oxford Heart Centre, National Institute for Health Research Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom.
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Alkhalil M, Borlotti A, De Maria GL, Gaughran L, Langrish J, Lucking A, Ferreira V, Kharbanda RK, Banning AP, Channon KM, Dall’Armellina E, Choudhury RP. Dynamic changes in injured myocardium, very early after acute myocardial infarction, quantified using T1 mapping cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2018; 20:82. [PMID: 30567572 PMCID: PMC6300907 DOI: 10.1186/s12968-018-0506-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND It has recently been suggested that myocardial oedema follows a bimodal pattern early post ST-segment elevation myocardial infarction (STEMI). Yet, water content, quantified using tissue desiccation, did not return to normal values unlike oedema quantified by cardiovascular magnetic resonance (CMR) imaging. We studied the temporal changes in the extent and intensity of injured myocardium using T1-mapping technique within the first week after STEMI. METHODS A first group (n = 31) underwent 3 acute 3 T CMR scans (time-point (TP) < 3 h, 24 h and 6 days), including cine, native shortened modified look-locker inversion recovery T1 mapping, T2* mapping and late gadolinium enhancement (LGE). A second group (n = 17) had a single scan at 24 h with an additional T2-weighted sequence to assess the difference in the extent of area-at-risk (AAR) compared to T1-mapping. RESULTS The mean T1 relaxation time value within the AAR of the first group was reduced after 24 h (P < 0.001 for TP1 vs.TP2) and subsequently increased at 6 days (P = 0.041 for TP2 vs.TP3). However, the extent of AAR quantified using T1-mapping did not follow the same course, and no change was detected between TP1&TP2 (P = 1.0) but was between TP2 &TP3 (P = 0.019). In the second group, the extent of AAR was significantly larger on T1-mapping compared to T2-weighted (42 ± 15% vs. 39 ± 15%, P = 0.025). No change in LGE was detected while microvascular obstruction and intra-myocardial haemorrhage peaked at different time points within the first week of reperfusion. CONCLUSION The intensity of oedema post-STEMI followed a bimodal pattern; while the extent of AAR did not track the same course. This discrepancy has implications for use of CMR in this context and may explain the previously reported disagreement between oedema quantified by imaging and tissue desiccation.
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Affiliation(s)
- Mohammad Alkhalil
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Alessandra Borlotti
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
| | - Lisa Gaughran
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jeremy Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
| | - Andrew Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
| | - Vanessa Ferreira
- Division of Cardiovascular Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Oxford, UK
| | - Rajesh K. Kharbanda
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
| | - Adrian P. Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
| | - Keith M. Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Erica Dall’Armellina
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Robin P. Choudhury
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, OX3 9DU UK
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
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Deng X, Wang X, Shen L, Yao K, Ge L, Ma J, Zhang F, Qian J, Ge J. Association of eosinophil-to-monocyte ratio with 1-month and long-term all-cause mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Thorac Dis 2018; 10:5449-5458. [PMID: 30416794 DOI: 10.21037/jtd.2018.09.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To determine the relationship between eosinophil-to-monocyte ratio (EMR) on admission and one-month and long-term all-cause mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (P-PCI). Methods A total of 426 consecutive STEMI patients treated with P-PCI were enrolled and categorized in terms of tertiles of EMR on admission between September 2015 and October 2017. Final follow-up for long-term outcomes was January 2017. Results As EMR decreased, all-cause mortality at 1 month (mean, 29.5±3.5 days) and at mean 14.1±7.8 months follow-up increased (P=0.012, P=0.003, respectively). Kaplan-Meier survival curve analysis showed EMR was associated with 1-month and long-term all-cause mortality (P=0.048, P=0.015, respectively). In multivariate Cox proportional hazards analysis, EMR was independently associated with one-month and long-term mortality (hazard ratio =0.097; 95% CI, 0.010-0.899; P=0.04; hazard ration =0.176; 95% CI, 0.045-0.694; P=0.013). The area under the curve of EMR for the prediction of 1-month and long-term total mortality in receiver operating characteristic analysis was 0.789 (95% CI, 0.658-0.921; P=0.003) and 0.752 (95% CI, 0.619-0.884; P=0.001), respectively. Conclusions EMR on admission was independently correlated with 1-month and long-term all-cause mortality in STEMI patients undergoing P-PCI, suggesting EMR as a potential simple, useful, and inexpensive index for risk stratification of STEMI patients.
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Affiliation(s)
- Xin Deng
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiaoyan Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Kang Yao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lei Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jianying Ma
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Feng Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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De Maria GL, Alkhalil M, Borlotti A, Wolfrum M, Gaughran L, Dall'Armellina E, Langrish JP, Lucking AJ, Choudhury RP, Kharbanda RK, Channon KM, Banning AP. Index of microcirculatory resistance-guided therapy with pressure-controlled intermittent coronary sinus occlusion improves coronary microvascular function and reduces infarct size in patients with ST-elevation myocardial infarction: the Oxford Acute Myocardial Infarction - Pressure-controlled Intermittent Coronary Sinus Occlusion study (OxAMI-PICSO study). EUROINTERVENTION 2018; 14:e352-e359. [PMID: 29792403 DOI: 10.4244/eij-d-18-00378] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
AIMS The Oxford Acute Myocardial Infarction PICSO (OxAMI-PICSO) study aimed to assess the efficacy of index of microcirculatory resistance (IMR)-guided therapy with pressure-controlled intermittent coronary sinus occlusion (PICSO) in anterior ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS Patients with anterior STEMI treated with primary percutaneous coronary intervention (pPCI) were enrolled. Pre-stenting IMR was measured and PICSO treatment delivered if pre-stenting IMR was >40. No PICSO treatment was considered in patients with a pre-stenting IMR ≤40. The control group was derived from a historical cohort of STEMI patients with pre-stenting IMR >40 enrolled in the observational OxAMI study. IMR was measured after completion of pPCI in all patients and within 48 hours in PICSO patients and controls. Cardiac magnetic resonance imaging was performed per protocol for infarct size (IS) assessment within 48 hours after pPCI and at six months. A total of 105 patients were enrolled (25 PICSO, 50 controls with pre-stenting IMR >40, 30 with pre-stenting IMR ≤40). Compared to controls, patients treated with PICSO had a lower IMR at 24-48 hours (24.8 [18.5-35.9] vs. 45.0 [32.0-51.3], p<0.001) and lower IS at six months (26.0% [20.2-30.0] vs. 33.0% [28.0-37.0], p=0.006). CONCLUSIONS An IMR-guided treatment with PICSO in anterior STEMI is feasible and may be associated with reduced IS and improved microvascular function.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
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Cyrne Carvalho H. Microvascular reperfusion in myocardial infarction: The new concept of the open artery in the 21st century. Rev Port Cardiol 2017; 36:743-745. [PMID: 29037834 DOI: 10.1016/j.repc.2017.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Henrique Cyrne Carvalho
- Centro Hospitalar e Universitário do Porto, Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.
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De Maria G, Alkhalil M, Wolfrum M, Fahrni G, Borlotti A, Gaughran L, Dawkins S, Langrish J, Lucking A, Choudhury R, Porto I, Crea F, Dall’Armellina E, Channon K, Kharbanda R, Banning A. The ATI score (age-thrombus burden-index of microcirculatory resistance) determined during primary percutaneous coronary intervention predicts final infarct size in patients with ST-elevation myocardial infarction: a cardiac magnetic resonance validation study. EUROINTERVENTION 2017. [DOI: 10.4244/eij-d-17-00367] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bajrangee A, Collison D, Oldroyd K. Resistance to flow in the coronary microcirculation – we can measure it but what does it mean? EUROINTERVENTION 2017; 13:901-903. [DOI: 10.4244/eijv13i8a133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Microvascular reperfusion in myocardial infarction: The new concept of the open artery in the 21st century. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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De Maria GL, Patel N, Wolfrum M, Fahrni G, Kassimis G, Porto I, Dawkins S, Choudhury RP, Forfar JC, Prendergast BD, Channon KM, Kharbanda RK, Garcia-Garcia HM, Banning AP. The influence of coronary plaque morphology assessed by optical coherence tomography on final microvascular function after stenting in patients with ST-elevation myocardial infarction. Coron Artery Dis 2017; 28:198-208. [PMID: 27926579 PMCID: PMC5404714 DOI: 10.1097/mca.0000000000000458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The index of microcirculatory resistance (IMR) provides a reproducible assessment of the status of coronary microvasculature in patients with ST-elevation myocardial infarction (STEMI). Frequency-domain optical coherence tomography (FD-OCT) enables detailed assessment of the morphology of coronary plaque.We sought to determine the influence of the initial culprit coronary plaque anatomy within the infarct-related artery on IMR after stenting in STEMI. PATIENTS AND METHODS In 25 STEMI patients IMR was measured immediately before and after stent implantation. FD-OCT imaging was performed at the same time points and atherothrombotic volume (ATV) before stenting, prolapsed+floating ATV after stenting and ΔATV was measured using three different strategies. RESULTS There were no relationships between preprocedural IMR and FD-OCT parameters. Prestenting IMR was related only to pain to wire time (P: 0.02). Irrespective of the method adopted, the final IMR was related to prestenting ATV (ρ: 0.44, P: 0.03 for method I, ρ: 0.48, P: 0.02 for method II and ρ: 0.30, P: 0.06 for method III) and ΔATV (ρ: 0.41, P: 0.04 for method II and ρ: 0.44, P: 0.03 for method III). CONCLUSION IMR measured before stenting is independent of the appearances of the culprit coronary plaque within the infarct-related artery. IMR after stenting, and more importantly, the change in IMR after stenting, reflect the degree of distal embolization during stent implantation.
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Affiliation(s)
- Giovanni L De Maria
- aOxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals bRadcliffe Department of Medicine, Acute Vascular Imaging Centre cDivision of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK dCardiovascular Department, Università Cattolica del Sacro Cuore, Rome, Italy eMedStar Washington Hospital Center, Washington, DC, USA
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De Maria GL, Alkhalil M, Oikonomou EK, Wolfrum M, Choudhury RP, Banning AP. Role of deferred stenting in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention: A systematic review and meta-analysis. J Interv Cardiol 2017; 30:264-273. [PMID: 28370496 DOI: 10.1111/joic.12380] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/23/2017] [Accepted: 03/05/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES We conducted a meta-analysis of studies comparing deferred stenting strategy versus the conventional approach with immediate stenting in patients with ST elevation myocardial infarction. BACKGROUND Deferring stent after mechanical flow restoration has been proposed as a strategy to reduce the risk of "no reflow" in patients with STEMI undergoing primary percutaneous coronary intervention (pPCI). Conflicting evidence is available currently, especially after the recent publication of three randomized clinical trials. METHODS Searches in electronic databases were performed. Comparisons between the two strategies were performed for both hard clinical endpoints (all cause-mortality, cardiovascular mortality, unplanned revascularization, myocardial infarction and readmission for heart failure) and surrogate angiographic endpoints (TIMI flow < 3 and myocardial blush grade (MBG) < 2). RESULTS Eight studies (three randomized and five non-randomized) were deemed eligible, accounting for a total of 2101 patients. No difference in terms of hard clinical endpoints was observed between deferred and immediate stenting (OR [95% CI]: 0.79 [0.54-1.15], for all-cause mortality; odds ratio (OR) [95% CI]: 0.79 [0.47-1.31] for cardiovascular mortality; OR [95% CI]: 0.95 [0.64-1.41] for myocardial infarction; OR [95% CI]: 1.37 [0.87-2.16], for unplanned revascularization and OR [95% CI]: 0.50 [0.21-1.17] for readmission for heart failure). Notably, the deferred stenting approach was associated with improved outcome of the surrogate angiographic endpoints (OR [95% CI]: 0.43 [0.18-0.99] of TIMI flow < 3 and OR [95% CI]: 0.25 [0.11-0.57] for MBG < 2. CONCLUSIONS A deferred stenting strategy could be a feasible alternative to the conventional approach with immediate stenting in "selected" STEMI patients undergoing pPCI.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Mohammad Alkhalil
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | | | - Mathias Wolfrum
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Robin P Choudhury
- Radcliffe Department of Medicine, Acute Vascular Imaging Centre, University of Oxford, Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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Vrints C, Haine S. Prevention of coronary microvascular plugging: the next target in STEMI? EUROINTERVENTION 2016; 12:1201-1202. [DOI: 10.4244/eijv12i10a197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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