The value of microvascular obstruction according to contrast-enhanced cardiac magnetic resonance imaging in assessing the prognosis of patients with acute ST-segment elevation myocardial infarction

Aim. To study the relationship between the presence and size of microvascular obstruction (MVO) and the prognosis of patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) within one year.

Material and methods. The study included 50 patients with a first STEMI who underwent PPCI on the infarct-related artery. After 3-7 days and 12 months, contrast-enhanced cardiac magnetic resonance imaging was performed to assess left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and MVOs. After 12 months, patients were rehospitalized and prognosis was assessed based on data on cardiovascular events.

Results. Patients with MVO had a significantly lower LVEF in the acute period of MI (44,1±10,6%) compared to patients without MVO (52,9±10,5%), p=0,0209, as well as during reassessment after a year (44,8±11,1%) compared with patients without MVO (58,9±8,0%), p=0,0004. A significant inverse correlation was found between LVEF in the initial and repeat examination and MVO size in the initial examination as follows: ρ=-0,42 (95% confidence interval (CI): -0,66 — -0,12, p=0,008) and ρ=-0,61 (95% CI: -0,78 — -0,34, p=0,0001). There was also a significant inverse correlation between LVEF and MVO size at reassessment, ρ=-0,40 (95% CI: -0,65 — -0,07, p=0,0205). A significant direct correlation was identified between MVO size in the acute MI period and LVEDV one year later, ρ=0,35 (95% CI: 0,02-0,62, p=0,0409). The development of a left ventricular (LV) aneurysm was registered in 40% of patients with MVO during the initial study and was not registered among patients without MVO (p=0,0039).

Conclusion. MVOs was associated with post-infarction LV aneurysm. An increase in MVO size correlated with a decrease in LVEF and an increase in LVEDV both in the acute period and one year after MI.

1. Bahit MC, Kochar A, Granger CB. Post-Myocardial Infarction Heart Failure. JACC Heart Fail. 2018;6(3):179-86. doi:10.1016/j.jchf.2017.09.015.

2. Bulluck H, Dharmakumar R, Arai AE, et al. Cardiovascular Magnetic Resonance in Acute ST-Segment-Elevation Myocardial Infarction: Recent Advances, Controversies, and Future Directions.Circulation.2018;137(18):1949-64. doi:10.1161/CIRCULATIONAHA.117.030693.

3. van Kranenburg M, Magro M, Thiele H, et al. Prognostic value of microvascular obstruction and infarct size, as measured by CMR in STEMI patients. JACC Cardiovasc Imaging. 2014;7(9):930-9. doi:10.1016/j.jcmg.2014.05.010.

4. Terenicheva MA, Stukalova OV, Shakhnovich RM, et al. The role of cardiac magnetic resonance imaging in defining the prognosis of patients with acute ST-segment elevation myocardial infarction. Part 2. Assessment of the disease prognosis. Terapevticheskii Arkhiv (Ter. Arkh.). 2022;94(4):552-7. (In Russ.) doi:10.26442/00403660.2022.04.201458.

5. Stone GW, Selker HP, Thiele H, et al. Relationship Between Infarct Size and Outcomes Following Primary PCI: Patient-Level Analysis From 10 Randomized Trials. J Am Coll Cardiol. 2016;67(14):1674-83. doi:10.1016/j.jacc.2016.01.069.

6. Thygesen K, Alpert JS, Jaffe AS, et al. Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-64. doi:10.1016/j.jacc.2018.08.1038.

7. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal. 2018;39;2:119-77. doi:10.1093/eurheartj/ehx393.

8. Ageev FT, Arutyunov GP, Begrambekova YuL, et al. 2020 Clinical practice guidelines for Chronic heart failure Russian Journal of Cardiology. 2020;25(11):4083. (In Russ.) doi:10.15829/1560-4071-2020-4083.

9. Symons R, Pontone G, Schwitter J, et al. Long-Term Incremental Prognostic Value of Cardiovascular Magnetic Resonance After ST-Segment Elevation Myocardial Infarction: A Study of the Collaborative Registry on CMR in STEMI. JACC Cardiovasc Imaging. 2018;11(6):813-25. doi:10.1016/j.jcmg.2017.05.023.

10. Abbas A, Matthews GH, Brown IW, et al. Cardiac MR assessment of microvascular obstruction. Br J Radiol. 2015;88(1047):20140470. doi:10.1259/bjr.20140470.

11. Wu KC, Zerhouni EA, Judd RM, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation. 1998;97(8):765-72. doi:10.1161/01.cir.97.8.765.

12. Hamirani YS, Wong A, Kramer CM, et al. Effect of microvascular obstruction and intramyocardial hemorrhage by CMR on LV remodeling and outcomes after myocardial infarction: a systematic review and meta-analysis. JACC Cardiovasc Imaging. 2014;7(9):940-52. doi:10.1016/j.jcmg.2014.06.012.

13. Rios-Navarro C, Marcos-Garces V, Bayes-Genis A, et al. Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction: Looking Back to Move Forward. Focus on CMR. Clin. Med. 2019;8(11):1805. doi:10.3390/jcm8111805.