Impact Of Primary Coronary Angioplasty Delay

1. Impact Of Primary Coronary Angioplasty Delay On Myocardial Salvage, Infarct Size And Microvascular Damage in Patients with ST-Elevation Myocardial Infarction: Insight From Cardiovascular Magnetic Resonance Francone M, Bucciarelli-Ducci C*, Carbone I, Canali E, Scardala R, Calabrese F, Sardella G, Mancone M, Catalano C, Fedele F, Passariello R, Bogaert J** and Agati L Umberto I Hospital, University “La Sapienza”, Rome, Italy *Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, United Kingdom **Leuven University, Belgium

2. Background Time is muscle De Luca, Circulation 2004

3. Background Challenges What happens to the muscle? How much salvageable myocardium is there? How to recognize salvageable myocardium?

4. Background MYOCARDIAL NECROSIS Kim RJ et al, Circulation 1999 MYOCARDIUM AT RISK MICROVASCULAR DAMAGE Rochitte C et al, Circulation 1998 Aletras AH et al, Circulation 2006

5. Aims of the Study • To investigate the correlation between the extent and the nature of myocardial damage in relation to different time-to-reperfusion intervals • To investigate the relationship between time-to-reperfusion • intervals, myocardial damage and subsequent LV remodeling

6. Study Protocol n=70 STEMI, primary PCI Time-to-reperfusion ≤90min >90-150min >150-360min >360min n=19 n=17 n=17 n=17

7. CMR Protocol 3±2 days 6 months Cine

8. CMR Protocol 3±2 days T2 w T1 w gadolinium T1 w gadolinium increased signal intensity (myocardial edema) increased signal intensity reduced signal intensity Myocardium at risk Infarct Size Microvascular Obstruction

9. Results: Myocardium at Risk p=0.37 Myocardial Edema (% LV) Time to reperfusion (min)

10. Results: Infarct Size p=0.002 p=0.005 * * Infarct Size (% LV) Time to reperfusion (min)

11. Myocardium at Risk – Infarct size Time to reperfusion (min)

12. Myocardial Salvage p=0.003 * Myocardial Salvage (%) p=0.001 * Time to reperfusion (min)

13. Microvascular Obstruction p=0.04 p=0.001 * MVO (% LV) * Time to reperfusion (min)

14. EDV: Baseline p=0.03 EDV (ml) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

15. EDV: Baseline vs 6 Months p=0.002 p=0.005 p=0.05 p=0.003 Baseline 6 months EDV (ml) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

16. ESV: Baseline p=0.02 ESV (ml) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

17. ESV: Baseline vs 6 Months p=0.003 p=0.006 p=0.001 Baseline p=0.06 6 months ESV (ml) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

18. EF: Baseline p=0.06 EF (%) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

19. EF: Baseline vs 6 Months p=0.04 p= ns p=ns p=0.04 Baseline 6 months EF (%) ≤90 min >90-150 min >150-360 min >360 min Time to reperfusion (min)

20. LAD Infarctions ≤90 min >90-150 min >150-360 min >360 min Myocardium at Risk Infarct Size Time to reperfusion (min) * MVO

21. Non-LAD Infarctions ≤90 min >90-150 min >150-360 min >360 min Myocardium at Risk Infarct Size Time to reperfusion (min) * MVO

22. Conclusions-1 • First in-vivo, clinical, non invasive evaluation of the consequences of early and delayed coronary reperfusion on myocardial damage

23. Conclusions-2 LV remodeling • Time is muscle Longer time-to-reperfusion (>360min) Larger infarct size and more MVO Less salvaged myocardium • Myocardial salvage, infarct size and MVO by CMR surrogate endpoints for clinical trials assessing the efficacy of reperfusion strategies