Coronary Thermodilution Waveforms After Acute Reperfused ST-Segment-Elevation Myocardial Infarction: Relation to Microvascular Obstruction and Prognosis

Shu Ning Yew, David Carrick, David Corcoran, Nadeem Ahmed, Jaclyn Carberry, Vannesa Teng Yue May, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Mitchell Lindsay, Stuart Hood, Stuart Watkins, Andrew Davie, Ahmed Mahrous, Ify Mordi, Ian Ford, Keith G Oldroyd, Colin Berry, Shu Ning Yew, David Carrick, David Corcoran, Nadeem Ahmed, Jaclyn Carberry, Vannesa Teng Yue May, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Mitchell Lindsay, Stuart Hood, Stuart Watkins, Andrew Davie, Ahmed Mahrous, Ify Mordi, Ian Ford, Keith G Oldroyd, Colin Berry

Abstract

Background Invasive measures of microvascular resistance in the culprit coronary artery have potential for risk stratification in acute ST-segment-elevation myocardial infarction. We aimed to investigate the pathological and prognostic significance of coronary thermodilution waveforms using a diagnostic guidewire. Methods and Results Coronary thermodilution was measured at the end of percutaneous coronary intervention, (PCI) and contrast-enhanced cardiac magnetic resonance imaging (MRI) was intended on day 2 and 6 months later to assess left ventricular (LV) function and pathology. All-cause death or first heart failure hospitalization was a pre-specified outcome (median follow-up duration 1469 days). Thermodilution recordings underwent core laboratory assessment. A total of 278 patients with acute ST-segment elevation myocardial infarction EMI (72% male, 59±11 years) had coronary thermodilution measurements classified as narrow unimodal (n=143 [51%]), wide unimodal (n=100 [36%]), or bimodal (n=35 [13%]). Microvascular obstruction and myocardial hemorrhage were associated with the thermodilution waveform pattern ( P=0.007 and 0.011, respectively), and both pathologies were more prevalent in patients with a bimodal morphology. On multivariate analysis with baseline characteristics, thermodilution waveform status was a multivariable associate of microvascular obstruction (odds ratio [95% confidence interval]=5.29 [1.73, 16.22];, P=0.004) and myocardial hemorrhage (3.45 [1.16, 10.26]; P=0.026), but the relationship was not significant when index of microvascular resistance (IMR) >40 or change in index of microvascular resistance (5 per unit) was included. However, a bimodal thermodilution waveform was independently associated with all-cause death and hospitalization for heart failure (odds ratio [95% confidence interval]=2.70 [1.10, 6.63]; P=0.031), independent of index of microvascular resistance>40, ST-segment resolution, and TIMI (Thrombolysis in Myocardial Infarction) Myocardial Perfusion Grade. Conclusions The thermodilution waveform in the culprit coronary artery is a biomarker of prognosis and may be useful for risk stratification immediately after reperfusion therapy.

Keywords: magnetic resonance imaging; myocardial infarction; pathophysiology.

Figures

Figure 1
Figure 1
Thermodilution waveforms obtained in the culprit coronary artery at the end of PCI in 3 patients with acute STEMI. The coronary thermodilution curves are obtained in triplicate at rest (blue) and then again during hyperemia (orange) induced by intravenous infusion of adenosine (140 μg/[kg·min]). The green‐highlighted curve represents the “live” measurement of interest according to the software settings. A, A patient with a narrow unimodal waveform and the image obtained using CMR with late gadolinium enhancement (showing a subendocardial infarct with no microvascular obstruction) 2 days later; (B) a wide unimodal waveform and a larger area of transmural infarction revealed by CMR; (C) a bimodal waveform in association with an extensive area of infarction complicated by microvascular obstruction (central dark zone within the bright area of infarction). CMR indicates coronary magnetic resonance imaging; MRI, magnetic resonance imaging; PCI, percutaneous coronary intervention; STEMI, ST‐segment–elevation myocardial infarction.
Figure 2
Figure 2
CONSORT (Consolidated Standards of Reporting Trials) flow diagram of the study. CMR indicates cardiac magnetic resonance; STEMI, ST‐segment–elevation myocardial infarction.

References

    1. O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis‐Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST‐elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425.
    1. McGeoch R, Watkins S, Berry C, Steedman T, Davie A, Byrne J, Hillis S, Lindsay M, Robb S, Dargie H, Oldroyd K. The index of microcirculatory resistance measured acutely predicts the extent and severity of myocardial infarction in patients with ST‐segment elevation myocardial infarction. JACC Cardiovasc Interv. 2010;3:715–722.
    1. Carrick D, Haig C, Ahmed N, McEntegart M, Petrie MC, Eteiba H, Hood S, Watkins S, Lindsay M, Davie A, Mahrous A, Mordi I, Rauhalammi S, Sattar N, Welsh P, Radjenovic A, Ford I, Oldroyd K, Berry C. Myocardial hemorrhage after acute reperfused ST‐segment‐elevation myocardial infarction: relation to microvascular obstruction and prognostic significance. Circ Cardiovasc Imaging. 2016;9:e004148.
    1. Frohlich GM, Meier P, White SK, Yellon DM, Hausenloy DJ. Myocardial reperfusion injury: looking beyond primary PCI. Eur Heart J. 2013;34:1714–1722.
    1. Carrick D, Haig C, Rauhalammi S, Ahmed N, Mordi I, McEntegart M, Petrie MC, Eteiba H, Hood S, Watkins S, Lindsay M, Mahrous A, Ford I, Tzemos N, Sattar N, Welsh P, Radjenovic A, Oldroyd KG, Berry C. Prognostic significance of infarct core pathology revealed by quantitative non‐contrast in comparison with contrast cardiac magnetic resonance imaging in reperfused ST‐elevation myocardial infarction survivors. Eur Heart J. 2016;37:1044–1059.
    1. de Waha S, Desch S, Eitel I, Fuernau G, Zachrau J, Leuschner A, Gutberlet M, Schuler G, Thiele H. Impact of early vs. late microvascular obstruction assessed by magnetic resonance imaging on long‐term outcome after ST‐elevation myocardial infarction: a comparison with traditional prognostic markers. Eur Heart J. 2010;31:2660–2668.
    1. van ‘t Hof AW, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation. 1998;97:2302–2306.
    1. Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ, McCabe CH, Van De Werf F, Braunwald E. Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation. 2000;101:125–130.
    1. Nijveldt R, Beek AM, Hirsch A, Stoel MG, Hofman MB, Umans VA, Algra PR, Twisk JW, van Rossum AC. Functional recovery after acute myocardial infarction: comparison between angiography, electrocardiography, and cardiovascular magnetic resonance measures of microvascular injury. J Am Coll Cardiol. 2008;52:181–189.
    1. Eitel I, de Waha S, Wohrle J, Fuernau G, Lurz P, Pauschinger M, Desch S, Schuler G, Thiele H. Comprehensive prognosis assessment by CMR imaging after ST‐segment elevation myocardial infarction. J Am Coll Cardiol. 2014;64:1217–1226.
    1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‐Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranchx P, Widimsky P; ESC Scientific Group . 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). Eur Heart J. 2018;39:119–177.
    1. Fearon WF, Low AF, Yong AS, McGeoch R, Berry C, Shah MG, Ho MY, Kim HS, Loh JP, Oldroyd KG. Prognostic value of the index of microcirculatory resistance measured after primary percutaneous coronary intervention. Circulation. 2013;127:2436–2441.
    1. Carrick D, Haig C, Ahmed N, Carberry J, Teng VYM, McEntegart M, Petrie MC, Eteiba H, Lindsay M, Hood S, Watkins S, Davie A, Mahrous A, Mordi I, Ford I, Radjenovic A, Oldroyd KG, Berry C. Comparative prognostic utility of indexes of microvascular function alone or in combination in patients with an acute ST‐segment‐elevation myocardial infarction. Circulation. 2016;134:1833–1847.
    1. Fukunaga M, Fujii K, Kawasaki D, Sawada H, Miki K, Tamaru H, Imanaka T, Iwasaku T, Nakata T, Shibuya M, Akahori H, Masutani M, Kobayashi K, Ohyanagi M, Masuyama T. Thermodilution‐derived coronary blood flow pattern immediately after coronary intervention as a predictor of microcirculatory damage and midterm clinical outcomes in patients with ST‐segment‐elevation myocardial infarction. Circ Cardiovasc Interv. 2014;7:149–155.
    1. Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E. Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update. J Cardiovasc Magn Reson. 2013;15:91.
    1. Flett AS, Hasleton J, Cook C, Hausenloy D, Quarta G, Ariti C, Muthurangu V, Moon JC. Evaluation of techniques for the quantification of myocardial scar of differing etiology using cardiac magnetic resonance. JACC Cardiovasc Imaging. 2011;4:150–156.
    1. Ghugre NR, Ramanan V, Pop M, Yang Y, Barry J, Qiang B, Connelly KA, Dick AJ, Wright GA. Quantitative tracking of edema, hemorrhage, and microvascular obstruction in subacute myocardial infarction in a porcine model by MRI. Magn Reson Med. 2011;66:1129–1141.
    1. Kandler D, Lucke C, Grothoff M, Andres C, Lehmkuhl L, Nitzsche S, Riese F, Mende M, de Waha S, Desch S, Lurz P, Eitel I, Gutberlet M. The relation between hypointense core, microvascular obstruction and intramyocardial haemorrhage in acute reperfused myocardial infarction assessed by cardiac magnetic resonance imaging. Eur Radiol. 2014;24:3277–3288.
    1. O'Regan DP, Ariff B, Neuwirth C, Tan Y, Durighel G, Cook SA. Assessment of severe reperfusion injury with T2* cardiac MRI in patients with acute myocardial infarction. Heart. 2010;96:1885–1891.
    1. Anderson LJ, Holden S, Davis B, Prescott E, Charrier CC, Bunce NH, Firmin DN, Wonke B, Porter J, Walker JM, Pennell DJ. Cardiovascular T2‐star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. Eur Heart J. 2001;22:2171–2179.
    1. Giri S, Chung YC, Merchant A, Mihai G, Rajagopalan S, Raman SV, Simonetti OP. T2 quantification for improved detection of myocardial edema. J Cardiovasc Magn Reson. 2009;11:56.
    1. Verhaert D, Thavendiranathan P, Giri S, Mihai G, Rajagopalan S, Simonetti OP, Raman SV. Direct T2 quantification of myocardial edema in acute ischemic injury. JACC Cardiovasc Imaging. 2011;4:269–278.
    1. Eitel I, Desch S, Fuernau G, Hildebrand L, Gutberlet M, Schuler G, Thiele H. Prognostic significance and determinants of myocardial salvage assessed by cardiovascular magnetic resonance in acute reperfused myocardial infarction. J Am Coll Cardiol. 2010;55:2470–2479.
    1. Berry C, Kellman P, Mancini C, Chen MY, Bandettini WP, Lowrey T, Hsu LY, Aletras AH, Arai AE. Magnetic resonance imaging delineates the ischemic area at risk and myocardial salvage in patients with acute myocardial infarction. Circ Cardiovasc Imaging. 2010;3:527–535.
    1. Payne AR, Casey M, McClure J, McGeoch R, Murphy A, Woodward R, Saul A, Bi X, Zuehlsdorff S, Oldroyd KG, Tzemos N, Berry C. Bright‐blood T2‐weighted MRI has higher diagnostic accuracy than dark‐blood short tau inversion recovery MRI for detection of acute myocardial infarction and for assessment of the ischemic area at risk and myocardial salvage. Circ Cardiovasc Imaging. 2011;4:210–219.
    1. Francone M, Bucciarelli‐Ducci C, Carbone I, Canali E, Scardala R, Calabrese FA, Sardella G, Mancone M, Catalano C, Fedele F, Passariello R, Bogaert J, Agati L. Impact of primary coronary angioplasty delay on myocardial salvage, infarct size, and microvascular damage in patients with ST‐segment elevation myocardial infarction: insight from cardiovascular magnetic resonance. J Am Coll Cardiol. 2009;54:2145–2153.
    1. Payne AR, Berry C, Doolin O, McEntegart M, Petrie MC, Lindsay MM, Hood S, Carrick D, Tzemos N, Weale P, McComb C, Foster J, Ford I, Oldroyd KG. Microvascular resistance predicts myocardial salvage and infarct characteristics in ST‐elevation myocardial infarction. J Am Heart Assoc. 2012;1:e002246 DOI: 10.1161/JAHA.112.002246.
    1. Steg PG, James SK, Atar D, Badano LP, Blomstrom‐Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez‐Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van ‘t Hof A, Widimsky P, Zahger D. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation. Eur Heart J. 2012;33:2569–2619.
    1. TIMI‐Study‐Group . The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J Med. 1985;312:932–936.
    1. Gibson CM, Cannon CP, Daley WL, Dodge JT Jr, Alexander B Jr, Marble SJ, McCabe CH, Raymond L, Fortin T, Poole WK, Braunwald E. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation. 1996;93:879–888.
    1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction , Katus HA, Lindahl B, Morrow DA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez‐Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–2035.
    1. Hicks KA, Tcheng JE, Bozkurt B, Chaitman BR, Cutlip DE, Farb A, Fonarow GC, Jacobs JP, Jaff MR, Lichtman JH, Limacher MC, Mahaffey KW, Mehran R, Nissen SE, Smith EE, Targum SL; American College of Cardiology; American Heart Association . 2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Cardiovascular Endpoints Data Standards). J Nucl Cardiol. 2015;22:1041–1144.
    1. Meier P, Zierler KL. On the theory of the indicator‐dilution method for measurement of blood flow and volume. J Appl Physiol. 1954;6:731–744.

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