Angiography-Derived and Sensor-Wire Methods to Assess Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction

Scarsini, Roberto; Portolan, Leonardo; Mora, Francesco Della; Marin, Federico; Mainardi, Andrea; Ruzzarin, Alessandro; Levine, Molly; Banning, Adrian; Ribichini, Flavio; Garcia, Hector M.; Maria, Giovanni Luigi De

doi:10.1016/j.jcmg.2023.01.017

Cited by 12 publications

(3 citation statements)

References 63 publications

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“…6 However, additional costs, need for further instrumentation of the infarct-related artery and for pharmacological induction of steady-state hyperemia have deeply restricted the widespread use of IMR in everyday clinical practice, especially in the emergent setting of pPCI. 15 NH-IMR angio has been recently proposed as a pressure-wire-free measure of myocardial reperfusion and CMI that can be easily calculated at completion of pPCI from standard angiographic views without requiring additional procedural steps, adenosine infusion, or extraprocedural time (Figure 1). This readily available tool was described for the first time in 2020 by De Maria et al 7 and it has demonstrated to be a valuable alternative to the invasively measured IMR or to microvascular obstruction at CMR for the detection of post-STEMI CMI.…”

Section: Discussionmentioning

confidence: 99%

Angiography-Derived Index of Microcirculatory Resistance to Define the Risk of Early Discharge in STEMI

Scarsini,

Kotronias,

Della Mora

et al. 2024

Circ: Cardiovascular Interventions

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BACKGROUND: Patients with ST-segment–elevation myocardial infarction but no coronary microvascular injury are at low risk of early cardiovascular complications (ECC). We aim to assess whether nonhyperemic angiography-derived index of microcirculatory resistance (NH-IMR angio ) could be a user-friendly tool to identify patients at low risk of ECC, potentially candidates for expedited care pathway and early hospital discharge. METHODS: Retrospective analysis of 2 independent, international, prospective, observational cohorts included 568 patients with ST-segment–elevation myocardial infarction. NH-IMR angio was calculated based on standard coronary angiographic views with 3-dimensional-modeling and computational analysis of the coronary flow. RESULTS: Overall, ECC (a composite of cardiovascular death, cardiogenic shock, acute heart failure, life-threatening arrhythmias, resuscitated cardiac arrest, left ventricular thrombus, post-ST-segment–elevation myocardial infarction mechanical complications, and rehospitalization for acute heart failure or acute myocardial infarction at 30 days follow-up), occurred in 54 (9.3%) patients. NH-IMR angio was significantly correlated with pressure/thermodilution-based index of microcirculatory resistance (r=0.607; P <0.0001) and demonstrated good accuracy in predicting ECC (area under the curve, 0.766 [95% CI, 0.706–0.827]; P <0.0001). Importantly, ECC occurred more frequently in patients with NH-IMR angio ≥40 units (18.1% versus 1.4%; P <0.0001). At multivariable analysis, NH-IMR angio provided incremental prognostic value to conventional clinical, angiographic, and echocardiographic features (adjusted-odds ratio, 14.861 [95% CI, 5.177–42.661]; P <0.0001). NH-IMR angio <40 units showed an excellent negative predictive value (98.6%) in ruling out ECC. Discharging patients with NH-IMR angio <40 units at 48 hours after admission would reduce the total in-hospital stay by 943 days (median 2 [1–4] days per patient). CONCLUSIONS: NH-IMR angio is a valuable risk-stratification tool in patients with ST-segment–elevation myocardial infarction. NH-IMR angio guided strategies to early discharge may contribute to safely shorten hospital stay, optimizing resources utilization.

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Section: Discussionmentioning

confidence: 99%

Angiography-Derived Index of Microcirculatory Resistance to Define the Risk of Early Discharge in STEMI

Scarsini,

Kotronias,

Della Mora

et al. 2024

Circ: Cardiovascular Interventions

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“…In parallel, the ongoing development of angiography-based tools using 3-dimensional modeling and simplified computational flow-dynamics techniques to derive microvascular function surrogates could facilitate risk stratification as it avoids the additional costs, procedural time, and complexity associated with the use of a pressure wire. 18…”

Section: Discussionmentioning

confidence: 99%

Pressure-Controlled Intermittent Coronary Sinus Occlusion (PiCSO) in Acute Myocardial Infarction: The PiCSO-AMI-I Trial

De Maria,

Greenwood,

Zaman

et al. 2024

Circ: Cardiovascular Interventions

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BACKGROUND: Primary percutaneous coronary intervention (pPCI) has improved clinical outcomes in patients with ST-segment-elevation myocardial infarction. However, as many as 50% of patients still have suboptimal myocardial reperfusion and experience extensive myocardial necrosis. The PiCSO-AMI-I trial (Pressure-Controlled Intermittent Coronary Sinus Occlusion-Acute Myocardial Infarction-I) evaluated whether PiCSO therapy can further reduce myocardial infarct size (IS) in patients undergoing pPCI. METHODS: Patients with anterior ST-segment–elevation myocardial infarction and Thrombolysis in Myocardial Infarction flow 0-1 were randomized at 16 European centers to PiCSO-assisted pPCI or conventional pPCI. The PiCSO Impulse Catheter (8Fr balloon-tipped catheter) was inserted via femoral venous access after antegrade flow restoration of the culprit vessel and before proceeding with stenting. The primary end point was the difference in IS (expressed as a percentage of left ventricular mass) at 5 days by cardiac magnetic resonance. Secondary end points were the extent of microvascular obstruction and intramyocardial hemorrhage at 5 days and IS at 6 months. RESULTS: Among 145 randomized patients, 72 received PiCSO-assisted pPCI and 73 conventional pPCI. No differences were observed in IS at 5 days (27.2%±12.4% versus 28.3%±11.45%; P =0.59) and 6 months (19.2%±10.1% versus 18.8%±7.7%; P =0.83), nor were differences between PiCSO-treated and control patients noted in terms of the occurrence of microvascular obstruction (67.2% versus 64.6%; P =0.85) or intramyocardial hemorrhage (55.7% versus 60%; P =0.72). The study was prematurely discontinued by the sponsor with no further clinical follow-up beyond 6 months. However, up to 6 months of PiCSO use appeared safe with no device-related adverse events. CONCLUSIONS: In this prematurely discontinued randomized trial, PiCSO therapy as an adjunct to pPCI did not reduce IS when compared with conventional pPCI in patients with anterior ST-segment–elevation myocardial infarction. PiCSO use was associated with increased procedural time and contrast but no increase in adverse events up to 6 months. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03625869.

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“…This is certainly a limiting factor towards a broader implementation of IMR in pPCI as it requires additional procedural time, costs, and procedural risks. Various versions of angiography-derived IMR have been proposed in recent years, all showing good diagnostic accuracy in detecting an abnormal IMR (comparable to its invasive counterpart), and good correlations with clinical outcomes and MVO detection using cMRI in STEMI patients [134,135]. More recently, angiography-derived IMR (namely, IMR angio ) has shown a 98% negative predictive value in ruling out the occurrence of in-hospital and 30-day adverse events in STEMI patients, configuring itself as a promising tool to non-invasively risk-stratify STEMI patients [136].…”

Section: Coronary No-reflow: How To Diagnose It?mentioning

confidence: 99%

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction—What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

Zuccarelli,

Andreaggi,

Walsh

et al. 2024

JCM

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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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Angiography-Derived and Sensor-Wire Methods to Assess Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction

Cited by 12 publications

References 63 publications

Angiography-Derived Index of Microcirculatory Resistance to Define the Risk of Early Discharge in STEMI

Angiography-Derived Index of Microcirculatory Resistance to Define the Risk of Early Discharge in STEMI

Pressure-Controlled Intermittent Coronary Sinus Occlusion (PiCSO) in Acute Myocardial Infarction: The PiCSO-AMI-I Trial

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction—What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

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