Recurrent MI is common in patients with coronary artery disease and associates with high mortality. Here we developed a surgical mouse model in which two subsequent MIs affect different left ventricular regions in the same mouse. Recurrent MI was induced by ligating the left circumflex followed by the left anterior descending branch of the coronary artery. We characterized the resulting ischemia by whole-heart fluorescent coronary angiography after optical organ clearing and by cardiac MRI. We report that a first MI induces bone marrow "memory" via a circulating signal, thereby affecting hematopoietic factor expression in bone marrow macrophages. This altered the organism's reaction to subsequent events. Inspite at least similar extent of injury reported by blood troponin, recurrent MI caused reduced emergency hematopoiesis and less leukocytosis than a first MI. Consequently, fewer leukocytes migrated to the ischemic myocardium. The hematopoietic response to lipopolysaccharide was also mitigated after a previous MI. Our data suggest that hematopoietic and innate immune responses are shaped by a preceding MI. ! 2 ! 3 ! 4 S. Cremer and M.J. Schloss developed and validated the mouse model of recurrent MI. C. Vinegoni developed fluorescent coronary angiography. S. Cremer, M.J. Schloss, S. Zhang, D. Rohde and C.Vinegoni performed experiments and collected, analyzed and discussed data. G. Wojtkiewicz and S. Schmitt performed imaging experiments and collected data. S. Cremer, F. Swirski and M. Nahrendorf conceived experiments and discussed results and strategy. M. Nahrendorf conceived, designed and directed the study. S. Cremer and M. Nahrendorf wrote the manuscript, which was revised and approved by all authors. ! 13 ! 28 Supplementary Figure 2. HSPC numbers 10 days after MI. (A) Experimental outline. Mice had LAD MI 10 days before bone marrow analysis. (B) Dot plots and (C) quantification of HSPC in bone marrow of mice with MI compared to naive mice. (D) Numbers of mature leukocytes in bone marrow. *p<0.05, n=5 Student's t-test. Data are mean ± s.e.m.. ! 29 Supplementary Figure 3. Troponin after a first versus recurrent MI. (A) Experimental design. (B) Troponin levels after LAD ligation as the first compared to recurrent MI. n=5-9. ! 30 Supplementary Figure 4. Macrophage gating. (A) Gating strategy for bone marrow macrophages with antibody directed against F4/80 and (B) isotype control. (C) Histograms in red depicting the expression of MHCII, Cx3cr1, CD169 and Vcam1 in Gr1 hi monocytes and bone marrow macrophages. Isotype controls are shown in blue. ! 31 Supplementary Video 1: MRI short axis cine loop of LCX infarct. Delayed enhancement MRI short axis views of a mouse with LCX MI demonstrating injury of posterolateral left ventricular wall. Supplementary Video 2: MRI short axis cine loop after recurrent MI (LCX followed by LAD ligation). Delayed enhancement MRI short axis views of the same mouse as in supplementary video 1, now also showing injury of the anterior left ventricular wall.! 32