universitÄt leipzig h e r z z e n t r u m infarct transmurality and infarct size assessed by...
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UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Infarct transmurality and infarct size assessed by delayed enhancement
magnetic resonance imaging: Association with time-to-treatment, ST-
segment resolution, and TIMI-flow grades
Holger Thiele, MD; Axel Linke, MD; Sandra Erbs, MD; Enno Boudriot, MD; Alexander Lebcke, MD;
Dietmar Kivelitz, MD; and Gerhard Schuler, MD
Department of Internal Medicine/Cardiology, University of Leipzig – Heart Center
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Background
• The TIMI flow, ST-segment resolution and time-to-reperfusion are associated with mortality in ST-elevation myocardial infarction (STEMI) after either fibrinolysis or percutaneous coronary intervention. Boersma et al. Lancet 1996;96:771-775De Luca et al. J Am Coll Cardiol 2003; 42:991-997GUSTO-I. N Engl J Med 1993; 329:1615-1623Stone et al. Circulation 2001; 104:636-641de Lemos et al. J Am Coll Cardiol 2001;38:1283-1294
• As a result of excellent spatial resolution delayed enhancement magnetic resonance imaging allows assessment of infarct transmurality and infarct size.Simonetti et al. Radiology 2001;218:215-223
• Whether these clinical, angiographic and ECG measures are also associated with infarct size and infarct transmurality, has not yet been investigated.
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Background
As a consequence of excellent spatial resolution DE-MRI might also allow to assess the assumed “wavefront phenomenon” of myocardial necrosis in humans.
Reimer et al. Circulation 1977;56:786-794
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Hypothesis
We hypothesized that these measures (Time-to-
Reperfusion / ST-Resolution / TIMI-Flow) would also be associated with infarct size and infarct transmurality as assessed by delayed enhancement MRI.
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Patients with Angina (< 6 h) n=164
Methods and Materials: Patients (Leipzig Prehospital Fibrinolysis Study)
Prehospital Fibrinolysis (n=82) Facilitated PCI (n=82)
Lost to 6 month follow-up (n=1)
Primary Endpoint Analysis (Infarct Size) (n=66)Secondary Combined Endpoint Analysis (n=80)
Primary Endpoint Analysis (Infarct Size) (n=69)Secondary Combined Endpoint Analysis (n=79)
Lost to 6-month follow-up (n=0)
Excluded, no infarction (n=2)
Rescue Angioplasty (n=14)
Excluded, no infarction (n=2)
No Stent (n=4) not necessary (n=3) not possible (n=1)
12-lead-ECG STEMI
Exclusion criteria?, Informed consent?
Randomization and hospital assignment (3 PCI, 4 non-PCI-center)
Prehospital combination fibrinolysis ASA 500 mg, Heparin (60IE/kg BW), Abciximab (0.25 mg/kg BW), Reteplase
Double-Bolus 5 U
Thiele H, et al. Eur Heart J 2005; 26:1956-1963
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Methods: MR Image Analysis
Blinded observers:
Manual drawing of endocardial, epicardial, papillarypapillary, and
infarct contours
%Infarct Size = (Volume Infarct/Volume LV mass)
1
2
3
4
5
613
7
12
11
10
9
8
14
15
1617
Transmurality for each segment of 17 segment model:
> 50% transmurality
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Methods Patient Stratification
135 Patients
3 Groups:Defined by Tertile Symptom-Treatment-Interval
Lower Tertile (<120 min)
Middle Tertile (120-240 min)
Upper Tertile (> 240 min)
Median Symptom-Treatment-Time: 118 min.
135 Patients
3 Groups:Defined by ST-Segment Resolution
No ST-Resolution (<30%)
Intermediate ST-Resolution (30-70%)
Complete ST-Resolution (>70%)
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Results: Infarct Size and Transmurality – Time to treatment
0
2
4
6
8
10
12
14
16
18
< 2h 2-4 h > 4h
Infa
rct S
ize
(%L
V)
Prehospital lysis
8.2 (3.0;15.6)
14.3 (6.6;20.9)
14.5 (3.2;21.8)
Facilitated PCI
3.9 (0.9;7.8)
10.3 (1.8;14.5)
12.8 (9.1;18.6)
7.5 (2.5;14.0)
14.0 (5.8;20.5)
13.5 (3.0;17.0)
Infarct size
0
2
4
6
8
10
12
14
16
18
< 2h 2-4 h > 4h
Tra
nsm
ural
ity
Sco
re
5.0 (2.0;8.0)
11.0 (2.3;15.0)
12.0 (11.3;18.3)
Transmurality Score
P<0.001P=0.007
P=0.02 P=0.02
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Results: Infarct Size and Transmurality - ST-Resolution
0
2
4
6
8
10
12
14
16
>70% 70-30% <30%
Infa
rct
size
(%
LV
)
p<0.001
ST-segment resolution
4.2 (1.6; 10.5)
13.6 (8.0; 16.4)12.4 (7.7; 17.9)
0
2
4
6
8
10
12
14
16
>70% 70-30% <30%T
ran
smu
rali
ty S
core
p<0.001
5.0 (2.0; 10.8)
11.0 (8.8; 16.3)
13.0 (8.0; 19.5)
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
0
2
4
6
8
10
12
TIMI 0-I TIMI II-III
Results: Infarct Size and Transmurality -Pre-PCI TIMI-Flow
IS (
% L
V)
p = 0.002
10.8%LV (IQR 7.6; 17.3)
3.9%LV (IQR 0.9; 9.6)
n=69, Facilitated PCI-Group
0
2
4
6
8
10
12
TIMI 0-I TIMI II-IIIT
rans
mur
alit
y S
core
p = 0.003
11.5 (IQR 8.0; 16.5; )
5.0 (IQR 2.0; 9.5)
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
Wavefront Phenomenon - Human Data
Time (min)
20
0 60 120 180 240 300 360
30
40
50
60
70
80
90
1125 13
9
99
6
14
19
20
Prehospital Lysis
Facilitated PCI
Pro
bab
ilit
y T
ran
smu
rali
ty >
50%
(%
)
Time (min)0 60 120 180 240 300 360
80
70
60
50
40
30
20
10
2019
6
14
9
9
91311
25
Prehospital Lysis
Facilitated PCI
Pro
bab
ilit
y In
farc
t S
ize
>10
% (
%)
Each 30 min delay in time-to-treatment 20-25% risk increase transmurality >50%
Each 30 min delay in time-to-treatment 20-25% risk increase infarct size >10%
UNIVERSITÄT LEIPZIG
H E R Z Z E N T R U M
The time from symptom-onset-to-treatment, ST-resolution and pre-PCI TIMI-flow influence the final infarct size and infarct transmurality for either prehospital fibrinolysis or prehospital initiated facilitated PCI.
This finding is in contrast to other studies with a primary PCI approach (STOPAMI 1+2 trial). These differences might be explained by the much shorter time to reperfusion in the current trial (mean 118 min vs. 180-215 min).
A prehospital initiated facilitated PCI approach is superior to prehospital fibrinolysis alone in particular in the early time period after symptom onset.
This underlines the assumed pathophysiological link between early flow restoration and perfusion in the infarct related artery, which is known as the “wavefront phenomenon”.
Summary and Conclusions
Major goal in STEMI treatment is very early complete reperfusion
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