Skip to main content
SpringerLink
Log in

Imaging microvascular obstruction and its clinical significance following acute myocardial infarction

  • Published:
Heart Failure Reviews Aims and scope Submit manuscript

Abstract

Obstruction of the coronary microvasculature contributes to the pathophysiology of MI and adversely affects post-MI recovery. This “no-reflow” phenomenon resulting from microvascular obstruction is an indicator of lack of adequate tissue perfusion within the infarcted myocardium, even after restoration of epicardial blood flow. Regions of microvascular obstruction can be detected and quantifed because of rapid advances in and refinement of imaging technologies over the past decade. This article focuses on the non-invasive imaging modalities used to assess MO, discusses the prognostic implications of MO, and briefly addresses strategies for reducing MO.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med 1980;303:897–902.

    Article  PubMed  CAS  Google Scholar 

  2. GISSI-2: a factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12,490 patients with acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico. Lancet 1990;336(8707):65–71.

    Google Scholar 

  3. ISIS-3: a randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin plus heparin vs aspirin alone among 41,299 cases of suspected acute myocardial infarction. ISIS-3 (Third International Study of Infarct Survival) Collaborative Group. Lancet 1992;339(8796):753–70.

    Google Scholar 

  4. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators. N Engl J Med 1993;329(22):1615–22.

    Google Scholar 

  5. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361(9351):13–20.

    Article  PubMed  Google Scholar 

  6. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. N Engl J Med 1999;341:1949–56.

    Article  PubMed  CAS  Google Scholar 

  7. Ito H, Tomooka T, Sakai N, et al. Lack of myocardial perfusion immediately after successful thrombolysis: a predictor of poor recovery of left ventricular function in anterior myocardial infarction. Circulation 1992;85:1699–1705.

    PubMed  CAS  Google Scholar 

  8. Ito H, Maruyama A, Iwakura K, et al. Clinical implications of the “no reflow” phenomenon: a predictor of complications and left ventricular remodeling in reperfused anterior wall myocardial infarction. Circulation 1996;93:223–28.

    PubMed  CAS  Google Scholar 

  9. Johnson TL, Topol EJ. Early, Complete Infarct Vessel Patency: Arriving at a Gold Standard for Future Clinical Investigation in Myocardial Reperfusion. J Thromb Thrombolysis 1997;4(2):259–66.

    Article  PubMed  Google Scholar 

  10. Wu KC, Zerhouni EA, Judd RM, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 1998;97:765–72.

    PubMed  CAS  Google Scholar 

  11. Morishima I, Sone T, Okumura K, et al. Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol 2000;36:1202–9.

    Article  PubMed  CAS  Google Scholar 

  12. Topol EJ, Yadav JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation 2001;101:570–80.

    Google Scholar 

  13. Roe MT, Ohman EM, Maas AC, et al. Shifting the open-artery hypothesis downstream: the quest for optimal reperfusion. J Am Coll Cardiol 2001;37(1):9–18.

    Article  PubMed  CAS  Google Scholar 

  14. Hombach V, Grebe O, Merkle N, et al. Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging. Eur Heart J 2005;26:549–57.

    Article  PubMed  Google Scholar 

  15. Kramer CM. The prognostic significance of microvascular obstruction after myocardial infarction as defined by cardiovascular magnetic resonance. Eur Heart J 2005;26:532–3.

    Article  PubMed  Google Scholar 

  16. Costantini CO, Stone GW, Mehran R, et al. Frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty and stenting, with and without glycoprotein IIb/IIIa inhibition, in acute myocardial infarction. J Am Coll Cardiol 2004;44(2):305–12.

    Article  PubMed  Google Scholar 

  17. Kloner RA, Ganote CE, Jennings RB. The “no-reflow” phenomenon after temporary coronary occlusion in the dog. J Clin Invest 1974;54:1496–1508.

    PubMed  CAS  Google Scholar 

  18. Rochitte CE, Lima JA, Bluemke DA, et al. Magnitude and time course of microvascular obstruction and tissue injury after acute myocardial infarction. Circulation 1998;98:1006–14.

    PubMed  CAS  Google Scholar 

  19. Wu KC, Kim RJ, Bluemke DA, et al. Quantification and time course of microvascular obstruction by contrast-enhanced echocardiography and magnetic resonance imaging following acute myocardial infarction and reperfusion. J Am Coll Cardiol 1998;32:1756–64.

    Article  PubMed  CAS  Google Scholar 

  20. Tarantini G, Cacciavillani L, Corbetti F, et al. Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: a study performed with contrast-enhanced magnetic resonance. J Am Coll Cardiol 2005;46(7):1229–35.

    Article  PubMed  Google Scholar 

  21. Steen H, Lehrke S, Wiegand UK, et al. Very early cardiac magnetic resonance imaging for quantification of myocardial tissue perfusion in patients receiving tirofiban before percutaneous coronary intervention for ST-elevation myocardial infarction. Am Heart J 2005;149(3):564.

    Article  PubMed  Google Scholar 

  22. Choi CJ, Haji-Momenian S, Dimaria JM, et al. Infarct involution and improved function during healing of acute myocardial infarction: the role of microvascular obstruction. J Cardiovasc Magn Reson 2004;6(4):917–25.

    Article  PubMed  Google Scholar 

  23. Sakuma T, Hayashi Y, Sumii K, et al. Prediction of short- and intermediate-term prognoses of patients with acute myocardial infarction using myocardial contrast echocardiography one day after recanalization. J Am Coll Cardiol 1998;32:890–97.

    Article  PubMed  CAS  Google Scholar 

  24. Bolognese L, Carrabba N, Parodi G, et al. Impact of microvascular dysfunction on left ventricular remodeling and long-term clinical outcome after primary coronary angioplasty for acute myocardial infarction. Circulation 2004;109:1121–26.

    Article  PubMed  Google Scholar 

  25. Kloner RA, Rude RE, Carlson N, et al. Ultrastructural evidence of microvascular damage and myocardial cell injury after coronary artery occlusion: which comes first? Circulation 1980;62(5):945–52.

    PubMed  CAS  Google Scholar 

  26. Braunwald E, Kloner RA. Myocardial reperfusion: a double-edged sword? J Clin Invest 1985;76(5):1713–19.

    Article  PubMed  CAS  Google Scholar 

  27. Gibson CM, Ryan KA, Murphy SA, et al. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction. J Am Coll Cardiol 1999;34(4):974–82.

    Article  PubMed  CAS  Google Scholar 

  28. The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J Med 1985;312(14):932–36.

    Google Scholar 

  29. Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 1996;93(5):879–88.

    PubMed  CAS  Google Scholar 

  30. Gibson CM, Cannon CP, Murphy SA, et al. Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation 2000;101(2):125–30.

    PubMed  CAS  Google Scholar 

  31. van ’t Hof AW, Liem A, Suryapranata H, et al. 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(23):2302–6.

    PubMed  Google Scholar 

  32. Iwakura K, Ito H, Takiuchi S, et al. Alternation in the coronary blood flow velocity pattern in patients with no reflow and reperfused acute myocardial infarction. Circulation 1996;94(6):1269–75.

    PubMed  CAS  Google Scholar 

  33. Yamamoto K, Ito H, Iwakura K, et al. Two different coronary blood flow velocity patterns in thrombolysis in myocardial infarction flow grade 2 in acute myocardial infarction: insight into mechanisms of microvascular dysfunction. J Am Coll Cardiol 2002;40(10):1755–60.

    Article  PubMed  Google Scholar 

  34. Morishima I, Sone T, Mokuno S, et al. Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty. Am Heart J 1995;130:239–43.

    Article  PubMed  CAS  Google Scholar 

  35. Piana RN, Paik GY, Moscucci M, et al. Incidence and treatment of ‘no-reflow’ after percutaneous coronary intervention. Circulation 1994;89(6):2514–18.

    PubMed  CAS  Google Scholar 

  36. Kemper AJ, O’Boyle JE, Cohen CA, et al. Hydrogen peroxide contrast echocardiography: quantification in vivo of myocardial risk area during coronary occlusion and of the necrotic area remaining after myocardial reperfusion. Circulation 1984;70(2):309–17.

    PubMed  CAS  Google Scholar 

  37. Janardhanan R, Dwivedi G, Hayat S, et al. Myocardial contrast echocardiography: a new tool for assessment of myocardial perfusion. Indian Heart J 2005;57(3):210–16.

    PubMed  Google Scholar 

  38. Villanueva FS. Myocardial contrast echocardiography in acute myocardial infarction. Am J Cardiol 2002;90(10A):38J–47J.

    Article  PubMed  Google Scholar 

  39. Iwakura K, Ito H, Kawano S, et al. Predictive factors for development of the no-reflow phenomenon in patients with reperfused anterior wall acute myocardial infarction. J Am Coll Cardiol 2001;38(2):472–77.

    Article  PubMed  CAS  Google Scholar 

  40. Porter TR, Li S, Oster R, et al. The clinical implications of no reflow demonstrated with intravenous perfluorocarbon containing microbubbles following restoration of Thrombolysis In Myocardial Infarction (TIMI) 3 flow in patients with acute myocardial infarction. Am J Cardiol 1998;82(10):1173–77.

    Article  PubMed  CAS  Google Scholar 

  41. Lima JA, Judd RM, Bazille A, et al. Regional heterogeneity of human myocardial infarcts demonstrated by contrast-enhanced MRI: potential mechanisms. Circulation 1995;92:1117–25.

    PubMed  CAS  Google Scholar 

  42. Judd RM, Lugo-Olivieri CH, Arai M KT, et al. Physiological basis of myocardial contrast enhancement in fast magnetic resonance images of 2-day-old reperfused canine infarcts. Circulation 1995;92:1902–10.

    PubMed  CAS  Google Scholar 

  43. Kim RJ, Chen EL, Lima JA, et al. Myocardial Gd-DTPA kinetics determine MRI contrast enhancement and reflect the extent and severity of myocardial injury after acute reperfused infarction. Circulation 1996;94(12):3318–26.

    PubMed  CAS  Google Scholar 

  44. Fieno DS, Kim RJ, Chen EL, et al. Contrast-enhanced magnetic resonance imaging of myocardium at risk: distinction between reversible and irreversible injury throughout infarct healing. J Am Coll Cardiol 2000;36(6):1985–91.

    Article  PubMed  CAS  Google Scholar 

  45. Gibson CM, Cannon CP, Murphy SA, et al. Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 2002;105(16):1909–13.

    Article  PubMed  Google Scholar 

  46. Henriques JP, Zijlstra F, van ’t Hof AW, et al. Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade. Circulation 2003;107(16):2115–9.

    Article  PubMed  Google Scholar 

  47. Gerber BL, Rochitte CE, Melin JA, et al. Microvascular obstruction and left ventricular remodeling early after acute myocardial infarction. Circulation 2000;101:2734–41.

    PubMed  CAS  Google Scholar 

  48. Gorog DA, Foale RA, Malik I. Distal myocardial protection during percutaneous coronary intervention: when and where? J Am Coll Cardiol 2005;46(8):1434–45.

    Article  PubMed  Google Scholar 

  49. Neumann FJ, Blasini R, Schmitt C, et al. Effect of glycoprotein IIb/IIIa receptor blockade on recovery of coronary flow and left ventricular function after the placement of coronary-artery stents in acute myocardial infarction. Circulation 1998;98(24):2695–2701.

    PubMed  CAS  Google Scholar 

  50. Montalescot G, Barragan P, Wittenberg O, et al. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001;344(25):1895–1903.

    Article  PubMed  CAS  Google Scholar 

  51. Kunichika H, Ben-Yehuda O, Lafitte S, et al. Effects of glycoprotein IIb/IIIa inhibition on microvascular flow after coronary reperfusion: a quantitative myocardial contrast echocardiography study. J Am Coll Cardiol 2004;43:276–83.

    Article  PubMed  CAS  Google Scholar 

  52. Ito H, Taniyama Y, Iwakura K, et al. Intravenous nicorandil can preserve microvascular integrity and myocardial viability in patients with reperfused anterior wall myocardial infarction. J Am Coll Cardiol 1999;33:654–60.

    Article  PubMed  CAS  Google Scholar 

  53. Sugimoto K, Ito H, Iwakura K, et al. Intravenous nicorandil in conjunction with coronary reperfusion therapy is associated with better clinical and functional outcomes in patients with acute myocardial infarction. Circ J 2003;67:295–300.

    Article  PubMed  CAS  Google Scholar 

  54. Klein LW, Kern MJ, Berger P, et al. Society of cardiac angiography and interventions: suggested management of the no-reflow phenomenon in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2003;60(2):194–201.

    Article  PubMed  Google Scholar 

  55. Ross AM, Gibbons RJ, Stone GW, et al. A randomized, double-blinded, placebo-controlled multicenter trial of adenosine as an adjunct to reperfusion in the treatment of acute myocardial infarction (AMISTAD-II). J Am Coll Cardiol 2005;45(11):1775–80.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Case Western Reserve University School of Medicine, Cleveland, OH

    Albert K. Luo

  2. Division of Cardiology, Department of Medicine, Johns Hopkins, University, 600 N. Wolfe Street/Carnegie 568, Baltimore, MD, 21287

    Katherine C. Wu

Authors
  1. Albert K. Luo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katherine C. Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Katherine C. Wu.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Luo, A.K., Wu, K.C. Imaging microvascular obstruction and its clinical significance following acute myocardial infarction. Heart Fail Rev 11, 305–312 (2006). https://doi.org/10.1007/s10741-006-0231-0

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10741-006-0231-0

Keywords

Search

Navigation