Methodist Journal

FEATURED GUEST EDITOR

ISSUE INTRO

The Burgeoning Field of Cardio-Oncology

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RECOGNITIONS

Barry H. Trachtenberg Leads Issue on Cardio-Oncology

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REVIEW ARTICLES See More

Heart Failure in Relation to Anthracyclines and Other Chemotherapies

Heart Failure in Relation to Tumor-Targeted Therapies and Immunotherapies

The Role of Cardiovascular Imaging and Serum Biomarkers in Identifying Cardiotoxicity Related to Cancer Therapeutics

Prevention and Treatment of Chemotherapy-Induced Cardiotoxicity

Cardiovascular Toxicities of Radiation Therapy

Electrophysiologic Complications in Cancer Patients

Vascular Toxicity in Patients with Cancer: Is There a Recipe to Clarify Treatment?

Future Directions in Cardio-Oncology

CASE REPORTS See More

A Rare Case of Pancreatitis-Induced Thrombosis of the Aorta and Superior Mesenteric Artery

Anomalous Origin of the Right Coronary Artery from the Left Main Coronary Artery in the Setting of Critical Bicuspid Aortic Valve Stenosis

Simultaneous Transfemoral Mitral and Tricuspid Valve in Ring Implantation: First Case Report with Edwards Sapien 3 Valve

Uneventful Follow-Up 2 Years after Endovascular Treatment of a High Flow Iatrogenic Aortocaval Fistula Causing Pulmonary Hypertension and Right Heart Failure

MUSEUM OF HMH MULTIMODALITY IMAGING CENTER See More

Do Not Pass Flow: Microvascular Obstruction on Cardiac Magnetic Resonance After Reinfarction Following Primary Percutaneous Coronary Intervention

CLINICAL PERSPECTIVES See More

EXCERPTA

Cardio-Oncology, Then and Now: An Interview with Barry Trachtenberg

POINTS TO REMEMBER

Onconephrology: An Evolving Field

POINTS TO REMEMBER

Herbal Nephropathy

EXCERPTA

Rolling the Dice on Red Yeast Rice

EDITORIALS

Letter to the Editor in Response to “Cardiac Autonomic Neuropathy in Diabetes Mellitus”

Vol 15, Issue 4 (2019)

Article Full Text

MUSEUM OF HMH MULTIMODALITY IMAGING CENTER

Do Not Pass Flow: Microvascular Obstruction on Cardiac Magnetic Resonance After Reinfarction Following Primary Percutaneous Coronary Intervention

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Article Citation:

Al-Sabeq B, Bontiff C, Nabi F. Do Not Pass Flow: Microvascular Obstruction on Cardiac Magnetic Resonance after Reinfarction Following Primary Percutaneous Coronary Intervention. Methodist DeBakey Cardiovasc J. 2019;15(4):303-4.



Keywords
no reflow , cardiac magnetic resonance , microvascular obstruction , late gadolinium enhancement

CASE PRESENTATION

A 69-year-old man with a history of coronary artery bypass presented to the emergency department with ischemic chest pain. Initial surface electrocardiography (ECG) revealed an acute inferolateral ST elevation myocardial infarction. The patient received emergent primary percutaneous coronary intervention (PCI) with a drug-eluting stent to a proximally occluded posterolateral branch of a large dominant right coronary artery (RCA). Reperfusion was successful (Figure 1 A), and his symptoms resolved. Nine hours later, he returned to the cardiac catheterization laboratory due to recurrent chest pain and more pronounced inferolateral ST elevations on ECG. He was found to have an acute reinfarction, with an occluded RCA just proximal to the stented artery and a high thrombus burden along the entire vessel (Figure 1 B). Percutaneous intervention was unsuccessful, and he was not deemed to be an appropriate candidate for repeat surgical revascularization.

Figure 1. Coronary angiograms in right anterior oblique projections demonstrate (A) successful perfusion of a culprit right posterolateral branch artery immediately after primary percutaneous coronary intervention, and (B) occlusion of the right coronary artery shortly thereafter. The coronary stent is visible (asterisk).

Cardiac magnetic resonance (CMR) imaging for viability 6 days after his initial procedure revealed characteristic findings of microvascular obstruction in the basal to mid-inferior wall. Specifically, imaging after gadolinium-based contrast injection during late inversion recovery sequences showed a hypoenhanced zone within a full-thickness transmural infarct (Figure 2). There were two characteristics that differentiated it from a thrombus: (1) it was confined within the myocardium, and (2) the hypoenhancement on repeat imaging decreased over time from contrast administration, with gradual penetration of contrast into the damaged microvasculature.

Figure 2. Phase-sensitive inversion recovery cardiac magnetic resonance applied to late gadolinium enhancement in (A) short axis midpapillary, (B) 2-chamber, and (C) 3-chamber views demonstrate hypoenhanced inferior and inferolateral microvascular obstruction zones (asterisks) surrounded by hyperenhanced infarct (arrowheads).

Microvascular obstruction is characterized by damage and dysfunction of the myocardial microvasculature, resulting in a “no-reflow” phenomenon in which blood flow cannot penetrate beyond the myocardial capillary bed.1 CMR is currently considered the superior noninvasive imaging modality for detecting microvascular obstruction. More than half of STEMI patients successfully reperfused with PCI have been shown to have microvascular obstruction.2 Its ominous prognostic significance as a predictor of adverse left ventricular remodeling, major adverse cardiac events, and cardiac death incremental to infarct size is well established.2,3

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