European Radiology

, Volume 29, Issue 2, pp 941–950 | Cite as

Microvascular perfusion in infarcted and remote myocardium after successful primary PCI: angiographic and CMR findings

  • Anne BethkeEmail author
  • Limalanathan Shanmuganathan
  • Geir Øystein Andersen
  • Jan Eritsland
  • David Swanson
  • Nils Einar Kløw
  • Pavel Hoffmann



The aim of this study was to investigate the association between TIMI myocardial perfusion (TMP) grading acute and cardiac magnetic resonance (CMR) first-pass perfusion early and at 4 months in patients with ST-segment-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI).

Material and methods

One hundred ninety-eight STEMI patients were recruited from the POSTEMI study. TMP grade was assessed after PCI; CMR was performed at day 2 and after 4 months. Signal intensity was measured on first-pass perfusion images, and a maximum contrast enhancement index (MCE) was calculated.


Patients with TMP grade 2-3 (n = 108) after PCI had significantly better EF (59 ± 10 vs. 51 ± 13, p < 0.001) and smaller infarct volume (12 ± 8 vs. 19 ± 12 %, p < 0.001) at 4 months compared with patients with TMP grade 0-1 (n = 81). MCE in the infarcted (MCEi) and remote myocardium (MCEr) improved from early to follow-up CMR, MCEi from 94 ± 56 to 126 ± 59, p < 0.001, and MCEr from 112 ± 51 to 127 ± 50, p < 0.001. In patients with the lowest CMR perfusion early, perfusion at 4 months remained decreased compared with the other groups, MCEi 108 ± 75 vs. 133 ± 51, p = 0.01, and MCEr 115 ± 41 vs. 131 ± 52, p = 0.047.


TMP grade and early CMR first-pass perfusion were associated with CMR outcomes at 4 months. First-pass perfusion improved after 4 months in the infarcted and remote myocardium. However, in patients with the lowest CMR perfusion early, perfusion was still reduced after 4 months.

Key Points

• Cardiac magnetic resonance myocardial first-pass perfusion and TMP grading after successful PCI helps to assess risk in patients with ST elevation myocardial infarction.

• Cardiac magnetic resonance myocardial first-pass perfusion shows that microvascular perfusion after ST elevation myocardial infarction can be impaired in both infarcted and non-infarcted myocardium.

• Microvascular perfusion improves over time in patients with ST elevation myocardial infarction treated with primary PCI.


ST elevation myocardial infarction Magnetic resonance imaging Myocardial reperfusion Percutaneous coronary intervention 



Area at risk


Cardiac magnetic resonance




End-diastolic volume


Ejection fraction


End-systolic volume


Infarct related artery


Late gadolinium enhancement


Myocardial “blush” grade


Maximum contrast enhancement index


MCE in the infarcted myocardium


MCE in the remote myocardium


Percutaneous coronary intervention


Postconditioning in STEMI study


Signal intensity


Thrombolysis in myocardial infarction


TIMI myocardial perfusion


Time to peak contrast enhancement



The authors thank the radiographers and staff of the Department of Cardiology and Radiology at the Oslo University Hospital, Ullevål.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Pavel Hoffmann.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors, David Swanson, has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Several articles on the cohort of patients included in the POSTEMI trial have been published [1-5]. The results reported were mainly clinical and biochemical endpoints. CMR results reported were infarct size, left ventricular function, microvascular obstruction, area at risk and myocardial salvage. Data on CMR first-pass perfusion have not been published yet.

1. Limalanathan S, Eritsland J, Andersen GO, Klow NE, Abdelnoor M, Hoffmann P (2013) Myocardial salvage is reduced in primary PCI-treated STEMI patients with microvascular obstruction, demonstrated by early and late CMR. PLoS One 8 (8):e71780. doi:10.1371/journal.pone.0071780

2. Limalanathan S, Andersen GO, Klow NE, Abdelnoor M, Hoffmann P, Eritsland J (2014) Effect of ischemic postconditioning on infarct size in patients with ST-elevation myocardial infarction treated by primary PCI results of the POSTEMI (POstconditioning in ST-Elevation Myocardial Infarction) randomized trial. J Am Heart Assoc 3 (2):e000679. doi:10.1161/JAHA.113.000679

3. Limalanathan S, Eritsland J, Klow NE, Abdelnoor M, Hoffmann P, Andersen GO (2015) Influence of ischemic postconditioning on myocardial dysfunction measured by speckle tracking echocardiography in patients with ST-elevation myocardial infarction. Int J Cardiol 187:459-461. doi:10.1016/j.ijcard.2015.03.192

4. Shetelig C, Limalanathan S, Eritsland J, Hoffmann P, Seljeflot I, Gran JM, Aukrust P, Ueland T, Andersen GO (2017) Osteoprotegerin levels in ST-elevation myocardial infarction: Temporal profile and association with myocardial injury and left ventricular function. PLoS One 12 (3):e0173034. doi:10.1371/journal.pone.0173034

5. Ritschel V, Shetelig C, Seljeflot I, Limalanathan S, Hoffmann P, Halvorsen S, Arnesen H, Eritsland J, Andersen GO (2017) Evaluation of circulating levels of CCN2/connective tissue growth factor in patients with ST-elevation myocardial infarction. Sci Rep 7 (1):11945. doi:10.1038/s41598-017-12372-w


• prospective

• randomized controlled trial

• performed at one institution


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of Radiology and Nuclear MedicineDivision of Diagnostics and InterventionOsloNorway
  2. 2.Institute for Clinical MedicineUniversity of OsloOsloNorway
  3. 3.Feiring Heart ClinicFeiringNorway
  4. 4.Department of CardiologyOslo University HospitalUllevålNorway
  5. 5.Institute of Basic Medical Sciences, Department of BiostatisticsUniversity of OsloOsloNorway
  6. 6.Department of Cardiology, Section for Interventional CardiologyOslo University HospitalUllevålNorway

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