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(Circulation. 2004;109:1121-1126.)
© 2004 American Heart Association, Inc.

Clinical Investigation and Reports

Impact of Microvascular Dysfunction on Left Ventricular Remodeling and Long-Term Clinical Outcome After Primary Coronary Angioplasty for Acute Myocardial Infarction

Leonardo Bolognese, MD, FESC; Nazario Carrabba, MD; Guido Parodi, MD; Giovanni M. Santoro, MD, FESC; Piergiovanni Buonamici, MD; Giampaolo Cerisano, MD; David Antoniucci, MD

From the Division of Cardiology, S. Donato Hospital (L.B.), Arezzo, Italy, and Division of Cardiology, Careggi Hospital (N.C., G.P., G.M.S., P.B., G.C., D.A.), Florence, Italy.

Correspondence to Leonardo Bolognese, MD, FESC, Division of Cardiology, Careggi Hospital, Viale Morgagni, 85, 50134 Florence, Italy. E-mail leonardobolognese{at}hotmail.com

Received October 15, 2002; de novo received September 28, 2003; revision received November 20, 2003; accepted November 25, 2003.

Background— We hypothesized that preserved microvascular integrity in the area at risk would favorably influence left ventricular (LV) remodeling and long-term outcome after acute myocardial infarction.

Methods and Results— Before and after successful primary angioplasty (percutaneous transluminal coronary angioplasty [PTCA]), 124 patients with acute myocardial infarction underwent intracoronary myocardial contrast echo (MCE). An MCE score index (MCESI) was derived by averaging the single-segment score (0=not visible, 1=patchy, 2=homogeneous contrast effect) within the area at risk. An MCESI 1 was considered adequate reperfusion. Mean follow-up was 46±32 months. After PTCA, 100 patients showed adequate reperfusion (no microvascular dysfunction, NoMD), whereas 24 did not (MD). MD patients had a higher mean creatine kinase (4153±2422 versus 2743±1774 U/L; P=0.002) and baseline wall-motion score index (2.61±0.31 versus 2.25±0.42; P<0.001) and a lower baseline ejection fraction (33±8% versus 40±7%; P<0.001). From day 1 on, LV volumes progressively increased in the MD patients (n=19) and were larger than those of NoMD patients (n=85) at 6 months (end-diastolic volume 170±55 versus 115±29 mL; P<0.001). MCESI was the most important independent predictor of LV dilation (OR 0.61, 95% CI 0.52 to 0.71, P<0.000001). By Cox analysis, MD represented the only predictor of cardiac death (OR 0.26, 95% CI 0.09 to 0.72, P=0.010) and combined events (cardiac death, reinfarction, and heart failure; OR 0.44, 95% CI 0.23 to 0.85, P=0.014). MD patients showed worse survival in terms of cardiac death (P<0.0001) and combined events (P<0.0001).

Conclusions— In reperfused acute myocardial infarction, MD within the risk area is an important predictor of both LV remodeling and unfavorable long-term outcome.

Key Words: myocardial infarction • angioplasty • remodeling • survival • microcirculation

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