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Microvascular obstruction detected by cardiac MRI after AMI for the prediction of LV remodeling and MACE: A meta-analysis of prospective trials

2015; Elsevier BV; Volume: 202; Linguagem: Inglês

10.1016/j.ijcard.2015.08.197

1874-1754

Jorge Romero, Florentino Lupercio, Juan Carlos Díaz, David Goodman‐Meza, Linda B. Haramati, Jeffrey M. Levsky, Nada Shaban, Ileana L. Piña, Mario J. García,

Advanced MRI Techniques and Applications

The present study represents a meta-analysis of the current literature evaluating the prognostic implication of microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) demonstrated by cardiac magnetic resonance imaging (CMRI) early after acute myocardial infarction (AMI) in predicting left ventricular (LV) adverse remodeling and major adverse cardiovascular events (MACE). We searched PubMed, Embase, and Cochrane Central Register of Clinical Trials. The included studies fulfilled the following criteria: 1) the study had to be prospectively designed; 2) the population was composed of patients who suffered either ST or non-ST elevation AMI; 3) patients underwent coronary reperfusion either with percutaneous coronary intervention (PCI) or pharmacological thrombolysis; 4) patients underwent CMRI with gadolinium to detect MVO and/or IMH; and 5) follow-up duration was at least six months to determine whether MACE and/or participants had repeat CMRI at least 3 months after AMI to assess for adverse remodeling as defined by changes in LV end-systolic volume index (LVESVi) and LV end-diastolic volume index (LVEDVi). Statistical analysis was performed using Review Manager (RevMan), version 5.1.7. Heterogeneity was assessed using the I2 statistics [ [1] Moher D. Liberati A. Tetzlaff J. Altman D.G. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009; 339: b2535 Crossref PubMed Scopus (15207) Google Scholar ]. Data from changes in baseline LVEDVi and LVESVi were combined using the weighted mean difference (WMD) method. Likewise, we calculated the incidence of MACE for all patients using relative risk (RR) ratios and 95% confidence intervals with the use of the Mantel–Haenszel method. Twenty-two studies (Table 1, Table 2) with a total of 2540 patients were included in the analysis. The prognostic yield of MVO and IMH by CMRI for LV adverse remodeling after revascularization was assessed from fourteen studies that enrolled a total of 1116 patients [mean age 56 years (SD = +/−7); male: 84%]. The mean interval between AMI and initial CMRI was 5.4 +/− 2 days with a MVO incidence of 53.6% and a subsequent follow-up imaging evaluation at a mean of 4.9 +/− 2 months after AMI. The mean LV volumes for patients in whom MVO was demonstrated were significantly higher, both initially (LVEDVi = 95 +/− 18 cm3/m2–LVESVi = 56+/−16 cm3/m2) and at follow-up (LVEDVi = 100 +/− 23 cm3/m2–LVESVi = 57 +/− 17 cm3/m2), than those without demonstration of MVO (initial LVEDVi = 80 +/− 18 cm3/m2 and LVESVi = 43 +/− 14 cm3/m2 and follow-up LVEDVi = 81 +/− 18 cm3/m2–LVESVi = 37 +/− 13 cm3/m2). Eight studies evaluated for presence of MVO (Table 1 — Group A). Among this group, the WMD (MVO+ vs. MVO−) in LVEDVi and LVESVi between the initial CMRI after AMI and the follow-up CMRI after at least three months was 8.86 ml/m2 (95% CI = 5.67–12.06, p < 0.00001) and 8.34 ml/m2 (95% CI = 4.30–12.39, p < 0.00001), respectively. Four studies assessed the presence of both MVO and IMH (Table 1 — Group B). The WMD in LVEDVi and LVESVi in this group was 7.49 ml/m2 (95% CI = 3.75–11.23, p < 0.0001) and 5.28 ml/m2 (95% CI: 2.35–8.21 p = 0.0004), respectively. Two studies investigated the prognostic yield of IMH (Table 1 — Group C) and demonstrated a LVEDVi WMD of 12.17 ml/m2 (95% CI = 10.09–14.24, p < 0.00001) and a LVESVi WMD of 9.62 ml/m2 (95% CI = 8.08–11.16, p < 0.00001). The overall WMD for LVEDVi was 8.94 ml/m2 (95% CI = 6.93–10.96, p < 0.00001) whereas for LVESVi was 7.61 ml/m2 (95% CI = 5.36–9.85, p < 0.00001) (Fig. 1). Table 1A. Baseline characteristics of prospective studies evaluating the prognostic yield of MVO and IMH in CMRI for left ventricle adverse remodeling. B. Initial and follow-up LVEDVi and LVESVi for detected and absent "No Reflow" injury by CMRI. A. First author, year Patients Male (%) Age (years) Time after initial CMRI Time after follow-up CMRI CMRI protocol CMRI device ACS type MVO (%) Group A (MVO+) Bekkers et al., 2009 76 71 60 5 days 3 months LGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 59% Bogaert et al., 2007 52 88 55 7 days 4 months EGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 61% Hombach et al., 2005 110 87 60 6 days 8 months LGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 64% Nijveldt et al., 2007 45 87 57 6 days 4 months LGE 1.5 Tesla Siemens Sonata STEMI 58% Nijveldt et al., 2008 60 90 55 6 days 4 months LGE 1.5 Tesla Siemens Sonata STEMI 57% Nijveldt et al., 2009 56 91 55 5 days 4 months LGE 1.5 Tesla Siemens Sonata STEMI 66% Orn et al., 2009 42 82 57 7 days 12 months LGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 36% Weir et al., 2009 87 77 79 4 days 6 months LGE 1.5 Tesla Siemens Sonata STEMI 64% Group B (MVO+/IMH+) Bekkers et al., 2010 90 72 60 5 days 3.5 months LGE and T2W 1.5 Tesla-Intera, Philips Medical Systems STEMI 54% Husser et al., 2013 304 80 58 7 days 6 months LGE and T2W 1.5 Tesla Siemens Sonata STEMI 42% Kidambi et al., 2013 31 96 57 2 days 3 months LGE and T2W 1.5 Tesla-Intera, Philips Medical Systems STEMI 46% Mather et al., 2011 30 90 57 2 days 3 months EGE and T2W 1.5 Tesla-Philips Medical Systems STEMI 63% Group C (IMH+) Beek et al., 2010 45 89 57 7 days 4 months LGE and T2W 1.5 Tesla Siemens Sonata STEMI 60% Ganame et al., 2009 98 83 60 7 days 4 months EGE and T2W 1.5 Tesla-Intera, Philips Medical Systems STEMI NR* Abbreviations: ACS: acute coronary syndrome, CMRI: cardiac magnetic resonance imaging, EGE: early gadolinium enhancement, IMH: intramyocardial hemorrhage, MVO: microvascular obstruction, LGE: late gadolinium enhancement, T2W: T2-weighted, STEMI: ST elevation myocardial infarction, *NR: no reported. B. First author, year "No Reflow" injury detected "No Reflow" injury absent Initial LVEDVi Follow–up LVEDVi Initial LVESVi Follow-up LVESVi Initial LVEDVi Follow-up LVEDVi Initial LVESVi Follow-up LVESVi Group A (MVO+) Bekkers et al., 2009 86 +/− 12 84 +/− 22 NR* NR* 81 +/− 14 76 +/− 17 NR* NR* Bogaert et al., 2007 83 +/− 15 89 +/− 22 45 +/− 11 48 +/− 17 80 +/− 10 75 +/− 13 39 +/− 7 24 +/− 13 Hombach et al., 2005 82 +/− 20 84 +/− 21 38 +/− 16 34 +/− 15 79 +/− 17 78 +/− 18 32 +/− 12 27 +/− 11 Nijveldt et al., 2007 103 +/− 23 107 +/− 33 64 +/− 22 66 +/− 28 92 +/− 27 87 +/− 23 50 +/− 21 45 +/− 18 Nijveldt et al., 2008 106 +/− 22 113 +/− 27 64 +/− 22 68 +/− 24 90 +/− 25 85 +/− 24 50 +/− 19 43 +/− 17 Nijveldt et al., 2009 107 +/− 21 116 +/− 30 65 +/− 20 69 +/− 13 92 +/− 27 87 +/− 24 51 +/− 21 44 +/− 9 Orn et al., 2009 95 +/− 3 101 +/− 7 55 +/− 3 53 +/− 6 79 +/− 5 75 +/− 5 40 +/− 4 29 +/− 4 Weir et al., 2009 84 +/− 17 93 +/− 15 44 +/− 13 48 +/− 13 84 +/− 21 81 +/− 16 43 +/− 19 36 +/− 13 Group B (MVO+/IMH+) Bekkers et al., 2010 88 +/− 17 88 +/− 20 47 +/− 13 45 +/− 15 81 +/− 14 78 +/− 18 38 +/− 11 34 +/− 12 Husser et al., 2013 91 +/− 27 94 +/− 24 53 +/− 23 54 +/− 22 75 +/− 21 70 +/− 16 34 +/− 17 29 +/− 10 Kidambi et al., 2013 93 +/− 22 100 +/− 27 58 +/− 20 59 +/− 23 84 +/− 14 85 +/− 19 47 +/− 14 42 +/− 17 Mather et al., 2011 102 +/− 13 112 +/− 21 69 +/− 11 68 +/− 18 85 +/− 15 82 +/− 18 47 +/− 14 39 +/− 15 Group C (IMH+) Beek et al., 2010 104 +/− 22 111 +/− 29 65 +/− 19 67 +/− 24 89 +/− 22 83 +/− 22 49 +/− 17 43 +/− 15 Ganame et al., 2009 100 +/− 18 114 +/− 21 59 +/− 13 67 +/− 6 27 +/− 17 89 +/− 20 44 +/− 12 42 +/− 13 Abbreviations: CMRI: cardiac magnetic resonance imaging, IMH: intramyocardial hemorrhage, MVO: microvascular obstruction, LVEDVi: left ventricle end diastolic volume index, LVESVi: left ventricle end systolic volume index, *NR: not reported. Open table in a new tab Table 2Baseline characteristics of prospective studies evaluating the prognostic yield of MVO and IMH detected in CMRI for MACE. First author, year Patients Male (%) Age (years) Time for initial CMRI Time for MACE follow-up CMRI protocol CMRI device ACS type MVO (%) Group A (MVO+) Bodi et al., 2009 214 84 57 7 days 12 months LGE 1.5 Tesla Siemens Sonata Magnetom STEMI 72% Cochet et al., 2009 184 77 61 5 days 12 months LGE 1.5 Tesla Siemens Sonata Magnetom STEMI 47% Cochet et al., 2010 61 77 63 5 days 12 months LGE 3 Tesla-Imager, Trio TIM Siemens NSTEMI 17% de Waha et al., 2010 408 75 65 3 days 19 months LGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 72% Hombach et al., 2005 110 86 59 6 days 7 months LGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 46% Klug et al., 2012 107 81 56 8 days 36 months EGE 1.5 Tesla-Intera, Philips Medical Systems STEMI 69% Wu et al., 1998 44 75 58 10 days 16 months EGE 1.5 Tesla-Signa, General Electric. STEMI 25% Group B (MVO+/IMH+) Amabile et al., 2011 60 83 58 6 days 12 months LGE and T2W 1.5 Tesla-Symphony TIM, Siemens. STEMI 56% Eitel et al., 2011 346 74 64 3 days 6 months LGE and T2W 1.5 Tesla-Intera, Philips Medical Systems STEMI 66% Husser et al., 2013 304 80 58 7 days 35 months LGE and T2W 1.5 Tesla Siemens Sonata STEMI 42% Abbreviations: ACS: acute coronary syndrome, CMRI: cardiac magnetic resonance imaging, EGE: early gadolinium enhancement, IMH: intramyocardial hemorrhage, MVO: microvascular obstruction, LGE: late gadolinium enhancement, NSTEMI: non-ST elevation myocardial infarction, T2W: T2-weighted, STEMI: ST elevation myocardial infarction. Open table in a new tab Abbreviations: CMRI: cardiac magnetic resonance imaging, IMH: intramyocardial hemorrhage, MVO: microvascular obstruction, LVEDVi: left ventricle end diastolic volume index, LVESVi: left ventricle end systolic volume index, *NR: not reported. Abbreviations: ACS: acute coronary syndrome, CMRI: cardiac magnetic resonance imaging, EGE: early gadolinium enhancement, IMH: intramyocardial hemorrhage, MVO: microvascular obstruction, LGE: late gadolinium enhancement, NSTEMI: non-ST elevation myocardial infarction, T2W: T2-weighted, STEMI: ST elevation myocardial infarction.