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Number 09-12: Role of CMR in acute myocardial infarction, primary angioplasty, and autologous stem c
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Number 09-12: Role of CMR in acute myocardial infarction, primary angioplasty, and autologous stem cell therapy

Case from: J Peterson, C. Schmalfuss, C. Pepine, & G. Cooper
Institute: University of Florida, Gainesville, Florida, USA.
Images courtesy of Cardiovascular Cell Therapy Research Network.  

Clinical history: 50 y/o male with a 3 week history of accelerated angina was transported to the ED for a one hour history of continuous chest pain. EKG showed anteroseptal Q waves and ST segment elevation. Cardiac markers confirmed myocardial infarction. (click EKG to enlarge)

 

 

 

 

Initial transthoracic echo demonstrated a large area of apical, antero-apical, and inferoapical dyskinesis (Movie 1).

 

 

Movie 1

 

The patient was brought directly to the cath lab. His LAD was totally occluded (Movie 2). Primary PCI with placement of bare metal stent was successfully performed (Movie 3).

 

 

Movie 2                                               Movie 3

 

He then agreed to participate in the Cardiovascular Cell Therapy Research Network (CCTRN) TIME trial of autologus bone marrow stem cell therapy. To most accurately evaluate base line LV function, the extent of myocardial necrosis, and valve function the CCTRN protocol uses CMR with SSSP cine (Movie 4, long-axis views and Movie 5, short-axis views), rest perfusion (Movie 6, basal, mid-cavity and apical slices), and late gadolinium enhancement (Movie 7, 2ch- (a), 4ch- (b) and stack of short axis (c) views) as the method to access the co-primary end points: global and regional left ventricular function. A number of secondary endpoints are also assessed by CMR: LV mass, end systolic end diastolic volume, infarct size. Microvascular obstruction is also assessed.

 

 

Movie 4                                                  Movie 5

 

 

                                                         Movie 6

  

 

                                                   Movies 7 (a,b,c)

 

Conclusions: The CMR study demonstrates a large apical, apical anterior, apical septal and apical inferior, area of dyskinesis. The rest Gadolinium perfusion study shows hypoperfusion in these same locations. There was evidence of microvascular obstruction (no reflow) and late Gadolinium enhancement in these segments. A small pericardial effusion is also present.
Repeat CMR evaluation is planned at 6, 12 and 24 months.

Perspective: CMR offers the ability to determine left ventricular function, the presence of cardiac valve abnormalities, the presence of microvascular obstruction, and identify the size and location of infarction. It is an ideal tool to aid in the planning of delivery of autologous stem cells.
This case demonstrates the potential added value of CMR and its key role in the future of cardiovascular imaging, particulary in the application of stem cells.

Reference:
V. Bodi, J Sanchis et al: Prognostic Value of a Comprehensive Cardiac Magnetic Resonance Assessment Soon After a First ST-Segment Elevation Myocardial Infarction; J Am Coll Cardiol Img 2009; 2:835-842.

 

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COTW handling editor: Chiara Bucciarelli-Ducci

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