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19 The randomised complete vs. lesion only primary PCI trial – cardiovascular MRI substudy (CVLPRIT-CMR)
  1. JN Khan1,
  2. JP Greenwood2,
  3. SA Nazir1,
  4. M Dalby3,
  5. N Curzen4,
  6. S Hetherington5,
  7. DJ Kelly6,
  8. D Blackman2,
  9. A Ring7,
  10. C Peebles4,
  11. J Wong3,
  12. M Flather8,
  13. H Swanton9,
  14. AH Gershlick1,
  15. GP McCann1
  1. 1Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, LE3 9QP, UK
  2. 2Multidisciplinary Cardiovascular Research Centre and the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
  3. 3Royal Brompton and Harefield Foundation Trust, Harefield Hospital, Hill End Road, Middlesex UB9 6JH, UK
  4. 4University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO16 6YD, UK
  5. 5Kettering General Hospital, Rothwell Road, Kettering, NN16 8UZ, UK
  6. 6Royal Derby Hospital, Derby DE22 3NE, UK
  7. 7Leicester Clinical Trials Unit, University of Leicester, Leicester UK and Department of Mathematical Statistics and Actuarial Science, University of the Free State, PO Box 339, Bloemfontein 9300, South Africa
  8. 8Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia Norwich NR4 7TJ, UK
  9. 9The Heart Hospital, University College London Hospitals, 16-18 Westmoreland Street, London W1G 8PH, UK

Abstract

Background Multivessel disease (MVD) occurs in ~40% of STEMI. Management is controversial. PRAMI and CVLPRIT showed improved clinical outcomes with complete versus infarct-related artery (IRA)-only revascularisation at primary percutaneous coronary intervention (PPCI). However, non-IRA PCI may cause additional infarcts. We aimed to determine whether in-hospital complete revascularisation was associated with increased myocardial injury versus an IRA-only strategy.

Methods Multicentre, prospective, randomised, blinded endpoint trial. STEMI patients with MVD and <12 hr symptoms were randomised to IRA-only or complete in-hospital PCI. 1.5T CMR was performed acutely (median 3 days post-PPCI) and with adenosine stress at 9 months. The primary CMR endpoint was acute infarct size on late gadolinium imaging. Myocardial salvage index (MSI) was the proportion of non-infarcted area-at-risk. n = 100 per group gave 80% power to detect ±4% infarct size. The primary clinical outcome was 12 month combined MACE (death, repeat revascularisation, heart failure, MI).

Validation studies optimised infarct, area-at-risk and strain quantification. Full-width half-maximum infarct quantification was more accurate, reproducible and correlated strongest with ejection fraction (LVEF) and infarct characteristics. Otsu’s Automated Thresholding most accurately and reproducibly assessed area-at-risk. Compared with tagging, Feature Tracking strain measurement was more robust, quicker, had better interobserver variability and correlated stronger with infarct, area-at-risk and MSI.

Results (summarised in Table 1) 203 patients (98 complete revascularisation, 105 IRA-only) completed acute CMR. The groups were well matched. There was no difference in infarct size, MSI, LVEF, circumferential strain or ischaemic burden between groups. Complete revascularisation patients had increased non-IRA MI at acute CMR (Figure 1). 12 month MACE was reduced in complete revascularisation patients (8.2% vs. 17.1%, p = 0.055, hazard ratio 0.43).

Conclusions Complete revascularisation in STEMI with MVD leads to a small increase in CMR-detected non-IRA MI, but total infarct size and 12 month MACE are not increased. This provides further reassurance that complete revascularisation can be considered at PPCI.

Abstract 19 Table 1

Baseline, angiographic and CMR characteristics

Abstract 19 Figure 1

Multiple infarcts on late gadolinium imaging in complete revascularisation patients The 2 images on left and 2 images on right are 2 different patients. A = main infarct-related artery territory infarct B = infarct in non-infarct related artery territory

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