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Aim: The aim of this study was to investigate predictors of transthoracic echocardiography (TTE)-occult left ventricular (LV) thrombi (LVT) and to propose a clinical model for improved detection of TTE-occult LVT post-ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing LVT. However, this complication often (up to 65%) remains undetected by using TTE, referred to as TTE-occult LVT., Methods and Results: In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic [ejection fraction, apical wall motion scores (AWMSs)] predictors were analysed. Primary endpoint was the presence of TTE-occult LVT identified by CMR imaging. From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. Transthoracic echocardiography-occult thrombi did not significantly differ in volume (1.4 vs. 2.74 cm3), diameter (19.0 vs. 23.3 mm), and number of fragments or shape compared with TTE-apparent LVT (all P > 0.05). For predicting these TTE-occult LVT, the 16-segment AWMS (AWMS16Seg) showed highest validity {area under the curve: 0.91 [95% confidence interval (CI): 0.89-0.93]; P < 0.001}, with an association independent of ejection fraction and 17-segment AWMS (AWMS17Seg) [odds ratio: 1.68 (95% CI: 1.43-1.97); P < 0.001] and clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional thrombolysis in myocardial infarction flow) associates of TTE-occult LVT (all P < 0.05). Dichotomization at AWMS16Seg ≥ 8 (n = 260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity: 100%), with a corresponding specificity of 77%., Conclusion: After acute STEMI, AWMS16Seg served as a simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LVT following STEMI., Competing Interests: Conflict of interest: None., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To investigate the prognostic value of pulmonary transit time (pTT) determined by cardiac magnetic resonance (CMR) after acute ST-segment-elevation myocardial infarction (STEMI)., Methods: Comprehensive CMR examinations were performed in 207 patients 3 days and 4 months after reperfused STEMI. Functional parameters and infarct characteristics were assessed. PTT was defined as the interval between peaks of gadolinium contrast time-intensity curves in the right and left ventricles in first-pass perfusion imaging. Cox regression models were calculated to assess the association between pTT and the occurrence of major adverse cardiac events (MACE), defined as a composite of death, re-infarction, and congestive heart failure., Results: PTT was 8.6 s at baseline and 7.8 s at the 4-month CMR. In Cox regression, baseline pTT (hazard ratio [HR]: 1.58; 95% CI: 1.12 to 2.22; p = 0.009) remained significantly associated with MACE occurrence after adjustment for left ventricular ejection fraction (LVEF) and cardiac index. The association of pTT and MACE remained significant also after adjusting for infarct size and microvascular obstruction size. In Kaplan-Meier analysis, pTT ≥ 9.6 s was associated with MACE (p < 0.001). Addition of pTT to LVEF resulted in a categorical net reclassification improvement of 0.73 (95% CI: 0.27 to 1.20; p = 0.002) and integrated discrimination improvement of 0.07 (95% CI: 0.02 to 0.13; p = 0.007)., Conclusions: After reperfused STEMI, CMR-derived pTT was associated with hard clinical events with prognostic information independent of and incremental to infarct size and LV systolic function., Key Points: • Pulmonary transit time is the duration it takes the heart to pump blood from the right chambers across lung vessels to the left chambers. • This prospective single-centre study showed inferior outcome in patients with prolonged pulmonary transit time after myocardial infarction. • Pulmonary transit time assessed by magnetic resonance imaging added incremental information to established prognostic markers., (© 2022. The Author(s).)

Background: Mitral annular disjunction (MAD) represents the detachment of the mitral leaflet hinge-point from the ventricular myocardium. Its role in patients with ST-segment-elevation myocardial infarction (STEMI) is unknown. This study aims to investigate the prevalence of MAD by cardiac magnetic resonance imaging (CMR) in STEMI-patients and its association with serious adverse events., Methods: STEMI-patients (n = 621) underwent CMR 4 days [interquartile range (IQR) 2-5] after percutaneous coronary intervention. Presence and longitudinal extent of MAD were obtained in long-axis cine-images, infarct characteristics in late gadolinium enhancement-images. During a median follow-up time of 366 days (IQR 136-454), patients were observed for the occurrence of major adverse cardiac events (MACE), comprising death, myocardial reinfarction, and congestive heart failure., Results: Overall, 307 patients (49 %) had MAD. Longitudinal MAD-distance was 4.6 ± 1.7 mm and the P3-segment was affected most frequently (n = 262, 85 % of MAD-patients). MAD-patients had a significantly smaller infarct size, lower prevalence of microvascular obstruction, and intramyocardial hemorrhage as well as a higher ejection fraction (all p < 0.03). During follow-up period, MACE occurred in 52 patients (8 %) and did not show significant difference between patients with and without MAD (7 % vs. 9 %, p = 0.424). Cardiovascular death occurred significantly more often in patients without MAD (n = 10, 3.2 % vs. n = 2, 0.7 %, p = 0.021)., Conclusion: MAD is a rather common finding in patients presenting with STEMI. Patients with MAD had less severe infarct characteristics, however, they were not more commonly affected by MACE. Further confirmation and longer follow-up intervals are necessary to define the exact role of MAD in STEMI patients., (Copyright © 2022. Published by Elsevier Ltd.)

Background: In patients with a first ST-segment elevation myocardial infarction (STEMI), the multi-annual evolution of myocardial tissue injury parameters, as assessed by cardiac magnetic resonance (CMR), has not yet been described., Objectives: This study examined myocardial tissue injury dynamics over a decade after STEMI., Methods: Sequential CMR examinations (within the first week after STEMI, and at 4, 12, months, and 9 years thereafter) were conducted in 74 patients with STEMI treated with primary percutaneous coronary intervention. Left ventricular function, infarct size (IS), and microvascular obstruction (MVO) were assessed at all time points. T2∗, T2, and T1 mapping (n = 59) were added at 9-year scan to evaluate the presence of iron and edema within the infarct core, respectively., Results: IS decreased progressively and significantly between all CMR time points (all P < 0.001), with an average reduction rate of 5.8% per year (IQR: 3.5%-8.8%) and a relative reduction of 49% (IQR: 39%-76%) over a decade. MVO was present in 61% of patients at baseline, but was not present at the follow-up examinations. At 9-year CMR, 17 of 59 (29%) patients showed iron deposition within the infarct core, whereas 82% had persistent edema. Persistent iron and edema were associated with greater IS on any occasion (all P < 0.001), as well as the presence of MVO (P < 0.001). Patients with persistent iron and edema showed a lower relative regression of IS (P = 0.005 and P = 0.032, respectively) and greater end-systolic volumes over a decade (all P < 0.012 and P > 0.023, respectively). A T1 hypointense infarct core without evidence of T2∗ iron deposition (14 of 59 [24%] patients) was attributed to lipomatous metaplasia of the infarct., Conclusions: The evolution of IS is a dynamic process that extends well beyond the first few months after STEMI. Persistence of iron and edema within the infarct core occurs up to a decade after STEMI and is associated with initial infarct severity and poor infarct healing., Competing Interests: Funding Support and Author Disclosures The study was supported by grants from the Austrian Science Fund (FWF): KLI 772-B (BM) and by the Austrian Society of Cardiology. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aim: We aimed to investigate the comparative prognostic value of left ventricular ejection fraction (LVEF), mitral annular plane systolic excursion (MAPSE), fast manual long-axis strain (LAS) and global longitudinal strain (GLS) determined by cardiac magnetic resonance (CMR) in patients after ST-segment elevation myocardial infarction (STEMI)., Methods and Results: This observational cohort study included 445 acute STEMI patients treated with primary percutaneous coronary intervention (pPCI). Comprehensive CMR examinations were performed 3 [interquartile range (IQR): 2-4] days after pPCI for the determination of left ventricular (LV) functional parameters and infarct characteristics. Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure. During a follow-up of 16 [IQR: 12-49] months, 48 (11%) patients experienced a MACE. LVEF (p = 0.023), MAPSE (p < 0.001), LAS (p < 0.001) and GLS (p < 0.001) were significantly related to MACE. According to receiver operating characteristic analyses, only the area under the curve (AUC) of GLS was significantly higher compared to LVEF (0.69, 95% confidence interval (CI) 0.64-0.73; p < 0.001 vs. 0.60, 95% CI 0.55-0.65; p = 0.031. AUC difference: 0.09, p = 0.020). After multivariable analysis, GLS emerged as independent predictor of MACE even after adjustment for LV function, infarct size and microvascular obstruction (hazard ratio (HR): 1.13, 95% CI 1.01-1.27; p = 0.030), as well as angiographical (HR: 1.13, 95% CI 1.01-1.28; p = 0.037) and clinical parameters (HR: 1.16, 95% CI 1.05-1.29; p = 0.003)., Conclusion: GLS emerged as independent predictor of MACE after adjustment for parameters of LV function and myocardial damage as well as angiographical and clinical characteristics with superior prognostic validity compared to LVEF., (© 2021. The Author(s).)

Background: For patients suffering from acute ST-elevation myocardial infarction (STEMI), it is controversial whether infarct location predicts worse clinical outcome independently of infarct size. We therefore aimed to investigate the prognostic relevance of infarct location in relation to infarct size in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI)., Methods: Cardiac magnetic resonance was performed in 355 patients with acute STEMI 3 (interquartile range [IQR]: 2-4) days after primary PCI. Infarct location, infarct size, and microvascular obstruction were assessed by late gadolinium enhancement (LGE). Patients were followed for major adverse cardiac events (MACE) at a median follow-up of 35 (IQR: 12-52) months., Results: One hundred and sixty five patients (47%) had anterior STEMI. These patients had a greater infarct size as compared to non-anterior STEMI patients (19 vs. 12% of left ventricular myocardial mass, p < .001), but no significant differences in microvascular obstruction occurrence and extent (p = .26 and p = .09, respectively). MACE occurred in 39 patients (11%). Patients with anterior STEMI had a higher risk of MACE (hazard ratio: 2.01; 95% confidence interval: 1.05-3.83; p = .03). In multivariable analysis, infarct severity by LGE imaging but not its location was independently associated with an increased risk of MACE (hazard ratio: 1.03; 95% confidence interval: 1.01-1.06; p = .01)., Conclusions: The higher rate of medium-term MACE in anterior STEMI treated with contemporary primary PCI is explained by a larger extent of myocardial damage as determined by CMR imaging without any further contribution of infarct location., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background In survivors of acute ST-segment-elevation myocardial infarction (STEMI), increased aortic stiffness is associated with worse clinical outcome; however, the underlying pathomechanisms are incompletely understood. We aimed to investigate associations between aortic stiffness and infarct healing using comprehensive cardiac magnetic resonance imaging in patients with acute STEMI. Methods and Results This was a prospective observational study including 103 consecutive STEMI patients treated with primary percutaneous coronary intervention. Pulse wave velocity (PWV), the reference standard for aortic stiffness assessment, was determined by a validated phase-contrast cardiac magnetic resonance imaging protocol within the first week after STEMI. Infarct healing, defined as relative infarct size reduction from baseline to 4 months post-STEMI, was determined using late gadolinium-enhanced cardiac magnetic resonance. Median infarct size significantly decreased from 17% of left ventricular mass (interquartile range 9% to 28%) at baseline to 12% (6% to 17%) at 4-month follow-up ( P <0.001). Relative infarct size reduction was 36% (interquartile range 15% to 52%). Patients with a reduction >36% were younger ( P =0.01) and had lower baseline NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentrations ( P =0.047) and aortic PWV values ( P =0.003). In a continuous (odds ratio 0.64 [95% CI, 0.49-0.84]; P =0.001) as well as categorical (PWV <7 m/s; odds ratio 4.80 [95% CI, 1.89-12.20]; P =0.001) multivariable logistic regression model, the relation between aortic PWV and relative infarct size reduction remained significant after adjustment for baseline infarct size, age, NT-proBNP, and C-reactive protein. Conclusions Aortic PWV independently predicted infarct size reduction as assessed by cardiac magnetic resonance, revealing a novel pathophysiological link between aortic stiffness and adverse infarct healing during the early phase after STEMI treated with contemporary primary percutaneous coronary intervention.