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Appendix
METHODS
This study was performed according to the recommendations specified in the
Cochrane Handbook for Systematic Reviews of Interventions(1).
Eligibility criteria
Studies performing IMR (index of microvascular resistance) using the
thermodilution principle at the end of the primary percutaneous coronary
intervention (PPCI) procedure and had a cardiovascular magnetic resonance
(CMR) performed within a week of the STEMI were screened. Only studies
reporting mean IMR ± standard deviation (SD) were included.
Search strategy
We searched MEDLINE and EMBASE databases up to June 2016.
Additionally, we screened editorials and web-based sources of information to
gain access to potential data from newly available or retrieved studies. The
following search
terms were
used:
“primary percutaneous
coronary
intervention”, “index of microvascular resistance”, “microvascular obstruction”,
“cardiovascular magnetic resonance” and “ST-segment elevation myocardial
infarction”.
Data extraction
Figure 1 shows the process of study selection as per preferred reporting items
for systematic reviews and meta-analyses (PRISMA)(2). 6 studies(3-8) were
identified and 2 reviewers performed data extraction independently. The study
characteristics including IMR values are shown in Table 1 and table 2.
Data synthesis and analysis
RevMan 5.2 (Nordic Cochrane Centre) was used to conduct a fixed-effect
meta-analysis for the weighted mean and weighted mean difference with 99%
confidence intervals. All reported P values are two-sided, with significance set
at P<0.05. Heterogeneity among trials was quantified using I2 statistics with I2
of 0-25%, 25-50% and 50-75% considered as low, moderate and high
heterogeneity, respectively.
Excluded studies
McGeoch 2010(9): Reported median IMR in group with and without MVO
Payne 2012(10): Did not report on IMR in the group with and without MVO.
References
1.
2.
3.
4.
5.
6.
Higgins JP, Altman DG, Gotzsche PC et al. The Cochrane Collaboration's tool for
assessing risk of bias in randomised trials. Bmj 2011;343:d5928.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Bmj 2009;339:b2535.
Yoo SH, Yoo TK, Lim HS, Kim MY, Koh JH. Index of microcirculatory resistance as
predictor for microvascular functional recovery in patients with anterior myocardial
infarction. Journal of Korean medical science 2012;27:1044-50.
Ahn SG, Lee SH, Lee JH et al. Efficacy of combination treatment with intracoronary
abciximab and aspiration thrombectomy on myocardial perfusion in patients with
ST-segment elevation myocardial infarction undergoing primary coronary stenting.
Yonsei Med J 2014;55:606-16.
Cuculi F, De Maria GL, Meier P et al. Impact of Microvascular Obstruction on the
Assessment of Coronary Flow Reserve, Index of Microcirculatory Resistance, and
Fractional Flow Reserve After ST-Segment Elevation Myocardial Infarction. Journal of
the American College of Cardiology 2014;64:1894-904.
Fukunaga M, Fujii K, Kawasaki D et al. Thermodilution-derived coronary blood flow
pattern immediately after coronary intervention as a predictor of microcirculatory
damage and midterm clinical outcomes in patients with ST-segment-elevation
myocardial infarction. Circulation Cardiovascular interventions 2014;7:149-55.
7.
8.
9.
10.
Hoole SP, Jaworski C, Brown AJ et al. Serial assessment of the index of
microcirculatory resistance during primary percutaneous coronary intervention
comparing manual aspiration catheter thrombectomy with balloon angioplasty
(IMPACT study): a randomised controlled pilot study. Open Heart 2015;2:e000238.
Ahn SG, Hung OY, Lee JW et al. Combination of the Thermodilution-Derived Index of
Microcirculatory Resistance and Coronary Flow Reserve Is Highly Predictive of
Microvascular Obstruction on Cardiac Magnetic Resonance Imaging After STSegment Elevation Myocardial Infarction. JACC Cardiovascular interventions
2016;9:793-801.
McGeoch R, Watkins S, Berry C et al. The index of microcirculatory resistance
measured acutely predicts the extent and severity of myocardial infarction in
patients with ST-segment elevation myocardial infarction. JACC Cardiovascular
interventions 2010;3:715-22.
Payne AR, Berry C, Doolin O et al. Microvascular Resistance Predicts Myocardial
Salvage and Infarct Characteristics in ST-Elevation Myocardial Infarction. Journal of
the American Heart Association 2012;1:e002246.
Table 1: Characteristics of the 6 included studies
Study
N
Timing of IMR
measurement
Timing of CMR
Primary Objective
Outcome
Yoo 2012 (3)
34
Anterior
STEMI
Immediately
post PPCI
6±4 days
To assess the micro-vascular
dysfunction by IMR and predicting
microvascular functional recovery in
patients with AMI who underwent
PPCI
The extent of MVO by CMR correlated with IMR.
IMR was significantly correlated with change in
regional wall motion score index and change in
left ventricular ejection fraction.
40
STEMI
Immediately
post PPCI
Day 5 (range 3-9)
To assess whether a combination of
IC abciximab and aspiration
thrombectomy is superior to each
treatment alone in terms of improving
MVO
Combination of IC abciximab with aspiration
thrombectomy improved IMR and reduced
frequency of MVO
45
STEMI
Immediately
post PPCI, at
day 1 and at 6
months
Day 1day
To describe how invasive coronary
microcirculation indices evolve and
are influenced by the presence of
MVO.
Patients with MVO had lower CFR immediately
post PPCI and at 24 hours and a trend towards
higher IMR. There were no significant
differences seen both in IMR and CFR at 6
months between those who developed MVO and
those who did not.
Fukunaga 2014
(6)
88
STEMI
Immediately
post PPCI
7.4±3.2 days
To evaluate whether CBF and IMR
values immediately after PPCI
predict early microvascular damage
Patients in the “bimodal group” had higher
prevalence of MVO on CMR when compared to
those in the “narrow unimodal” and “wide
unimodal groups” and were at higher risk of
death and rehospitalization for heart failure.
Hoole 2015(7)
41
STEMI
Immediately
post PPCI
48 hours
To investigate whether manual
thrombectomy would change
microvascular function measured by
IMR, compared with balloon
angioplasty (BA)
Manual thrombectomy was not superior to
balloon angioplasty to improve IMR and reduce
MVO
Ahn 2012(4)
Cuculi 2014(5)
MVO: 12-15
minutes post
gadolinium
MVO: 10-15
minutes post
gadolinium
MVO: 10-15
minutes post
gadolinium
MVO: 15 minutes
post gadolinium
Early MVO:
following first pass
perfusion
Late MVO: 5-10
minutes post
gadolinium
Ahn 2016(8)
40
Immediately
post PPCI
Median 7 days
(range 5 to 11)
MVO: 10-15
minutes post
gadolinium
To investigate the incremental
predictive values of the IMR, CFR,
and the combination of both to detect
MVO on CMR in patients treated with
primary PCI for STEMI
Increased coronary microvascular resistance
assessed by invasive physiological indexes (a
high IMR and low CFR) was associated with
MVO on CMR after reperfused STEMI.
Table 2: IMR in STEMI patients with and without MVO by CMR
Study
Patients with MVO
Patients without MVO
N with CMR data
IMR immediately post PPCI
N with CMR data
IMR immediately post PPCI
Yoo 2012(3)
18
38.1±16.7
16
16.7±12.4
Ahn 2014(4)
15
53.4±44.3
16
21.5±5.2
Cuculi 2014(5)
21
42.9±24.4
22
31.3±16.0
Fukunaga
2014(6)
40
58.2±41.8
28
28.8±30.6
Hoole 2015(7)
13
53.8±37.3
17
38.9±28.4
Ahn 2016
23
42.0±20.0
17
20.0±8.0
Total
130
49.1 (99% CI 41.4 to 56.8)
116
26.8 (99% CI 21.6 to 32.0)
Figure 1: PRISMA 2009 flow diagram
This figure shows the process via which 6 studies were selected for inclusion in this meta-analysis