Imaging the myocardial microcirculation post-myocardial infarction

The myocardial microcirculation provides the vital pressure control and metabolic homeostasis for normal muscle function. Microvascular dysfunction is implicated in chronic cardiac disease and can signify higher risk, but its effect in acute myocardial infarction (AMI) can be profound. Modern management of AMI is focussed entirely on timely epicardial coronary patency, but as a result can leave microcirculatory devastation in its wake. The 'no-reflow' phenomenon occurs in up to 40 % of those successfully reperfused following an ST-elevation AMI (STEMI), and reflects significant microvessel injury that at its most severe involves both microvascular obstruction (MVO) and intramyocardial haemorrhage. Myocardial contrast echocardiography and cardiac magnetic resonance imaging have both led the field in establishing MVO as the prime determinant of adverse left ventricular (LV) remodeling, LV dysfunction, heart failure and increased mortality. These imaging techniques will be essential to support future research endeavours and shift focus to the maintenance of microvascular flow in AMI.