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No-Reflow Phenomenon in Cardiac MRI: Diagnosis and Clinical Implications

¹ Department of Radiology, Unitat de Ressonància Magnètica, Hospital General Vall d'Hebron, Pg. De la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
² Cardiology Department, Hospital General Vall d'Hebron, Barcelona, Spain.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Drawing shows recovery of myocardial perfusion depends on adequacy of reperfusion at both epicardial (A) and microvascular (B) levels.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —58-year-old man with acute myocardial infarction. Coronary angiogram shows complete occlusion (arrow) of proximal circumflex coronary artery.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —58-year-old man with acute myocardial infarction. Coronary angiogram after angioplasty shows patency (arrow) of circumflex coronary artery.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —58-year-old man with acute myocardial infarction. Short-axis (C) and four-chamber (D) gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°). Segmental images obtained soon after angioplasty show perfusion defect (arrow) in lateral wall despite restored blood flow in circumflex coronary artery.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —58-year-old man with acute myocardial infarction. Short-axis (C) and four-chamber (D) gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°). Segmental images obtained soon after angioplasty show perfusion defect (arrow) in lateral wall despite restored blood flow in circumflex coronary artery.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —62-year-old woman with acute myocardial infarction. Coronary angiogram before angioplasty depicts severe stenosis (arrow) in middle of left anterior descending artery (LAD).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —62-year-old woman with acute myocardial infarction. Coronary angiogram after angioplasty shows LAD flow (arrow).

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —62-year-old woman with acute myocardial infarction. Four-chamber gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°) in multiple temporal phases soon after angioplasty show incomplete apical tissue reperfusion despite restoration of thrombolysis in myocardial infarction grade 3 flow in LAD.

View larger version (77K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —62-year-old woman with acute myocardial infarction. Four-chamber gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°) in multiple temporal phases soon after angioplasty show incomplete apical tissue reperfusion despite restoration of thrombolysis in myocardial infarction grade 3 flow in LAD.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E —62-year-old woman with acute myocardial infarction. Four-chamber gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°) in multiple temporal phases soon after angioplasty show incomplete apical tissue reperfusion despite restoration of thrombolysis in myocardial infarction grade 3 flow in LAD.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3F —62-year-old woman with acute myocardial infarction. Four-chamber gradient-echo first-pass perfusion MR images (TR/TE, 203/1.06; flip angle, 50°) in multiple temporal phases soon after angioplasty show incomplete apical tissue reperfusion despite restoration of thrombolysis in myocardial infarction grade 3 flow in LAD.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —54-year-old man with revascularized acute myocardial infarction. Short-axis gradient-echo first-pass perfusion segmental MR image (TR/TE, 450/1.26; flip angle, 50°) shows perfusion defect in inferolateral wall (arrow) after epicardial reperfusion, indicating no reflow.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —54-year-old man with revascularized acute myocardial infarction. Short-axis delayed-enhancement inversion recovery gradient-echo MR image (450/1.26; inversion time, 300 milliseconds; flip angle, 50°) shows hypoenhanced area (arrow) within hyperenhanced myocardium. Finding is consistent with microvascular obstruction.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —46-year-old man with revascularized acute myocardial infarction. Short-axis gradient-echo first-pass segmental perfusion MR image (TR/TE, 203/1.06; flip angle, 50°) obtained after angioplasty shows perfusion defect in anterior wall (arrow), indicating no reflow.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —46-year-old man with revascularized acute myocardial infarction. Short-axis delayed-enhancement inversion recovery gradient-echo MR image (450/1.26; inversion time, 280 milliseconds; flip angle, 50°) obtained 10 minutes after contrast administration shows nontransmural infarction and small perfusion defect has become hyperenhanced (arrow) owing to diffusion of extracellular contrast medium from surrounding regions.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —59-year-old woman with reperfused anterior infarction. Four-chamber delayed-enhancement inversion recovery gradient-echo MR image (TR/TE, 450/1.26; inversion time, 300 milliseconds; flip angle, 50°) shows transmural apical necrosis. Dark area within infarct core represents microvascular obstruction (arrow).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —59-year-old woman with reperfused anterior infarction. Four-chamber delayed-enhancement inversion recovery gradient-echo MR image (450/1.26; inversion time, 270 milliseconds; flip angle, 50°) obtained after 6-month follow-up period shows dark area has become hyperenhanced (arrow).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —55-year-old man with revascularized acute myocardial infarction. Two-chamber delayed-enhancement inversion recovery gradient-echo MR image (TR/TE, 450/1.26; inversion time; 250 milliseconds; flip angle, 50°) shows transmural infarct with black core (arrow) corresponding to no reflow. Small apical thrombus (arrowhead) is evident.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —55-year-old man with revascularized acute myocardial infarction. Two-chamber T2-weighted MR image (700/49) shows high signal intensity in infarcted region consistent with myocardial edema (arrow). Pericardial thickening (arrowhead) caused by epistenocardiac pericarditis is evident.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —62-year-old man with acute myocardial infarction. Angiogram obtained before stent placement shows obstruction (arrow) of proximal left anterior descending coronary (LAD) artery.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —62-year-old man with acute myocardial infarction. Angiogram obtained after stent placement shows restored LAD artery flow (arrow) with persistent black dot of contrast material (arrowhead) in distal LAD artery indicating distal microembolization.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —62-year-old man with acute myocardial infarction. Two-chamber (C) and four-chamber (D) delayed-enhancement inversion recovery gradientecho MR images (TR/TE, 450/1.26; inversion time, 300 milliseconds; flip angle, 50°) depict apical hypoenhanced area (arrow) caused by microvascular injury surrounded by hyperenhanced area of infarct.

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8D —62-year-old man with acute myocardial infarction. Two-chamber (C) and four-chamber (D) delayed-enhancement inversion recovery gradientecho MR images (TR/TE, 450/1.26; inversion time, 300 milliseconds; flip angle, 50°) depict apical hypoenhanced area (arrow) caused by microvascular injury surrounded by hyperenhanced area of infarct.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —67-year-old man with revascularized acute myocardial infarction. Four-chamber delayed-enhancement inversion recovery gradient-echo MR image (TR/TE, 450/1.26; inversion time, 280 milliseconds; flip angle, 50°) obtained after revascularization shows no-reflow area (arrow) in apical septal wall.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —67-year-old man with revascularized acute myocardial infarction. Steady-state free precession four-chamber cine MR image (3.6/1.8; flip angle, 55°) obtained after revascularization shows absence of apical septal wall thickening (arrow, C).

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —67-year-old man with revascularized acute myocardial infarction. Steady-state free precession four-chamber cine MR image (3.6/1.8; flip angle, 55°) obtained after revascularization shows absence of apical septal wall thickening (arrow, C).

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9D —67-year-old man with revascularized acute myocardial infarction. Follow-up four-chamber cine MR images (3.6/1.8; flip angle, 55°) obtained 6 months after B and C show left ventricular remodeling and no improvement in wall motion (arrow, E).

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9E —67-year-old man with revascularized acute myocardial infarction. Follow-up four-chamber cine MR images (3.6/1.8; flip angle, 55°) obtained 6 months after B and C show left ventricular remodeling and no improvement in wall motion (arrow, E).

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