Background: Severity of myocardial tissue injury is a main determinant of morbidity and death related to ST‐segment–elevation myocardial infarction (STEMI). Temporal trends of infarct characteristics at the myocardial tissue level have not been described. This study sought to assess temporal trends in infarct characteristics through a comprehensive assessment by cardiac magnetic resonance imaging at a standardized time point early after STEMI. Methods and Results: We analyzed patients with STEMI treated with percutaneous coronary intervention at the University Hospital of Innsbruck who underwent cardiac magnetic resonance imaging between 2005 and 2021. The study period was divided into terciles. Myocardial damage characteristics were assessed using a multiparametric cardiac magnetic resonance imaging protocol within the first week after STEMI and compared between groups. A total of 843 patients with STEMI (17% women) with a median age of 57 (interquartile range, 51–66) years were analyzed. While age, sex, and the clinical risk profile expressed as thrombolysis in myocardial infarction risk score were comparable across the study period, there were differences in guideline‐recommended therapies. At the same time, there was no significant change in infarct size ( P =0.25), microvascular obstruction ( P =0.50), and intramyocardial hemorrhage ( P =0.34). Left ventricular remodeling indices and left ventricular ejection fraction remained virtually unchanged (all P >0.05). Major adverse cardiovascular events at 4 (interquartile range, 4–5) months were similar between groups ( P =0.36). Conclusions: In this magnetic resonance imaging study investigating patients with STEMI treated with primary percutaneous coronary intervention over the past 15 years, no change in infarct severity at the myocardial level has been observed. Clinical research on novel therapeutic approaches to reduce myocardial tissue injury should be a priority.

In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium. In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days. Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P = .0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P = .028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P = .15). Two patients in the treatment group died for non-device-related reasons. In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure. Direct cardiac shockwave therapy (SWT) in addition to coronary artery bypass graft (CABG) surgery improves left ventricular ejection fraction (LVEF), physical capacity and quality of life in patients with ischaemic heart failure. 6MWT, 6-min walking test; FUP, follow-up; GDMT, guideline-directed medical therapy; NYHA, New York Heart Association; iCMP, ischaemic cardiomyopathy

BACKGROUND: Microvascular injury in the course of acute ST-segment–elevation myocardial infarction (STEMI) has been identified as determinant of adverse outcomes and manifests as microvascular obstruction (MVO). MVO has long been regarded as a transient finding, vanishing within a few weeks after infarction. However, recent studies have shown that it may persist beyond the early phase, resulting in adverse remodeling. However, its clinical implications remain unclear. This study aims to evaluate the association of MVO persistence and major adverse cardiac events after STEMI. METHODS: In total, 609 patients with revascularized first-time STEMI underwent cardiac magnetic resonance imaging (CMR) at 4 days, 4 months, and 12 months after STEMI to assess MVO, infarct size, and left ventricular function. Major adverse cardiac events were defined as composite of death, reinfarction, and new congestive heart failure within a median interval of 3.2 years. RESULTS: Baseline MVO was present in 365 (60%) patients and persisted in 35 (10%) patients at 4-month CMR and in 20 (5%) patients at 12-month CMR. Compared with transient MVO not present at follow-up, patients with MVO persistence ≥4 months were more likely to experience major adverse cardiac events during follow-up (29% versus 13%; P =0.016). Within patients with MVO, those with MVO persistence had lower left ventricular ejection fraction ( P =0.002), larger infarcts ( P =0.00001), and more frequent intramyocardial hemorrhage ( P =0.001) at baseline CMR. CONCLUSIONS: Persistent MVO after STEMI occurs in up to 10% of patients with baseline MVO and is linked to major adverse cardiac events. Patients with MVO persistence had larger infarcts, lower left ventricular function, and more frequent intramyocardial hemorrhage at baseline CMR. All patients with MVO persisting ≥12 months initially showed intramyocardial hemorrhage.

Photon-counting detector computed tomography (PCD-CT) represents a revolutionary new generation of computed tomography (CT) for the imaging of patients with cardiovascular diseases. Since its commercial market introduction in 2021, numerous studies have identified advantages of this new technology in the field of cardiovascular imaging, including improved image quality due to an enhanced contrast-to-noise ratio, superior spatial resolution, reduced artifacts, and a reduced radiation dose. The aim of this narrative review was to discuss the current scientific literature, and to find answers to the question of whether PCD-CT has yet led to a true step-change and significant progress in cardiovascular imaging.

Background: Spinal cord ischemia (SCI) remains a devastating complication after aortic dissection or repair. A primary hypoxic damage is followed by a secondary damage resulting in further cellular loss via apoptosis. Affected patients have a poor prognosis and limited therapeutic options. Shock wave therapy (SWT) improves functional outcome, neuronal degeneration and survival in murine spinal cord injury. In this first‐in‐human study we treated 5 patients with spinal cord ischemia with SWT aiming to prove safety and feasibility. Methods and Results: Human neurons were subjected to ischemic injury with subsequent SWT. Reactive oxygen species and cellular apoptosis were quantified using flow cytometry. Signaling of the antioxidative transcription factor NRF2 (nuclear factor erythroid 2‐related factor 2) and immune receptor Toll‐like receptor 3 (TLR3) were analyzed. To assess whether SWT act via a conserved mechanism, transgenic tlr3 ^−/− zebrafish created via CRISPR/Cas9 were subjected to spinal cord injury. To translate our findings into a clinical setting, 5 patients with SCI underwent SWT. Baseline analysis and follow‐up (6 months) included assessment of American Spinal Cord Injury Association (ASIA) impairment scale, evaluation of Spinal Cord Independence Measure score and World Health Organization Quality of Life questionnaire. SWT reduced the number of reactive oxygen species positive cells and apoptosis upon ischemia via induction of the antioxidative factor nuclear factor erythroid 2‐related factor 2. Inhibition or deletion of tlr3 impaired axonal growth after spinal cord lesion in zebrafish, whereas tlr3 stimulation enhanced spinal regeneration. In a first‐in‐human study, we treated 5 patients with SCI using SWT (mean age, 65.3 years). Four patients presented with acute aortic dissection (80%), 2 of them exhibited preoperative neurological symptoms (40%). Impairment was ASIA A in 1 patient (20%), ASIA B in 3 patients (60%), and ASIA D in 1 patient (20%) at baseline. At follow‐up, 2 patients were graded as ASIA A (40%) and 3 patients as ASIA B (60%). Spinal cord independence measure score showed significant improvement. Examination of World Health Organization Quality of Life questionnaires revealed increased scores at follow‐up. Conclusions: SWT reduces oxidative damage upon SCI via immune receptor TLR3. The first‐in‐human application proved safety and feasibility in patients with SCI. SWT could therefore become a powerful regenerative treatment option for this devastating injury.

The aim of this study was to investigate predictors of TTE-occult LV thrombi and to propose a clinical model for improved detection of TTE-occult LV thrombi post ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing left ventricular (LV) thrombi. However, this complication often (up to 65%) remains undetected by using transthoracic echocardiography (TTE), referred to as TTE-occult LV thrombus. In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LV thrombus detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic (ejection fraction, apical wall motion scores) predictors were analyzed. Primary endpoint was the presence of TTE-occult LV thrombus identified by CMR Imaging. From the overall cohort, 37 patients (4%) showed an LV thrombus by CMR. Of these thrombi, 25 (68%) were not identified by TTE. TTE-occult thrombi did not significantly differ in volume (1.4 vs. 2.74cm³), diameter (19.0 vs. 23.3 mm), number of fragments or shape compared with TTE-apparent LV thrombi (all p>0.05). For predicting these TTE-occult LV thrombi, apical wall motion score using the 16-segment model (AWMS_16Seg) showed highest validity (area under the curve:0.91 [95%CI:0.89-0.93]; p<0.001), with an association independent of ejection fraction and AWMS_17Seg (odds ratio: 1.68 [95%CI:1.43-1.97]; p<0.001), clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional TIMI flow) associates of TTE-occult LV thrombi (all p<0.05). Dichotomization at AWMS_16Seg ≥8 (n=260, 30%) allowed for a detection of all TTE-occult LV thrombi (sensitivity:100%), with a corresponding specificity of 77%. After acute STEMI, AWMS_16Seg served as simple and very robust predictor of TTE-occult LV thrombi. An AWMS_16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LV thrombi following STEMI.