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Microvascular obstruction: time to bust the clot hypothesis?

Primary percutaneous coronary intervention (PPCI) is a cornerstone of treatment for acute myocardial infarction (AMI). Despite major achievements in the procedure itself and in the infrastructure allowing timely delivery of PPCI, a substantial proportion of patients will suffer significant myocardial injury despite successful treatment of the epicardial coronary artery. Microvascular obstruction (MVO), due to a combination of distal thrombotic embolisation, ischaemia reperfusion injury and related endothelial dysfunction, myocardial oedema and intramyocardial haemorrhage (IMH), is postulated as a mechanism for this residual myocardial injury. When measured by cardiac magnetic resonance (CMR) early after AMI, MVO is predictive of subsequent longerterm outcomes. At the time of PPCI, potential predictors of MVO include AMI characteristics, such as anterior territory AMI, and procedurally assessed characteristics, the most common being reduced or slow intracoronary flow.