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• W2608474071 abstract "HomeCirculationVol. 135, No. 17Letter by Fernandez-Jimenez et al Regarding Article, “Protective Effects of Ticagrelor on Myocardial Injury After Infarction” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Fernandez-Jimenez et al Regarding Article, “Protective Effects of Ticagrelor on Myocardial Injury After Infarction” Rodrigo Fernandez-Jimenez, MD, Javier Sanchez-Gonzalez, PhD and Borja Ibanez, MD, PhD Rodrigo Fernandez-JimenezRodrigo Fernandez-Jimenez From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., B.I.); CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain (R.F.-J., B.I.); Philips Healthcare, Madrid, Spain (J.S.-G.); and IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain (B.I.). Search for more papers by this author , Javier Sanchez-GonzalezJavier Sanchez-Gonzalez From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., B.I.); CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain (R.F.-J., B.I.); Philips Healthcare, Madrid, Spain (J.S.-G.); and IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain (B.I.). Search for more papers by this author and Borja IbanezBorja Ibanez From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., B.I.); CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain (R.F.-J., B.I.); Philips Healthcare, Madrid, Spain (J.S.-G.); and IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain (B.I.). Search for more papers by this author Originally published25 Apr 2017https://doi.org/10.1161/CIRCULATIONAHA.116.026578Circulation. 2017;135:e1002–e1003To the Editor:We read with interest the article by Vilahur and colleagues.1 The authors should be congratulated for using the human-like pig model of ischemia/reperfusion to provide evidence that ticagrelor may limit myocardial injury (necrosis and edema formation), as measured by cardiac magnetic resonance (CMR).Given that CMR can accurately identify myocardial areas with high water content, it has been widely used in the past years to retrospectively delineate the myocardium at risk (MaR). It is interesting to note that it has been assumed that the postischemia/reperfusion edematous reaction is stable for several days after myocardial infarction. On this basis, experimental and clinical studies performed CMR examinations at a variable time after myocardial infarction. Our group recently demonstrated in a pig model of transmural myocardial infarction that myocardial edema after ischemia/reperfusion is not stable but rather follows a bimodal pattern.2 In this model, an initial hyperacute edema reaction on reperfusion largely resolves within 24 hours, and is followed by a deferred healing-related edema wave occurring a few days after reperfusion.3 This coordinated bimodal edema pattern suggests that CMR-quantified MaR may vary according to the day of imaging and degree of injury (and subsequent healing), but to date this has not been tested in a controlled manner.In the present article,1 intriguing data about histological (blue-dye injection) versus CMR (edema) measurements of the MaR are presented. Although the median of histological reference MaR was similar in all experimental groups (≈50% of the left ventricle), an important underestimation of MaR by T2-weighted short-tau inversion recovery CMR was reported at 24 hours in all study groups. Although individual comparison is not possible with the data presented, it is remarkable that even in placebo animals, a ≈25% underestimation of MaR by CMR was observed (47.5% of left ventricle by histology versus 36.2% by 24-hour CMR). Thus, it seems plausible that the physiological resorption of the initial wave of edema contributed to these histology-CMR discrepancies. In fact, according to the data presented, salvage index quantification [1 – (infarct size/MaR), %] in placebo animals using dye histology or 24-hour CMR would be as disparate as 14% or 35%, respectively.Consequently, although the infarct-limiting effect of ticagrelor in this article is robust, its effect on edema is less. The authors used T2-weighted short-tau inversion recovery CMR sequence, which suffers from technical limitations. Conversely, quantitative T2 mapping has been shown to strongly correlate with actual myocardial water content measurements.4 It might be that the use of T2 mapping and, especially, a serial imaging protocol, including a hyperacute and later time points, would have helped in the interpretation of the mechanisms leading to injury sparing by ticagrelor.Overall, we believe that the work by Vilahur et al adds incremental evidence of the risks of using nonstandardized CMR protocols and timings to measure MaR.Rodrigo Fernandez-Jimenez, MDJavier Sanchez-Gonzalez, PhDBorja Ibanez, MD, PhDDisclosuresDr Sánchez-González is an employee of Philips Healthcare. The other authors have no conflicts to disclose.FootnotesCirculation is available at http://circ.ahajournals.org.References1. Vilahur G, Gutiérrez M, Casani L, Varela L, Capdevila A, Pons-Lladó G, Carreras F, Carlsson L, Hidalgo A, Badimon L. Protective effects of ticagrelor on myocardial injury after infarction.Circulation. 2016; 134:1708–1719. doi: 10.1161/CIRCULATIONAHA.116.024014.LinkGoogle Scholar2. Fernández-Jiménez R, Sánchez-González J, Agüero J, García-Prieto J, López-Martín GJ, García-Ruiz JM, Molina-Iracheta A, Rosselló X, Fernández-Friera L, Pizarro G, García-Álvarez A, Dall’Armellina E, Macaya C, Choudhury RP, Fuster V, Ibáñez B. Myocardial edema after ischemia/reperfusion is not stable and follows a bimodal pattern: imaging and histological tissue characterization.J Am Coll Cardiol. 2015; 65:315–323. doi: 10.1016/j.jacc.2014.11.004.CrossrefMedlineGoogle Scholar3. Fernández-Jiménez R, García-Prieto J, Sánchez-González J, Agüero J, López-Martín GJ, Galán-Arriola C, Molina-Iracheta A, Doohan R, Fuster V, Ibáñez B. Pathophysiology underlying the bimodal edema phenomenon after myocardial ischemia/reperfusion.J Am Coll Cardiol. 2015; 66:816–828. doi: 10.1016/j.jacc.2015.06.023.CrossrefMedlineGoogle Scholar4. Fernández-Jiménez R, Sánchez-González J, Aguero J, Del Trigo M, Galán-Arriola C, Fuster V, Ibáñez B. Fast T2 gradient-spin-echo (T2-GraSE) mapping for myocardial edema quantification: first in vivo validation in a porcine model of ischemia/reperfusion.J Cardiovasc Magn Reson. 2015; 17:92. doi: 10.1186/s12968-015-0199-9.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 25, 2017Vol 135, Issue 17 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.026578PMID: 28438810 Originally publishedApril 25, 2017 PDF download Advertisement" @default.
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