No-reflow phenomenon persists long-term after ischemia/reperfusion in the rat and predicts infarct expansion

Background-No-reflow after reperfusion therapy for myocardial infarction is a strong predictor of clinical outcome. But its fate on a long-term basis and potential significance for infarct healing are not yet known. Methods and Results-Twenty-nine female Fisher rats were subjected to 60 minutes of coronary occlusion followed by reperfusion. At 4 weeks, 15 survivors were euthanized after measurement of regional myocardial blood flow (radioactive microspheres) and in vivo staining of perfused tissue (0.5 mL 50% Uniperse blue IV). Infarct size (34.3+/-3.4%), scar thickness (1.19+/-0.10 mm), and infarct expansion index (0.51+/-0.04) were assessed from histological sections (2 additional exclusions because of failed occlusion). Regional myocardial blood flow in the reperfused infarct was reduced significantly compared with noninfarcted tissue (1.98+/-0.47 versus 4.55+/-0.86 mL . min(-1) . g(-1), P < 0.003, apical slice, and 1.77+/-0.44 versus 5.34+/-0.38 mL . min . 1(-g) . 1, P < 0.0001, second slice), accompanied by a striking reduction of perfused capillaries within the infarct (n = 23+/-4 versus 163+/-8 in the noninfarcted tissue, P < 0.0001, microscopically assessed as capillaries containing blue particles per high-power field). Macroscopically, no-reflow areas were visible in 9 of 13 hearts. The number of perfused capillaries within the infarct correlated significantly with infarct expansion index (r = -0.76, P < 0.003), infarct thickness (r = 0.60, P < 0.03), and the ratio of infarct to septum thickness (r = 0.74, P < 0.004). Conclusions-The no-reflow phenomenon persists for 1 month after reperfusion and predicts worse scar thinning and infarct expansion. Thus, one might shift the "open-artery" hypothesis downstream to an "open-microvessel" hypothesis, relating infarct healing, infarct expansion, and outcome to the completeness of microvascular reperfusion above and beyond epicardial artery patency.