Microvascular obstruction in acute myocardial infarction: an old and unsolved mystery

In the setting of acute myocardial infarction, flow restoration in the culprit epicardial coronary artery is not synonymous with efficient reperfusion. Microvascular obstruction occurs in 50% of cases and represents a predictor of a long-term unfavorable outcome. Its prevalence has remained constant in recent years despite various treatment attempts. However, the success of targeted therapies could be mainly a problem of timing. Recent data bring evidence with regard to the role of pre-procedural distal embolization and highlight the relation between distal embolism, microvascular obstruction and intramyocardial inflammation. As a result, early detection of microvascular injury represents the first step in the development of targeted, individualized therapeutic approaches. In this context, the identification of new invasive surrogate parameters for the timely assessment and quantification of microvascular obstruction in the catheterization laboratory has become an important subject of current research. Among these, coronary wedge pressure is the most practical and revealing in the setting of primary percutaneous coronary intervention. It may offer comprehensive details on the mechanisms of microvascular injury and may therefore offer guidance for appropriate treatment selection.