Multidimensional ST Injury-State Dynamics During Controlled Human Coronary Occlusion and Balloon Deflation: An Analysis of the STAFF III Database

Background: The 12-lead electrocardiogram (ECG) is central to the evaluation of acute coronary syndromes, but conventional ST metrics compress a multilead, time-varying response into a small number of scalar amplitudes.We developed a multidimensional ST injury-state framework to quantify the magnitude, organization, and temporal evolution of the ischemic ECG response.Materials and methods: We performed a secondary analysis of 152 controlled balloon occlusions in 104 patients from the STAFF III database.The principal territory analysis included 149 occlusions in 102 patients with left anterior descending (LAD), right coronary artery (RCA), or left circumflex (LCx) occlusion.Using overlapping 10-second windows, we constructed a baseline-adjusted 6 × 7 ST injury surface (leads V1-V6 at R + 80 to R + 200 ms) and an eight-dimensional ST injury vector (leads I, II, and V1-V6).The primary outcomes were peak injury-surface burden and peak vector magnitude.Mechanistic analyses assessed surface singular-value structure, vector covariance organization, post-deflation geometric motion, and duration-matched 13-dimensional state-space speed.Inference used patient-clustered robust standard errors with Holm correction.Results: LAD occlusion produced greater peak injury-surface burden than RCA (adjusted geometric-mean ratio 1.64, 95% CI 1.16-2.31)and LCx (1.77, 1.19-2.63),and greater peak eight-dimensional vector magnitude than RCA (1.65, 1.14-2.41)and LCx (1.90, 1.25-2.88).During occlusion, the surface was nearly rank-one (median first-component energy fraction 0.991), and vector covariance was dominated by a single mode (median PC1 variance fraction 0.940).After balloon deflation, median surface burden fell from 71.7 to 37.7, singular-value entropy increased, and mean alignment between the injury vector and the dominant covariance axis decreased (mean change -0.195, 95% CI -0.259 to -0.132).In a duration-matched comparison, median 13-dimensional state-space speed increased from 0.084 in the final 60 seconds of occlusion to 0.252 in the first 60 seconds after deflation (mean change +0.141, 95% CI +0.111 to +0.172).Polarity exhibited the most pronounced territory-specific trajectory, with LAD differing from both RCA and LCx during occlusion and recovery.Conclusions: Controlled coronary occlusion produces a coherent multidimensional ST injury state.Balloon deflation reduces injury amplitude while triggering rapid electrical reorganization rather than simple reversal.Coronary territory is expressed both in peak injury magnitude and, most distinctly, in polarity dynamics.