<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Few studies have examined the effect of transmurality of myocardial necrosis on coronary microcirculation. The aim of this study was to examine the influence of cardiac magnetic resonance‐derived (<jats:styled-content style="fixed-case">GE</jats:styled-content>‐<jats:styled-content style="fixed-case">MRI</jats:styled-content>) structural determinants of coronary flow reserve (<jats:styled-content style="fixed-case">CFR</jats:styled-content>) after anterior myocardial infarction (<jats:styled-content style="fixed-case">STEMI</jats:styled-content>), and their predictive value on regional functional recovery.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Noninvasive <jats:styled-content style="fixed-case">CFR</jats:styled-content> and <jats:styled-content style="fixed-case">GE</jats:styled-content>‐<jats:styled-content style="fixed-case">MRI</jats:styled-content> were studied in 37 anterior <jats:styled-content style="fixed-case">STEMI</jats:styled-content> patients after primary coronary angioplasty. The wall motion score index in the left descending anterior coronary artery territory (A‐<jats:styled-content style="fixed-case">WMSI</jats:styled-content>) was calculated at admission and follow‐up (<jats:styled-content style="fixed-case">FU</jats:styled-content>). Recovery of regional left ventricular (<jats:styled-content style="fixed-case">LV</jats:styled-content>) function was defined as the difference in A‐<jats:styled-content style="fixed-case">WMSI</jats:styled-content> at admission and <jats:styled-content style="fixed-case">FU</jats:styled-content>. The necrosis score index (<jats:styled-content style="fixed-case">NSI</jats:styled-content>) and transmurality score index (<jats:styled-content style="fixed-case">TSI</jats:styled-content>) by <jats:styled-content style="fixed-case">GE</jats:styled-content>‐<jats:styled-content style="fixed-case">MRI</jats:styled-content> were calculated in the risk area. Baseline (<jats:styled-content style="fixed-case">BMR</jats:styled-content>) and hyperemic (<jats:styled-content style="fixed-case">HMR</jats:styled-content>) microvascular resistance, arteriolar resistance index (<jats:styled-content style="fixed-case">ARI</jats:styled-content>), and coronary resistance reserve (<jats:styled-content style="fixed-case">CRR</jats:styled-content>) were calculated at the Doppler echocardiography.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Bivariate analysis indicated that the <jats:styled-content style="fixed-case">CPK</jats:styled-content> and troponin I peak, heart rate, <jats:styled-content style="fixed-case">NSI</jats:styled-content>,<jats:styled-content style="fixed-case"> TSI</jats:styled-content>,<jats:styled-content style="fixed-case"> BMR</jats:styled-content>, the <jats:styled-content style="fixed-case">ARI</jats:styled-content>, and <jats:styled-content style="fixed-case">CRR</jats:styled-content> were related to <jats:styled-content style="fixed-case">CFR</jats:styled-content>. Multivariable analysis revealed that <jats:styled-content style="fixed-case">TSI</jats:styled-content> was the only independent determinant of <jats:styled-content style="fixed-case">CFR</jats:styled-content>. The <jats:styled-content style="fixed-case">CFR</jats:styled-content> value of >2.27, identified as optimal by <jats:styled-content style="fixed-case">ROC</jats:styled-content> analysis, was 77% specific and 73% sensitive with accuracy of 76% in identifying patients with functional recovery.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Preservation of microvascular function after <jats:styled-content style="fixed-case">AMI</jats:styled-content> is related to the extent of transmurality of myocardial necrosis, is an important factor influencing regional <jats:styled-content style="fixed-case">LV</jats:styled-content> recovery, and can be monitored by noninvasive <jats:styled-content style="fixed-case">CFR</jats:styled-content>.</jats:p></jats:sec>