The key steps involved in performing microscopic TTC staining are illustrated in Figure 1. After two rounds of TTC staining, a distinct punched pattern became visible on the surface of the heart. Serial slicing of the entire heart at 100-µm intervals yielded approximately 80 tissue sections, with the ligation site located around the 60th slice. In each section, the deep red staining of viable cardiomyocytes (viaCM) was clearly distinguishable from the yellow necrotic tissue (necCM), labeled by picric acid, yielding a sharply defined border (Figure 2A). The 3D reconstruction of all sections further visualized the spatial distribution and volume of viaCM and necCM within the heart (Figure 2B). A direct comparison of image quality to the conventional staining protocols shows that the microscopic protocol provides clearer and sharper boundaries and an improved viable-to-infarct signal ratio (Figure 2C). Filling the ventricular cavities with OCT during sample processing prevented cardiac contracture and maintained the heart in a physiological shape, without altering the quantification of infarct size or inducing structural damage, as evidenced by the intact endocardial layer (Figure 2D).
At microscopic resolution, the deep red formazan precipitates were primarily found within the cytoplasm of viable cardiomyocytes, as shown by the precise overlapping with cardiac troponin I (cTnI) staining (Figure 3). This result confirms that the current method reliably detects the viability of cardiomyocytes and precisely delineates the infarct area at the cellular level.
For the automated analysis of the large image dataset, we developed a color-based R program that outlines the infarct zone and the viable myocardium. Infarct size was computed at a single sectional level using planimetry and global volume-based measurement (Figure 4). The semi-automated algorithm rapidly calculates key image parameters of approximately 80 sections per heart, within 2 min. In our mouse MI model with 50 min of ischemia, the average infarct size (global) was 32.14% ± 8.3% (n = 5, mean ± SD), which roughly corresponds to the planimetric infarct size slightly above the mid-ventricular level. Notably, infarct size varied across different levels of the heart, reaching a maximum of 71.21% ± 6.8% (n = 5, mean ± SD) at the apical level and gradually decreasing to zero near the ligation site (Figure 4).
Conventional TTC staining is typically applied within the first 24 h following acute MI. Given its ability to reveal subtle differences in formazan intensity between myocytes and non-myocytes, we successfully extended the microscopic TTC assay beyond 24 h post-MI (Figure 5). In heart sections at 3 days post-MI ( = 3), yellow TTC staining was confined to the necrotic infarct core, while the peripheral region exhibited a pinkish-grey appearance consistent with immune cell infiltration and fibroblast activation7. Notably, in these regions, TTC signal intensity remained clearly distinguishable between myocytes and non-myocytes. Even at 7 days post-MI ( = 2), when fibrotic scar tissue had formed, a distinct contrast between myocytes and non-myocytes was still clearly detectable. To our knowledge, this is the first demonstration that TTC-based staining can be used to assess infarct size beyond the acute phase.
We also addressed the issue of the minimum ischemia duration required to induce a reproducible transmural MI in an experimental mouse model. Our results show that 30 min of cardiac ischemia (30-min MI, n = 3) resulted in a characteristic "wavefront" pattern of myocardial injury10, beginning in the endocardium and gradually progressing toward the epicardium (Figure 6). In contrast, when ischemia duration was extended beyond 40 min (n = 4, n = 5 for 50 min, and n = 2 for 60 min), a stable transmural infarct was consistently achieved. The microscopic imaging revealed that only a thin layer of endocardium and a portion of the epicardium remain positive. These results suggest that a minimum ischemia duration of 40 min is required to reliably induce a transmural infarct in a mouse model.

Figure 1: Workflow of the microscopic TTC staining protocol. The schematic diagram illustrates the detailed steps of perfusion and immersion staining, followed by cryosectioning and microscopic analysis. Please click here to view a larger version of this figure.

Figure 2: Microscopic TTC imaging of the infarcted heart. (A) Following two-step staining with 1% TTC solution (perfusion followed by immersion), the heart exhibited a distinct punched surface, with the viable myocardium appearing deep red and the necrotic regions light grey. Cryosectioning followed by fixation with Zamboni's fixative yielded high-quality images that demonstrated a sharply defined boundary between viable cardiomyocytes (viaCM, red) and necrotic cardiomyocytes (necCM, yellow). (B) Screenshot of the Volume Viewer interface in ImageJ software used for generating a 3D reconstruction of TTC-stained heart sections. The interactive surface plot function enables spatial visualization of infarcted and viable myocardial regions based on color intensity gradients. (C) A direct comparison of image quality between the two staining protocols shows that the microscopic protocol provides clearer and sharper boundaries, as well as an improved viable-to-infarct signal ratio compared to the conventional method. (D) Representative images of heart sections with and without filling OCT into ventricular cavities. The values of infarct size derived by both methods are identical (n = 3 and 5). Abbreviations: LA, left atrium; RV, right ventricle; LVAW, left ventricular anterior wall; IVS, interventricular septum. Please click here to view a larger version of this figure.

Figure 3: TTC positivity in cardiomyocytes. Photomicrographs of the TTC-stained heart section co-stained with cardiac troponin I (cTnI) and laminin revealed that TTC precipitates were localized intracellularly and precisely overlapped with cTnI-positive viable cardiomyocytes, confirming the specificity of TTC staining for viable myocardium. Please click here to view a larger version of this figure.

Figure 4: Asemi-automated algorithm for infarct size calculation. (A) A color-based R program automatically contours and quantifies the areas of the infarct zone and the viable myocardium. (B) The planimetric infarct size was determined on a per-section basis, revealing substantial variation across slices from the apex to the base of the heart. Global infarct size was calculated by dividing the total infarct (yellow) by the left ventricular volume (yellow + red), as indicated by the blue dotted line. Please click here to view a larger version of this figure.

Figure 5: Microscopic TTC staining across multiple time points. Microscopic TTC staining was performed on the hearts harvested at three time points following myocardial infarction (post-MI). High-quality images showing clear delineation between viable cardiomyocytes (deep red) and necrotic tissue (yellow) were obtained from hearts in the acute phase (1 day post-MI) as well as in the subacute phase (3-7 days post-MI), demonstrating the applicability of this protocol across an extended post-infarction time window. The global infarct size values obtained from the R script-based algorithm were within a similar range across all time points. Please click here to view a larger version of this figure.

Figure 6: Minimal ischemia duration required to induce transmural myocardial infarction (MI). When ischemia durations ranging from 0 to 60 minutes were compared, microscopic TTC images revealed a characteristic "wavefront" pattern of myocardial injury in hearts subjected to less than 30 min of ischemia. This pattern originated in the endocardium and progressed toward the epicardium, ultimately forming a transmural MI (as seen in the 30-min MI group). These findings suggest that a minimum of 40 min of cardiac ischemia is preferable to consistently induce a reproducible transmural MI. Please click here to view a larger version of this figure.
Supplementary File 1: R script for semi-automated algorithm for infarct detection. Image files in the dedicated folder were sequentially imported into the R platform, and pixels corresponding to infarcted areas and viable myocardium were detected colorimetrically. Segmental infarct size was computed at the single-section level, and global infarct size was calculated for the entire heart. Please click here to download this file.