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Not All TIMI Grade 3 Flow is Created Equally:Not All TIMI Grade 3 Flow is Created Equally:Not All TIMI Grade 3 Flow is Created Equally:Not All TIMI Grade 3 Flow is Created Equally:
0
1
2
3
4
5
6
Myocardial Perfusion Grade 3
Myocardial Perfusion Grade 3
Myocardial Perfusion Grade 2
Myocardial Perfusion Grade 2
Myocardial Perfusion Grades 0/1
Myocardial Perfusion Grades 0/1
N = 136N = 136 N = 34N = 34 N = 278N = 278
0.7%0.7%2.9%2.9%
5.4%5.4%
% M
ort
alit
y%
Mo
rtal
ity
P = 0.007P = 0.007
Gibson CM, et al. Circulation. 2000;101:125-130.Gibson CM, et al. Circulation. 2000;101:125-130.
Among Patients. With Successful Lysis, There is a 7 Fold Range in MortalityAmong Patients. With Successful Lysis, There is a 7 Fold Range in Mortality
TIMI 10 B: Independent Predictors of 2 Year MortalityTIMI 10 B: Independent Predictors of 2 Year MortalityTIMI 10 B: Independent Predictors of 2 Year MortalityTIMI 10 B: Independent Predictors of 2 Year Mortality
• TIMI Grade 3 Flow RR 0.61, p=0.047
• TIMI Myocardial Blush RR 0.50, p = 0.038
• TIMI Grade 3 Flow RR 0.61, p=0.047
• TIMI Myocardial Blush RR 0.50, p = 0.038
In a MV model correcting for :
Performance of PCI
Age
Gender
Pulse
Anterior MI
In a MV model correcting for :
Performance of PCI
Age
Gender
Pulse
Anterior MI
Pre-PCI Epicardial and Myocardial Flow Are Independently Associated with 2 Year Mortality
Gibson et al, Circulation 2002Gibson et al, Circulation 2002
A Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle System
TIMI Epicardial Flow Grade
TIMI Myocardial Perfusion Grade
Zwolle System
Grade 0 No flow No flow No flow
Grade 1 Penetrates but does not perfuse
Dye penetrates but is stuck in muscle
Very Pale
Grade 2 Slow flow in artery
Slow flow in muscle
Less Pale
Grade 3 Normal flow in artery
Normal flow in muscle
Normal flow in muscle
A Comparison of TMPG and Zwolle SystemA Comparison of TMPG and Zwolle SystemA Comparison of TMPG and Zwolle SystemA Comparison of TMPG and Zwolle System
TIMI Myocardial Perfusion Grade
Zwolle System
Grade 0 No flow No flow
Grade 1 Dye penetrates but is stuck in muscle
Very Pale
Grade 2 Slow flow in muscle
Less Pale
Grade 3 Normal flow in muscle
Normal flow in muscle
A Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle SystemA Comparison of TMPP and Zwolle System
TIMI Myocardial Perfusion Grade
Zwolle System
Grade 0 or 1 No flow = No flow
Grade 2 or 3 Normal or near normal = Normal or
near normal
Myocardial Perfusion After Primary PCI is Strongest Predictor of MortalityMyocardial Perfusion After Primary PCI is Strongest Predictor of MortalityMyocardial Perfusion After Primary PCI is Strongest Predictor of MortalityMyocardial Perfusion After Primary PCI is Strongest Predictor of Mortality
9090 360360 900900 14401440 22502250 27902790
0/1n=236
2n=393
3 n=148
Myocardial Blush GradesMyocardial Blush Grades
Time (days)Time (days)
8080
8585
9090
9595
33
22
0/10/1
100100
Cu
mu
lati
ve
Su
rviv
al
(%)
Cu
mu
lati
ve
Su
rviv
al
(%)
00 22 44 66 88 1010 12127575
Fin
al B
lus
h S
co
re (p
atie
nts
with
fina
l TIM
I gra
de
3 flo
w)
Fin
al B
lus
h S
co
re (p
atie
nts
with
fina
l TIM
I gra
de
3 flo
w)
Blush 1-Year MortalityBlush 1-Year Mortality
3322
0/10/1
6.8%6.8%13.2%13.2%18.3%18.3%
PP=0.004=0.004
RR* 95% CI P
MBG 0 and 1 vs 2 and 3 2.9 1.4 to 5.8 0.003
MVD 2 and 3 vs 1 2.3 1.1 to 4.7 0.02
LAD vs non-LAD MI 2.2 1.1 to 4.4 0.03
TIMI flow before: 0 to 2 vs 3 1.8 0.5 to 6.1 0.31
Independent Angiographic Variables as Risk Factors of Long-Term Independent Angiographic Variables as Risk Factors of Long-Term Mortality in Patients With TIMI Grade 3 flow After AngioplastyMortality in Patients With TIMI Grade 3 flow After Angioplasty
MBG 0/1(n=100)
MBG 2(n=74)
MBG 3(n=79) P
Death at 30 days
26.0% 9.9% 3.9% <0.001
Death at 1 year
35.1% 13.4% 9.4% <0.001
Death during F/U
39.0% 18.3% 12.4% <0.001
Relation of Myocardial Perfusion Grade to MortalityRelation of Myocardial Perfusion Grade to Mortality
2 of 3 pts have a closed muscle after 10 PCI
Mortality goes up 3 fold
2 of 3 pts have a closed muscle after 10 PCI
Mortality goes up 3 fold
Stone GW, et al. Stone GW, et al. J Am Coll Cardiol.J Am Coll Cardiol. 2002;39:591-597. 2002;39:591-597.
Haagar PK, et al. Haagar PK, et al. J Am Coll Cardiol.J Am Coll Cardiol. 2003;41:532-538 2003;41:532-538
Henriques JP, et al. Henriques JP, et al. Circulation.Circulation. 2003;107:2115-2119. 2003;107:2115-2119.
Peak Myocardial Brightness, Circumference and Circumference Growth Peak Myocardial Brightness, Circumference and Circumference Growth in Culprit and Non-culprit Arteries in Acute MI and in Normal Patientsin Culprit and Non-culprit Arteries in Acute MI and in Normal Patients
Peak Myocardial Brightness, Circumference and Circumference Growth Peak Myocardial Brightness, Circumference and Circumference Growth in Culprit and Non-culprit Arteries in Acute MI and in Normal Patientsin Culprit and Non-culprit Arteries in Acute MI and in Normal Patients
Murphy SA, Am J Cardiol 2003Murphy SA, Am J Cardiol 2003
Early Impaired Myocardial Perfusion is Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct SizeAssociated with Larger SPECT Infarct Size
Early Impaired Myocardial Perfusion is Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct SizeAssociated with Larger SPECT Infarct Size
0
2
4
6
8
10
12
14
16
0
2
4
6
8
10
12
14
16
Patients with a closed myocardium (TMPG 0/1) and patients without complete ST resolution (<70%) had larger infarcts.
In a multivariate model, both impaired TMPG and incomplete ST resolution were independently associated with larger infarct size
Patients with a closed myocardium (TMPG 0/1) and patients without complete ST resolution (<70%) had larger infarcts.
In a multivariate model, both impaired TMPG and incomplete ST resolution were independently associated with larger infarct size n=209n=209 n=111n=111
p<0.001p<0.001
0
2
4
6
8
10
12
14
0
2
4
6
8
10
12
14 Median = 13Median = 13
TMPGTMPG ST ResolutionST Resolution
p=0.004p=0.004
Res <70%Res <70% Res >70%Res >70%TMPG 0/1TMPG 0/1 TMPG 2/3TMPG 2/3
n=108n=108 n=113n=113
Median = 7Median = 7
Median = 6Median = 6
Median = 14Median = 14
% S
PE
CT
In
farc
t S
ize
Circulation 2002Circulation 2002
-25
-20
-15
-10
-5
0
5
-25
-20
-15
-10
-5
0
5
Red
uctio
n in
Pla
que
Vol
ume
(mm
3 )R
educ
tion
in P
laqu
e V
olum
e (m
m3 )
TMPG 3
Mortality 0%
TMPG 3
Mortality 0%
TMPG 0-2
Mortality 22%
TMPG 0-2
Mortality 22% P=0.077 for mortalityP=0.077
for mortality
P=0.0039P=0.0039
Greater Reduction in Plaque Area on IVUS is Associated with Greater Reduction in Plaque Area on IVUS is Associated with Impaired TIMI Myocardial Perfusion Grades (TMPG 0-2) in STEMIImpaired TIMI Myocardial Perfusion Grades (TMPG 0-2) in STEMI
Greater Reduction in Plaque Area on IVUS is Associated with Greater Reduction in Plaque Area on IVUS is Associated with Impaired TIMI Myocardial Perfusion Grades (TMPG 0-2) in STEMIImpaired TIMI Myocardial Perfusion Grades (TMPG 0-2) in STEMI
Kotani J,Mintz GS,Pregowski J et al for Wash Hosp Ctr, Am J Cardiol 2003; 92:728–732.Kotani J,Mintz GS,Pregowski J et al for Wash Hosp Ctr, Am J Cardiol 2003; 92:728–732.
N=17N=17
N=18N=18
Multivariate analysis indicated that the strongest predictor of a closed myocardium (TMPG 0-2) after primary PCI was a greater reduction in plaque volume on IVUS
Multivariate analysis indicated that the strongest predictor of a closed myocardium (TMPG 0-2) after primary PCI was a greater reduction in plaque volume on IVUS
22
31
0
5
10
15
20
25
30
35
22
31
0
5
10
15
20
25
30
35 66
36
0
10
20
30
40
50
60
70 66
36
0
10
20
30
40
50
60
70
FilterWire-ExFilterWire-Ex as an Adjunct to Primary PCIas an Adjunct to Primary PCI
Design:Compared use of the FilterWire-Ex (FW) distal embolic protection device as an adjunct to primary PCI (n=53) vs matched control (n=53) in patients with acute MI.
Results• FW successfully positioned in 89% patients without complication• FW use remained only independent predictor of ST-segment resolution (OR 0.18, 95% CI 0.06-0.56, p=0.003) and myocardial blush grade 3 (OR 0.33, 95% CI 0.13-0.81, p=0.01)• All 13 filters that underwent histological analysis contained multiple embolic debris• No difference in 30 day MACE rates (5% for FW vs 11% for controls, p=0.488)
Design:Compared use of the FilterWire-Ex (FW) distal embolic protection device as an adjunct to primary PCI (n=53) vs matched control (n=53) in patients with acute MI.
Results• FW successfully positioned in 89% patients without complication• FW use remained only independent predictor of ST-segment resolution (OR 0.18, 95% CI 0.06-0.56, p=0.003) and myocardial blush grade 3 (OR 0.33, 95% CI 0.13-0.81, p=0.01)• All 13 filters that underwent histological analysis contained multiple embolic debris• No difference in 30 day MACE rates (5% for FW vs 11% for controls, p=0.488)
Filter WireFilter Wire Control Control
%
80
54
0
20
40
60
80
100
80
54
0
20
40
60
80
100
ST-segmentResolution
p=0.006
ST-segmentResolution
p=0.006
%
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Co
ron
ary
Flo
w R
eser
veC
oro
nar
y F
low
Res
erve
AntithrombinAntithrombin Antithrombin
+ Eptifibatide
Antithrombin
+ Eptifibatide
1.28 + 0.41.28 + 0.4
1.78 + 0.951.78 + 0.95
N=27N=27 N=16N=16
P=0.02P=0.02
00
Gra
y p
er s
ecG
ray
per
sec
7.30 + 8.137.30 + 8.13
3.97 + 2.463.97 + 2.46
P=0.05P=0.05
N=27N=27 N=18N=18
Coronary Flow ReserveCoronary Flow Reserve Rate of Increase in DSA
Brightness (Gray /sec)
Rate of Increase in DSA
Brightness (Gray /sec)
5
10
5
10
Cir
cum
fere
nce
(cm
)C
ircu
mfe
ren
ce (
cm)
N=24N=24N=32N=32
7.2+ 3.27.2+ 3.2
8.5 + 4.08.5 + 4.0P=0.18P=0.18
Rate of Growth in
Blush Circumference
(cm / sec)
Rate of Growth in
Blush Circumference
(cm / sec)
ESPRIT Substudy: ResultsESPRIT Substudy: ResultsESPRIT Substudy: ResultsESPRIT Substudy: ResultsAll Patients Have TIMI Grade 3 Flow at Completion of Stenting & Antithrombin TreatmentAll Patients Have TIMI Grade 3 Flow at Completion of Stenting & Antithrombin Treatment
AntithrombinAntithrombin Antithrombin
+ Eptifibatide
Antithrombin
+ Eptifibatide
AntithrombinAntithrombin Antithrombin
+ Eptifibatide
Antithrombin
+ Eptifibatide
Gibson CM et al, Am J Cardiol 2001;87(11):1293-5.Gibson CM et al, Am J Cardiol 2001;87(11):1293-5.
TMPG and Maximum CK-MB 24 Hours Post-stentTMPG and Maximum CK-MB 24 Hours Post-stent
0
5
10
15
20
25
30
35
40
45
Open Muscle Closed Muscle
0
5
10
15
20
25
30
35
40
45
Open Muscle Closed Muscle
Max
imu
m C
K-M
B >
2x U
LN
(%
)M
axim
um
CK
-MB
>2x
UL
N (
%)
41.2%41.2%p = 0.002p = 0.002
1/24 14/34
4.2%4.2%
All Patients Have TIMI 3 Flow at Completion of StentingAll Patients Have TIMI 3 Flow at Completion of Stenting
Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.
Stain Stain
Slow Slow
Pale Pale Normal Normal
TMPG Post-stent and Composite Events by 48 Hrs & 1 YrTMPG Post-stent and Composite Events by 48 Hrs & 1 YrTMPG Post-stent and Composite Events by 48 Hrs & 1 YrTMPG Post-stent and Composite Events by 48 Hrs & 1 Yr
0
5
10
15
20
25
30
35
Open Muscle Closed Muscle
0
5
10
15
20
25
30
35
Open Muscle Closed Muscle
Co
mp
osi
te E
ven
t (%
)C
om
po
site
Eve
nt
(%)
1 Year Death, MI, Urgent TVR1 Year Death, MI, Urgent TVR
p = 0.01p = 0.0132.4%32.4%
4.2%4.2%
1/241/24 11/3411/34
All Patients Have TIMI 3 Flow at Completion of StentingAll Patients Have TIMI 3 Flow at Completion of Stenting
Stain Stain
Slow Slow
Pale Pale Normal Normal
Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.
A A DDecline in TMPG after Stenting is Associated with Larger Infarct Sizesecline in TMPG after Stenting is Associated with Larger Infarct SizesA A DDecline in TMPG after Stenting is Associated with Larger Infarct Sizesecline in TMPG after Stenting is Associated with Larger Infarct Sizes
Ricciardi, Gibson et al, CCD 2004Ricciardi, Gibson et al, CCD 2004Ricciardi, Gibson et al, CCD 2004Ricciardi, Gibson et al, CCD 2004
All patients had normal epicardial TIMI Grade 3 Flow before PCI
12 of 14 patients had normal TMPG 3 before PCI
Only 7 of 14 had normal TMPG 3 after PCI
All patients had normal epicardial TIMI Grade 3 Flow before PCI
12 of 14 patients had normal TMPG 3 before PCI
Only 7 of 14 had normal TMPG 3 after PCI
CK-MB p=0.01CK-MB p=0.01HE mass p=0.04HE mass p=0.04
NoNo YesYes00
1010
2020
3030
4040
5050
00
11
22
33
44
Decline in post-stent TMPGDecline in post-stent TMPGH
E m
ass
(gm
)H
E m
ass
(gm
)
CK
-MB
(ng
/dL)
CK
-MB
(ng
/dL)
==Ramondo et al,Catheter Cardiovasc Interv 2004;61:222–226.Ramondo et al,Catheter Cardiovasc Interv 2004;61:222–226.
0.31
0.5
0
0.1
0.2
0.3
0.4
0.5
0.6
0.31
0.5
0
0.1
0.2
0.3
0.4
0.5
0.6
4.5
7.9
0
1
2
3
4
5
6
7
8
9
4.5
7.9
0
1
2
3
4
5
6
7
8
9
Tn
I (n
g /
mL
)T
n I
(ng
/ m
L)
tn T
(n
g /
mL
)tn
T (
ng
/ m
L)
TMPG 0/1TMPG 0/1TMPG 2/3TMPG 2/3
P=0.006P=0.006 P=0.007P=0.007
TMPG 2/3TMPG 2/3 TMPG 0/1TMPG 0/1
Peak [tnT] and [tnI] by TIMI Myocardial Perfusion Grade (TMPG) status
Peak [tnT] and [tnI] by TIMI Myocardial Perfusion Grade (TMPG) status
Even when epicardial TIMI flow grade and the presence of thrombus were adjusted for, the presence of a closed microvasculature was independently associated with tnT elevation in a multivariate model (O.R. 1.79, p=0.017).
Even when epicardial TIMI flow grade and the presence of thrombus were adjusted for, the presence of a closed microvasculature was independently associated with tnT elevation in a multivariate model (O.R. 1.79, p=0.017).
Circulation 2002Circulation 2002
Event Free Survival is Associated with Tissue Level Perfusion in UA / Non Q Wave MI: TACTICS – TIMI 18
Event Free Survival is Associated with Tissue Level Perfusion in UA / Non Q Wave MI: TACTICS – TIMI 18