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C. Michael Gibson, M.S., M.D. The Pathophysiology of Myocardial Perfusion. Director TIMI Data Coordinating Center. Invasive Cardiologist Beth Israel Deaconess Medical Center & Chief of Clinical Research. Associate Professor of Medicine, Harvard Medical School. Closed Muscle in Life and Death.

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C. Michael Gibson, M.S., M.D.

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C michael gibson m s m d

C. Michael Gibson, M.S., M.D.

The Pathophysiology of Myocardial Perfusion

Director TIMI Data Coordinating Center

Invasive Cardiologist Beth Israel Deaconess Medical Center

& Chief of Clinical Research

Associate Professor of Medicine, Harvard Medical School


Closed muscle in life and death

Closed Muscle in Life and Death

Closed Muscle on Angiogram During Life

Closed Muscle on Angiogram After Death

Gibson CM, 2006

Erling Falk et al. Circulation 1985; 71: 699-708


Pathophysiology of downstream microvascular obstruction

Pathophysiology of Downstream Microvascular Obstruction

  • Platelet / fibrin aggregates (micro embolii)

  • Swelling and edema of endothelial and myocardial cells

  • Neutrophil plugging

  • Capillary leak


C michael gibson m s m d

TIMI Myocardial Perfusion (TMP) Grades

TMP Grade 3

TMP Grade 2

TMP Grade 1

TMP Grade 0

Normal ground glass

appearance of blush

Dye mildly persistent

at end of washout

Dye strongly persistent

at end of washout

Gone by next injection

Stain present

Blush persists

on next injection

No or minimal blush

6.2%

5.1%

p = 0.05

Mortality (%)

4.4%

2.0%

n = 79

n = 434

n = 46

n = 203

Gibson et al, Circulation 2000


C michael gibson m s m d

The Goal is to Restore Both Normal Epicardial & Normal Myocardial Blood Flow

p = 0.05

7.0%

3.7%

Mortality (%)

n = 487

n = 328

Epicardial TIMI Grade 3 Flow

Epicardial TIMI Grade 2 / 1 / 0 Flow

7.5%

5 way p = 0.007

5.4%

4.7%

Mortality (%)

2.9%

0.7%

n = 64

n = 226

n = 279

n = 34

n = 136

Myocardial

Perfusion

Grade 3

Myocardial

Perfusion

Grade 2

Myocardial

Perfusion

Grades 0/1

Myocardial

Perfusion

Grade 3

Myocardial

Perfusion

Grades 2/1/0

Gibson et al, Circulation 2000


Myocardial perfusion mortality 8 years of follow up

Myocardial Perfusion & Mortality: 8 Years of Follow-Up

3

  • Majority of patients have TIMI Grade 3 flow in epicardial artery after primary PCI

    However

  • 2 of 3 pts have a cosed muscle after0 primary PCI

n=148

2

n=393

Survival

0/1

n=236

90

2790

360

900

1440

2250

Time (days)

van ‘t Hof AWJet al. Circulation 1998; 97:2302-6.


C michael gibson m s m d

Two Chamber View

Abn TMPG

= 8 X Risk

Of HE

(p = 0.02)

Circulation. 2006;114:662-669.


Mri hyperenhancement and troponin release after pci

MRI Hyperenhancement and Troponin Release After PCI

  • 37% of patients had tn elevation after PCI, all had hyperenhancement on MRI

  • 63% had no tn elevation and none of these pts had hyperenhancement on MRI

  • Tn elevation was proportional to grams of MRI enhancement

  • Loss of myocardium was 5% of muscle mass

Selvanayagam, Circulation. 2005;111:1027-1032.


Early impaired myocardial perfusion is associated with larger spect infarct size poorer salvage

Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct Size & Poorer Salvage

p=0.004

Median = 13

In a multivariate model, TMPG 2/3 remained independently associated with a higher salvage index (p=0.001)

Dibra et al, JACC 2003:41: 925-929

Median = 7

% SPECT Infarct Size

n=113

n=108

TMPG 2/3

TMPG 0/1

Angeja et al; Circulation 2002


C michael gibson m s m d

Poorer TMPG is Associated with Higher Coronary Wedge Pressure (Pressure Distal to Stenosis) and Higher Pulmonary Capillary Wedge Pressure

28 mm Hg

% with PA wedge > 18 mm Hg

56%

p=0.001

p=0.02

44%

Coronary Wedge Pressure

9 mm Hg

Open

TMPG 2/3

Closed

TMPG 0/1

Open

TMPG 2/3

Closed

TMPG 0/1

K P Balachandran et al; Heart. 2004;90: 1450-1454.

Kirtane AJ et al; J Thromb Thrombolysis.2004;17:177-84


Wire passage in stemi can be associated with staining tmpg 1

Wire Passage in STEMI Can Be Associated with Staining (TMPG 1)

Gibson 2004


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