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Beyond TIMI 3 Flow. 0. 5. 6.2%. p= 0.003. 10. % Risk of In Hospital Mortality. 2.8%. 15. 0.0%. (n = 18/640). (n =35/563). 21. (n=41). 14 < CTFC < 40. CTFC < 14. CTFC > 40. Reproducibility: r = 0.97 between readers Accuracy: r=0.88 vs Doppler velocity. “TIMI 4” Flow.

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beyond timi 3 flow
Beyond TIMI 3 Flow

0

5

6.2%

p= 0.003

10

% Risk of In Hospital Mortality

2.8%

15

0.0%

(n = 18/640)

(n =35/563)

21

(n=41)

14 < CTFC < 40

CTFC < 14

CTFC > 40

Reproducibility:

r = 0.97 between readers

Accuracy:

r=0.88 vs Doppler velocity

“TIMI 4” Flow

TIMI 3 Flow

Hyperemic Flow

Gibson, Circulation 1999; 99: 1945-1950

slide2

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

not all timi grade 3 flow is created equally
Not All TIMI Grade 3 Flow is Created Equally:

Among Patients. With Successful Lysis, There is a 7 Fold Range in Mortality

P = 0.007

5.4%

2.9%

% Mortality

0.7%

N = 278

N = 34

N = 136

Myocardial

Perfusion

Grade 3

Myocardial

Perfusion

Grade 2

Myocardial

Perfusion

Grades 0/1

Gibson CM, et al.Circulation. 2000;101:125-130.

timi 10 b independent predictors of 2 year mortality
TIMI 10 B: Independent Predictors of 2 Year Mortality

Pre-PCI Epicardial and Myocardial Flow Are Independently Associated with 2 Year Mortality

  • 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

Gibson et al, Circulation 2002

slide5

TIMI Flow Grades

Myocardial Blush Grades

Survival

1.0

0.9

n=690

n=148

3

n=393

3

0.8

n=55

2

900

1440

2790

360

2250

90

0.7

n=236

2

0.6

p<0.0001

n=32

0/1

0/1

0.5

900

1440

2790

360

2250

90

Time (days)

Myocardial Reperfusion Score

Zwolle Myocardial Blush Grades

(n=777)

p<0.0001

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

myocardial perfusion after primary pci is strongest predictor of mortality

900

1440

2790

360

2250

90

Myocardial Perfusion After Primary PCI is Strongest Predictor of Mortality

Myocardial Blush Grades

100

3

n=148

2

n=393

95

3

0/1

n=236

90

Cumulative Survival (%)

Final Blush Score (patients with final TIMI grade 3 flow)

2

Time (days)

85

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

Blush 1-Year Mortality

0/1

3

6.8%

Relation of Myocardial Perfusion Grade to Mortality

80

2

13.2%

P=0.004

0/1

18.3%

75

0

2

4

6

8

10

12

Stone GW, et al. J Am Coll Cardiol. 2002;39:591-597.

Independent Angiographic Variables as Risk Factors of Long-Term Mortality in Patients With TIMI Grade 3 flow After Angioplasty

Haagar PK, et al. J Am Coll Cardiol. 2003;41:532-538

  • 2 of 3 pts have a closed muscle after 10 PCI
  • Mortality goes up 3 fold

Henriques JP, et al. Circulation. 2003;107:2115-2119.

slide10
Peak Myocardial Brightness, Circumference and Circumference Growth in Culprit and Non-culprit Arteries in Acute MI and in Normal Patients

Culprit AMI

Non-culprit AMI

Normal

p < 0.0001

p < 0.0001

p < 0.0001

p = 0.02

p = NS

p = NS

(cm/sec)

(cm)

n=182

n=305

n=161

n=85

n=187

n=290

n=377

n=65

n=88

Peak Circumference Growth

Peak Circumference

DSA Peak Gray Scale

Murphy SA, Am J Cardiol 2003

early impaired myocardial perfusion is associated with larger spect infarct size
Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct Size

p=0.004

p<0.001

Median = 13

Median = 14

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

Median = 7

% SPECT Infarct Size

Median = 6

n=108

n=113

n=209

n=111

TMPG 0/1

TMPG 2/3

Res <70%

Res >70%

TMPG

ST Resolution

Circulation 2002

slide12
Greater Reduction in Plaque Area on IVUS is Associated with Impaired TIMI Myocardial Perfusion Grades (TMPG 0-2) in STEMI

TMPG 0-2

Mortality 22%

TMPG 3

Mortality 0%

P=0.077

for mortality

N=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

P=0.0039

Reduction in Plaque Volume (mm3)

N=17

Kotani J,Mintz GS,Pregowski J et al for Wash Hosp Ctr, Am J Cardiol 2003; 92:728–732.

slide13

FilterWire-Exas an Adjunct to Primary PCI

ST-segment

Resolution

p=0.006

Myocardial

Blush Grade 3

p=0.006

Corrected TIMI Frame Count

p=0.005

  • 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)

%

%

TIMI Frame Count

Control

Filter Wire

Circulation 2003; 108:171-176

slide14

ESPRIT Substudy: Results

All Patients Have TIMI Grade 3 Flow at Completion of Stenting & Antithrombin Treatment

Rate of Increase in DSA

Brightness (Gray /sec)

Coronary Flow Reserve

Rate of Growth in

Blush Circumference

(cm / sec)

1.78 + 0.95

7.30 + 8.13

P=0.02

8.5 + 4.0

P=0.05

P=0.18

1.28 + 0.4

3.97 + 2.46

Circumference (cm)

Gray per sec

Coronary Flow Reserve

7.2+ 3.2

N=16

N=27

N=27

N=18

N=32

N=24

Antithrombin

Antithrombin

+ Eptifibatide

Antithrombin

Antithrombin

+ Eptifibatide

Antithrombin

Antithrombin

+ Eptifibatide

Gibson CM et al, Am J Cardiol 2001;87(11):1293-5.

tmpg and maximum ck mb 24 hours post stent
TMPG and Maximum CK-MB 24 Hours Post-stent

All Patients Have TIMI 3 Flow at Completion of Stenting

p = 0.002

41.2%

Slow

Maximum CK-MB >2x ULN (%)

Stain

4.2%

Pale

Normal

1/24

14/34

Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.

tmpg post stent and composite events by 48 hrs 1 yr
TMPG Post-stent and Composite Events by 48 Hrs & 1 Yr

All Patients Have TIMI 3 Flow at Completion of Stenting

1 Year Death, MI, Urgent TVR

32.4%

p = 0.01

Slow

Composite Event (%)

Stain

4.2%

Normal

Pale

11/34

1/24

Gibson CM et al, Am Heart J. 2002 Jan;143(1):106-110.

a d ecline in tmpg after stenting is associated with larger infarct sizes

CK-MB p=0.01

4

50

HE mass p=0.04

40

3

30

2

20

1

10

0

0

No

Yes

Decline in post-stent TMPG

A Decline in TMPG after Stenting is Associated with Larger Infarct Sizes

=

Ramondo et al,Catheter Cardiovasc Interv 2004;61:222–226.

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

HE mass (gm)

CK-MB (ng/dL)

Ricciardi, Gibson et al, CCD 2004

slide18

Peak [tnT] and [tnI] by TIMI Myocardial Perfusion Grade (TMPG) status

P=0.007

P=0.006

Tn I (ng / mL)

tn T (ng / mL)

TMPG 2/3

TMPG 0/1

TMPG 0/1

TMPG 2/3

Circulation 2002;106:202-207

slide19

Troponin Elevations on Admission are Associated with Tissue Level Perfusion Following PCI: TACTICS TIMI 18

p=0.004

p=0.013

% TMPG 0/1

% TMPG 0/1

Circulation 2002;106:202-207

troponin t angiographic findings
Troponin T & Angiographic Findings

P=0.021

P=0.007

P=0.0003

P=0.03

% Normal TMPG 3

% Thrombus

% Stenosis

% Vessel Occlusion

tnT -

tnT +

tnT -

tnT +

tnT -

tnT +

tnT -

tnT +

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 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

P = 0.018

% TMPG 3

TMPG 2/3 Pre or Post-PCI

Slow

Normal

N = 253

N = 253

p=0.026

“Upstream”

Duration

(> median)

TMPG 0/1 Pre &

Post PCI

Event Free Survival

Gibson CM, AHA 2001

Stain

Pale

  • Impaired tissue perfusion on diagnostic cath is associated with Tn + and adverse outcomes
  • Earlier upstream initiation of GPIIbIIIa inhibition is associated with improved tisse perfusion om diagnostic cath

Days

Circulation 2002;106:202-207

slide22

Troponin Elevations on Admission are Associated with Tissue Level Perfusion Following PCI: TACTICS TIMI 18

p=0.004

p=0.013

% TMPG 0/1

% TMPG 0/1

Circulation 2002