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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.

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

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  1. 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

  2. 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

  3. Pathophysiology of Downstream Microvascular Obstruction • Platelet / fibrin aggregates (micro embolii) • Swelling and edema of endothelial and myocardial cells • Neutrophil plugging • Capillary leak

  4. 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

  5. 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

  6. 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.

  7. Two Chamber View Abn TMPG = 8 X Risk Of HE (p = 0.02) Circulation. 2006;114:662-669.

  8. 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.

  9. 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

  10. 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

  11. Wire Passage in STEMI Can Be Associated with Staining (TMPG 1) Gibson 2004

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