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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.

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Beyond TIMI 3 Flow

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  1. 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

  2. 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

  3. 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.

  4. 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

  5. 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.

  6. A Comparison of TMPP and Zwolle System

  7. A Comparison of TMPG and Zwolle System

  8. A Comparison of TMPP and Zwolle System

  9. 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.

  10. 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

  11. 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

  12. 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.

  13. 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

  14. 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.

  15. 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.

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

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