The Pathophysiology of Myocardial Perfusion C Michael Gibson
The Pathophysiology of Myocardial Perfusion C. Michael Gibson, M. S. , M. D. Director TIMI Data Coordinating Center Invasive Cardiologist Beth Israel Deaconess Medical Center & Chief of Clinical Research Associate Professor of Medicine, Harvard Medical School Clinical Trial Results. org
Closed Muscle in Life and Death Closed Muscle on Angiogram During Life Gibson CM, 2006 Clinical Trial Results. org Closed Muscle on Angiogram After Death Erling Falk et al. Circulation 1985; 71: 699 -708
Pathophysiology of Downstream Microvascular Obstruction • Platelet / fibrin aggregates (micro embolii) • Swelling and edema of endothelial and myocardial cells • Neutrophil plugging • Capillary leak Clinical Trial Results. org
TIMI Myocardial Perfusion (TMP) Grades Mortality (%) TMP Grade 3 TMP Grade 2 Normal ground glass Dye strongly persistent appearance of blush at end of washout Dye mildly persistent Gone by next injection at end of washout p = 0. 05 4. 4% TMP Grade 1 TMP Grade 0 Stain present Blush persists on next injection No or minimal blush 6. 2% 5. 1% 2. 0% n = 203 Clinical Trial Results. org n = 46 n = 79 n = 434 Gibson et al, Circulation 2000
The Goal is to Restore Both Normal Epicardial & Normal Myocardial Blood Flow Mortality (%) p = 0. 05 7. 0% 3. 7% n = 487 n = 328 Epicardial TIMI Grade 3 Flow Epicardial TIMI Grade 2 / 1 / 0 Flow Mortality (%) 5 way p = 0. 007 5. 4% 7. 5% 4. 7% 2. 9% 0. 7% n = 136 Myocardial Perfusion Grade 3 Clinical Trial Results. org n = 34 Myocardial Perfusion Grade 2 n = 279 Myocardial Perfusion Grades 0/1 n = 64 Myocardial Perfusion Grade 3 n = 226 Myocardial Perfusion Grades 2/1/0 Gibson et al, Circulation 2000
Myocardial Perfusion & Mortality: 8 Years of Follow-Up 3 n=148 2 Survival n=393 § Majority of patients have TIMI Grade 3 flow in epicardial artery after primary PCI However 0/1 n=236 90 360 900 1440 2250 § 2 of 3 pts have a 0 cosed muscle after primary PCI 2790 Time (days) Clinical Trial Results. org van ‘t Hof AWJet al. Circulation 1998; 97: 2302 -6.
Two Chamber View Abn TMPG = 8 X Risk Of HE (p = 0. 02) Circulation. 2006; 114: 662 -669. Clinical Trial Results. org
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 Clinical Trial Results. org Selvanayagam, Circulation. 2005; 111: 1027 -1032.
Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct Size & Poorer Salvage p=0. 004 % SPECT Infarct Size Median = 13 Dibra et al, JACC 2003: 41: 925 -929 Median = 7 n=113 TMPG 2/3 n=108 TMPG 0/1 Angeja et al; Circulation 2002 Clinical Trial Results. org In a multivariate model, TMPG 2/3 remained independently associated with a higher salvage index (p=0. 001)
28 mm Hg p=0. 001 9 mm Hg % with PA wedge > 18 mm Hg Coronary Wedge Pressure Poorer TMPG is Associated with Higher Coronary Wedge Pressure (Pressure Distal to Stenosis) and Higher Pulmonary Capillary Wedge Pressure 56% p=0. 02 44% Closed Open TMPG 0/1 TMPG 2/3 K P Balachandran et al; Heart. 2004; 90: 1450 -1454. Clinical Trial Results. org Kirtane AJ et al; J Thrombolysis. 2004; 17: 177 -84
Wire Passage in STEMI Can Be Associated with Staining (TMPG 1) Clinical Trial Results. org Gibson 2004
- Slides: 11