(Circulation. 2000;101:2361.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Relation of Phasic Coronary Flow Velocity Characteristics With TIMI Perfusion Grade and Myocardial Recovery After Primary Percutaneous Transluminal Coronary Angioplasty and Rescue Stenting
From the Department of Cardiology, Kobe General Hospital, Kobe (T.A., T.K., S.K., Y.U., A.Y., T.T., T.H.), and the Department of Cardiology, Kawasaki Medical School, Okayama (K.Y.), Japan.
Correspondence to Takashi Akasaka, MD, Department of Cardiology, Kawasaki Medical School, Matsushima 577, Kurashiki City, Okayama, 701-0192, Japan. E-mail akasaka{at}med.kawasaki-m.ac.jp
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Abstract |
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Background—A residual stenosis and/or microvascular damage have been proposed as mechanisms of TIMI 2 flow for acute myocardial infarction. Coronary flow dynamics were assessed in patients with TIMI 2 flow to predict whether additional intervention would improve TIMI grade.
Methods and Results—In 35 patients who had a successfully recanalized anterior acute myocardial infarction using angioplasty or rescue stenting, coronary flow patterns were compared with corresponding TIMI grade and regional left ventricular wall motion (LVWM) 1 month after the intervention. After angioplasty, the time-averaged peak velocity (APV) was lower in patients with TIMI 2 flow (n=22) than in those with TIMI 3 flow (n=13; 7.9±3.9 versus 20.6±5.1 cm/s; P<0.001). Two different flow patterns were recorded in patients with TIMI 2 flow (versus TIMI 3, P<0.001); patients with type 1 TIMI 2 flow (n=15) had a reduced diastolic APV (8.3±4.8 versus 24.2±7.4 cm/s), prolonged diastolic deceleration time (1176±455 versus 728±205 ms), and a small diastolic/systolic APV ratio (1.3±0.6 versus 2.1±0.7); patients with type 2 TIMI 2 flow (n=7) had systolic flow reversal (systolic APV, -7.9±4.6 versus 11.7±4.5 cm/s), a rapid diastolic deceleration time (221±84 versus 728±205 ms), and a negative diastolic/systolic APV ratio (-2.1±1.4 versus 2.1±0.7). A significantly lower mean chord LVWM (-3.0±0.2 versus -1.9±0.8; P<0.001) and a greater number of chords <-2SD (50±2 versus 28±18; P<0.001) were present in patients with type 2 versus type 1 TIMI 2 flow. Stenting increased TIMI 2 flow to TIMI 3 flow more in patients with type 1 than type 2 flow (67% versus 0%; P=0.003). Patients with TIMI 2 flow after stenting continued to demonstrate a type 2 pattern, and they had poor LVWM recovery.
Conclusions—The differentiation between 2 types of TIMI 2 flow can predict the improvement of TIMI grade and LVWM recovery after additional stenting.
Key Words: angioplasty • coronary disease • diagnosis • myocardial infarction • reperfusion
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Introduction |
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The Thrombolysis in Myocardial Infarction (TIMI) Study Group grading scale1 has been widely accepted as a semiquantitative measure of coronary perfusion. Some have reported that the outcome of patients with TIMI 2 flow does not differ from that of patients with reperfusion failure.2 Recently, however, early TIMI 2 flow was associated with left ventricular (LV) functional recovery if flow normalized at follow-up.3 TIMI 2 flow may be due to a smaller minimal lumen diameter and a higher incidence of incomplete clot lysis and thrombus in the infarcted vessel.3 Although percutaneous transluminal coronary angioplasty (PTCA) produces superior recanalization rates and improved clinical outcomes when compared with thrombolytic therapy,4 5 6 persistently slow flow may indicate microvascular dysfunction associated with poor LV functional recovery.7 8 9 The differentiation between a residual stenosis and/or microvascular dysfunction as the main cause of slow radio-contrast flow in the infarct-related artery has implications for therapy and LV functional recovery.
Characteristic coronary flow velocity patterns with suppressed diastolic velocity and a smaller diastolic/systolic flow velocity ratio have been demonstrated in the poststenotic region.10 11 In patients with an acute myocardial infarction (AMI), slow-flow velocity has been reported in patients who have TIMI 2 flow12 with a characteristic coronary flow velocity pattern (systolic retrograde flow and rapid deceleration of diastolic flow) that is associated with the "no-reflow" phenomenon (determined using myocardial contrast echocardiography).13 Because 2 different types of coronary flow velocity patterns may be expected in TIMI 2 cases, we hypothesized that the type of flow velocity pattern in the infarcted artery could differentiate a residual coronary stenosis from microvascular damage. The purpose of this study was to assess the coronary flow dynamics of TIMI 2 flow before and after intervention for AMI to predict whether additional coronary intervention would improve TIMI grade and LV recovery.
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Methods |
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Study Patients
The study population consisted of 35 consecutive patients who had a successfully recanalized anterior AMI using primary PTCA (with or without rescue stenting) within 6 hours after the onset of symptoms. The diagnosis of AMI was defined as (1) chest pain continuing for >30 minutes, (2) ST elevation >2.0 mm in
2 contiguous
precordial ECG leads, (3) an increase of serum creatine
phosphokinase >3-fold of normal value, and (4) TIMI grade 0, 1, or 2
flow at initial coronary angiography. Patients with previous
myocardial infarction, valvular heart disease, primary
myocardial disease, and cardiogenic shock were excluded from the study.
After written informed consent was obtained, emergency coronary
angiography, PTCA (with or without rescue stenting), and
coronary flow velocity recordings were performed as
previously described.10 11 12 13
Coronary Angiography
Coronary angiography was performed using the standard
femoral approach. All patients received an intravenous
injection of 4000 U of heparin and an intracoronary injection
of 2 mg of isosorbide dinitrate before angiography. Cinefilm was
recorded at a speed of 30 frames/s. The angiographic TIMI flow
grade of the infarcted left anterior descending coronary artery
(LAD) was assessed before and after interventions using a cine
projector with a frame counter, as previously
described.12 14 Angiographic collateral circulation was
assessed before PTCA in accordance with the report of Rentrop et
al.15 To measure the percent diameter stenosis of
the culprit lesion of the LAD, quantitative coronary
angiography was performed using an auto-edge detection method with a
commercially available system (CMS, Medical Imaging Systems), according
to the previous report.16 17 An 8-Fr guiding catheter
(Cyber, Scimed, Boston Scientific) was used as a reference. Follow-up
coronary angiography and left ventriculography were also
performed in the same way using a 5-Fr catheter (Selecon, Clinical
Supply) 1 month (21±6 days) after intervention.
Coronary Intervention
After the diagnostic angiography, PTCA was performed
in the usual manner with a standard 8-Fr guiding catheter, balloon
catheters, and a 0.014-inch, 15 MHz, Doppler-tipped angioplasty
guidewire (Flo- Wire, Cardiometrics).18 19 This was
done after the administration of additional heparin to maintain an
active clotting time >300 s. No other anticoagulant or
antiplatelet agents were administered. Angioplasty success was
defined as <30% residual stenosis angiographically with TIMI
3 flow. In cases with 30% stenosis and/or TIMI 2
flow, rescue stenting was performed with a Palmaz-Schatz stent (Johnson
& Johnson). The final end point of coronary intervention, with
or without rescue stenting, was defined as a residual stenosis
<30% (determined angiographically), with TIMI 2 or 3 flow. The
balloon/artery ratio was obtained at the end of the intervention.
Coronary Flow Velocity Recordings
Coronary flow velocities were recorded in the
mid-LAD, distal to the culprit lesion, using the Doppler guidewire
and a velocimeter (FloMap, Cardiometrics) after
coronary angiography and after the interventions that were done
according to the previous reports.10 11 12 18 19
The time-average of the instantaneous spectral peak velocity (time-averaged peak velocity [APV]) during 1 cardiac cycle, the systolic and diastolic APVs, the diastolic/systolic APV ratio (DSVR), and the deceleration time of the diastolic velocity were measured from phasic coronary flow velocity recordings using off-line computerized planimetry in the same manner as previously reported.13 Coronary flow velocity reserve was obtained from the ratio of maximal hyperemic APV (induced by 0.14 mg · kg-1 · min-1 adenosine infusion intravenously) to the baseline resting APV.
Regional LV Function
LV wall motion (LVWM) was assessed by left ventriculograms
obtained 1 month (21±6 days) after intervention and analyzed
by the centerline method.20 21 22 The mean value of each
chord motion and the number of chords more severe than -2SD below the
mean of a normal reference was obtained in the territory of the LAD
defined by chords 10 to 66.20 22
Statistical Analysis
All data are expressed as mean±SD. Unpaired t tests
were performed to compare the angiographic data,
hemodynamic characteristics, and coronary flow
velocity data in the 2 groups of TIMI 2 flow after PTCA. One-way ANOVA
was used to compare the 5 groups of TIMI 2 or 3 flow before and after
PTCA and after stenting, and a Scheffe F-test was performed if the
ANOVA showed significant differences. Incidences of flow improvement
from TIMI 2 to 3 were compared with the 
2
test. P<0.05 was considered significant.
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Results |
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Patient Subgroups and Clinical Data
Baseline clinical characteristics and hemodynamic data are shown in Table 1
. At the initial
coronary angiography, TIMI grades 0, 1, 2, and 3 were observed
in 9, 10, 16, and 0 cases, respectively (Figure 1). After primary PTCA, TIMI 2 flow was
observed in 22 cases, and TIMI 3 flow in 13, including 6 who achieved
sufficient angiographic criteria. No cases had TIMI 0 or 1 flow.
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Rescue stenting after PTCA was performed in all 22 patients with TIMI 2 flow because of incomplete results by angiography and/or TIMI grade and in 7 of the 13 patients with TIMI 3 flow because of an insufficient angiographic end point.
After rescue stenting, TIMI 2 flow was demonstrated in 12 cases
and TIMI 3 flow was obtained in 17. Ten of 22 cases with TIMI 2 flow
after PTCA improved to TIMI 3 flow after rescue stenting. Twelve
patients remained in the TIMI 2 flow group, despite rescue stenting
(Figure 1
). TIMI 3 flow was obtained in 23 patients, including
17 with and 6 without a stent; TIMI 2 flow was observed in 12 patients
after final intervention.
No significant differences existed in the clinical characteristics or
hemodynamic data among the 5 groups of patients with
TIMI 2 or TIMI 3 flow that are listed in Table 1.
Coronary Angiography Data
In the frames-to-opacification count of coronary
angiography (Table 1), no significant
differences existed among the 3 groups of patients with angiographic
TIMI 2 flow before and after PTCA and after stent implantation
(P=0.40). A significant difference was demonstrated between
the groups with TIMI 2 and TIMI 3 flow
(P<0.001).
The percent diameter stenosis in patients with TIMI 2 flow before and after angioplasty was significantly greater than that in patients with TIMI 3 flow. No significant difference existed in the percent diameter stenosis between cases with TIMI 2 flow after stenting and those with TIMI 3 flow. The minimum lumen diameter in patients with TIMI 2 flow before and after angioplasty was significantly smaller than that in cases with TIMI 3 flow. The minimum lumen diameter in patients with TIMI 2 flow after stenting was not significantly different from that in cases with TIMI 3 flow. The end-diastolic diameter of the reference LAD and the balloon/artery ratio at the time of final intervention were not significantly different among the groups of patients with TIMI 2 or TIMI 3 flow.
Follow-up angiography demonstrated a patent LAD in all 35 patients. No significant differences in percent diameter stenosis existed among groups.
Coronary Flow Velocity Data: Comparison Between TIMI 2 and
TIMI 3 Flow
Before angioplasty, a characteristic phasic flow velocity
pattern with a reduced APV accompanying a restricted
diastolic APV, prolonged diastolic deceleration
time, and a small DSVR (type 1 pattern, Figures 2 and 3)
was observed in 15 of 16 patients with TIMI 2 flow; it was different
from the TIMI 3 flow pattern (Figure 3).
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After angioplasty, type 1 flow was observed in 15 of the 22
cases (Table 2 and Figure 1) with TIMI 2 flow. However, a
different phasic flow pattern, with a restricted APV accompanying a
systolic flow reversal, negative DSVR, and rapid
diastolic deceleration was observed in the remaining 7
cases (type 2 pattern; Table 2 and Figures 2 and 3). As a result, each of the indices in cases with TIMI 2 flow
after angioplasty had intermediate values resulting from the average of
the 2 different flow patterns (Table 3).
Figure 4 shows changes in APV,
systolic APV, DSVR, and deceleration time during the 3 study
periods.
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demonstrates TIMI 3 flow; 
indicates patients with TIMI 3 flow who
obtained angiographic end point without stenting.
After stenting, a type 2 flow pattern was demonstrated in all
patients with TIMI 2 flow (Table 3 and Figure 4). No
significant differences existed between indices of flow or
coronary flow reserve in the patients with TIMI 3 flow after
PTCA or stenting (Table 3).
Phasic Coronary Flow Velocity Patterns in TIMI 2
Flow
After rescue stenting, TIMI 2 flow remained in 5 of the 15
patients with type 1 flow, but their phasic flow pattern had changed
from type 1 to type 2. The remaining 10 of these 15 patients with type
1 TIMI 2 flow had TIMI 3 flow (Figures 1, 3, and 4) after stenting. A total of 7 type 2–pattern patients did not
change, even after stent implantation. The incidence of flow
improvement from TIMI 2 to 3 after rescue stenting was significantly
higher in patients with type 1 versus type 2 TIMI 2 flow (67% versus
0%; P=0.003; Figures 1 and 4).
Phasic Coronary Flow Velocity Patterns in TIMI 3
Flow
No significant differences existed in coronary flow
velocity patterns in TIMI 3 flow patients after PTCA or stenting (Table 3). In 7 of 13 cases with TIMI 3 flow after angioplasty, no
significant differences existed in coronary flow indices before
and after stenting. Furthermore, among the 3 types of patients with
TIMI 3 flow, including the 6 patients who achieved angiographic
criteria without stenting, 7 who underwent additional stenting because
of angiographic criteria, and 10 who improved from TIMI 2 to 3 flow
after rescue stenting (Figure 1), no significant differences
existed in the indices of coronary flow.
Phasic Coronary Flow and Relation to LV Function
Recovery
LVWM 1 month after treatment showed that mean chord motion
was significantly smaller and the number of chords <-2SD of LVWM was
significantly greater in patients with TIMI 2 flow after stenting
compared with those with TIMI 3 flow. No significant differences
existed in mean chord motion and number of cords <-2SD of the LVWM
among patients with TIMI 2 flow both before and after angioplasty and
those with TIMI 3 flow (Table 1). In cases with TIMI 2 flow after
angioplasty, mean chord LVWM was significantly smaller and the number
of chords <-2SD of LVWM were significantly greater in type 2 compared
with type 1 patients (Table 2). Furthermore, among the 3 different
groups with TIMI 3 flow including 6 cases without stenting, 7 cases who
were in TIMI 3 before and after stenting, and 10 cases who obtained
TIMI 3 after stenting (Figure 3), no significant differences existed in
mean chord motion and number of chords <-2SD of the LVWM 1
month after intervention. However, mean chord motion was significantly
greater (P=0.003, respectively) and the number of chords
<-2SD was significantly smaller (P=0.005, respectively) in
each TIMI 3 group compared with TIMI 2 patients after
stenting.
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Discussion |
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The present study demonstrated that coronary flow velocity measurements can distinguish between 2 different types of phasic TIMI 2 flow patterns after AMI recanalization and that these flow patterns are associated with different degrees of improvement in TIMI grade and LV function. Patients with the type 1 pattern (reduced APV with depressed diastolic APV, prolonged diastolic deceleration, and small DSVR) had a greater achievement of TIMI 3 flow, with good LVWM recovery after additional stenting. Patients with type 2 flow (restricted APV with systolic flow reversal and rapid diastolic deceleration) remained at TIMI 2, with poor LVWM recovery even after stent implantation. Thus, these 2 types of TIMI 2 flow predicted whether rescue stent implantation would improve outcome after PTCA for AMI, despite an angiographically successful PTCA result.
TIMI 2 Flow Before Angioplasty and After Stent
Implantation
A restricted APV, indicating a small amount of antegrade
coronary flow (confirmed by greater TIMI frame count compared
with TIMI 3 flow), was observed in patients with TIMI 2 flow, which is
consistent with earlier studies.12 This reduced
APV in the infarcted LAD was seen in cases both before PTCA and after
stenting; the difference is attributable to the degree of
stenosis in the infarcted coronary artery. Depressed
diastolic APV and a small DSVR in the distal
coronary artery have been reported in cases with a significant
coronary stenosis,10 11 and a reduced APV
can be expected in these cases. In the present study, this
characteristic flow pattern was demonstrated in patients with TIMI 2
flow before PTCA, which is consistent with the presence of a
significant coronary stenosis. In cases with the
no-reflow pattern caused by microvascular damage after angiographically
successful reperfusion, a coronary flow velocity pattern with
early systolic retrograde flow and rapid diastolic
deceleration has been described.13 In these cases, a
restricted APV may also be expected, without coronary
stenosis. In the present study, this distinctive flow
pattern was observed in 12 cases with TIMI 2 flow, even after stenting.
Thus, in patients with TIMI 2 flow, the mechanism of slow antegrade
flow may be different before angioplasty and after stenting, despite
the similar angiographic TIMI grade. A significant coronary
stenosis may cause type 1 TIMI 2 flow, and microvascular
damage, type 2 TIMI 2 flow. As a result, flow velocity patterns,
as shown in this study, can differentiate these 2 mechanisms.
TIMI 2 Flow After Balloon Angioplasty
Seven patients with type 2 flow after PTCA had a similar type 2
TIMI 2 flow after rescue stenting. The mechanism of the phasic flow
pattern in these 7 cases is thought to be related to microvascular
damage; this is supported in part by the fact that the flow velocity
pattern did not change after the elimination of the stenosis by
stent implantation. In addition, poor LVWM recovery was also
demonstrated in these TIMI 2 patients after rescue stenting. It has
been reported that the outcome of patients with TIMI 2 flow does not
differ from that of patients with reperfusion failure,2
which is consistent with the current findings. These data imply
that type 2 TIMI 2 flow after intervention may be caused predominantly
by microvascular damage.
In the 15 type 1 cases with TIMI 2 flow after angioplasty, the coronary flow velocity pattern showed reduced APV with suppressed diastolic APV and a small DSVR, which is consistent with a residual coronary stenosis. The greater percent diameter stenosis in these cases compared with patients after stenting and those with TIMI 3 flow also supports the presence of residual coronary stenosis. In these type 1 cases, additional stenting was associated with an improvement of TIMI grade and LVWM recovery in 10 of the 15 patient. In cases with AMI, it is difficult to estimate the degree of coronary stenosis by angiography alone, especially after angioplasty due to thrombus in the culprit lesion. However, the Doppler flow velocity patterns may indicate a significant residual stenosis, despite an angiographically insignificant appearance.23
The remaining 5 of the 15 type 1 cases demonstrated type 2 TIMI 2 flow after the release of the residual stenosis by additional stenting, which is consistent with persistent microvascular damage. This result suggests that, in cases with a significant epicardial coronary stenosis combined with microvascular dysfunction in AMI, the epicardial coronary stenosis may be the main limiting factor of the coronary flow pattern and that microvascular dysfunction might be concealed. Microvascular dysfunction can play an important role in coronary flow dynamics only after the release of the significant stenosis. Further study in patients with both coronary stenosis and microvascular damage would help to resolve the mechanism involved in the conversion from type 1 to type 2 flow patterns in patients with TIMI 2 flow.
From the practical point of view, the differentiation between TIMI 2 flow caused by microvascular damage and that by a residual stenosis is important because additional stenting in cases with microvascular damage without a stenosis would be unhelpful, whereas additional intervention would improve flow in cases with a residual stenosis.3 Furthermore, as shown here, better LVWM recovery could be expected, with flow improvement from TIMI 2 to TIMI 3.
Study Limitations
Several limitations of the present study must be
considered. Although the degree of coronary artery
stenosis was assessed by quantitative angiography in the
present study, the limitations of angiography in determining the
percent diameter stenosis after intervention are well
known.23 Thrombus in the culprit lesion makes it more
difficult to estimate the degree of stenosis correctly in the
acute period. Also, the study patients were limited to those with
anterior AMI. The predominance of systolic flow and small DSVR
have been described in the right coronary
artery.11 24 25 The differentiation between TIMI 2 flow
with a significant coronary stenosis and TIMI 3 flow
may be more difficult in the right coronary artery. Finally,
the number of study patients is relatively limited. However, the study
patients were consecutive. The clinical, angiographic, and
coronary flow results of intervention were similar to previous
studies.7 13 Relatively higher creatine phosphokinase
releases were observed in patients with TIMI 2 flow and, although not
statistically different from that of patients with TIMI 3 flow, these
levels may reflect larger infarcts and a greater chance for no reflow
patterns.
Conclusions
Two different types of phasic coronary flow velocity
patterns are associated with TIMI 2 flow. Type 1 flow has a reduced
diastolic peak velocity, prolonged diastolic
deceleration, and a small DSVR, suggesting a residual coronary
stenosis. It is associated with improved flow and LV function
after stenting. Type 2 flow has systolic flow reversal and
rapid diastolic deceleration, indicating microvascular
damage, and it does not usually improve after intervention. The
differentiation between these 2 types of TIMI 2 flow using Doppler
flow velocity measurements may facilitate decisions regarding
additional lesion intervention for an AMI after angiographically
successful PTCA.
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Acknowledgments |
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We thank Prof Morton J. Kern of St. Louis University Hospital for his assistance in the preparation of this manuscript.
Received May 11, 1999; revision received December 16, 1999; accepted December 22, 1999.
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