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Published on: May 28, 2019
The relationship of intracoronary stent placement following thrombolytic therapy to tissue level perfusion
C Michael Gibson1, Daniel Frisch, Sabina A Murphy
1Harvard Clinical Research Institute, Boston, MA 02215, USA.
Insights
Adjunctive stenting in acute myocardial infarction (AMI) improves epicardial blood flow and myocardial perfusion. However, increased dye staining suggests potential impairment of dye outflow after stenting.
Area of Science:
- Cardiology
- Interventional Cardiology
- Myocardial Perfusion Imaging
Background:
- Stenting enhances lumen diameter and epicardial blood flow.
- Tissue-level perfusion impact post-stenting remains undercharacterized.
Purpose of the Study:
- To evaluate the effect of adjunctive stenting on myocardial perfusion in patients with acute myocardial infarction (AMI).
- To assess changes in myocardial blush and tissue perfusion following stenting.
Main Methods:
- Analysis of data from the LIMIT trial involving patients with AMI treated with rhuMAb CD18.
- Adjunctive/rescue stenting performed per investigator discretion.
- Assessment of TIMI Myocardial Perfusion Grade (TMPG) and quantitative myocardial blush using digital subtraction angiography (DSA).
Main Results:
- Significant improvement in TIMI 3 flow (54.2% to 87.2%) and Corrected TIMI Frame Counts (CTFCs) post-stenting (p < 0.001).
- Reduction in TMPG 0 (25.2% to 14.3%, p = 0.03) and increase in TMPG 1 (13.5% to 28.6%, p = 0.004).
- Myocardial blush brightness by DSA showed a trend towards increase post-stenting (p = 0.07).
Conclusions:
- Adjunctive stenting improves epicardial flow and myocardial dye inflow in AMI.
- While reducing no-flow (TMPG 0), stenting increased myocardial staining (TMPG 1), indicating potential outflow impairment.
Background:
Stenting has been shown to improve lumen diameters and thereby improve epicardial blood flow, but the impact of stent placement on tissue level perfusion has not been well characterized.
Methods:
Data were drawn from the LIMIT trial of rhuMAb CD18 (anti WBC antibody) in acute myocardial infarction (AMI). Adjunctive/rescue stenting was performed at the discretion of the investigator. The TIMI Myocardial Perfusion Grade (TMPG) was assessed and digital subtraction angiography (DSA) was used to quantify brightness of the myocardial blush.
Results:
TIMI 3 flow was 54.2% (64/118) before stent placement, and improved to 87.2% (102/117, p < 0.001) following stent placement. Likewise, Corrected TIMI Frame Counts (CTFCs) improved from medians of 37.6 to 21 (p < 0.001). By DSA, the rate of growth in brightness also tended to be greater after stenting (2.3 +/- 0.4 Gray/sec, n = 54 vs 3.1 +/- 0.3, n = 54, p = 0.07). The incidence of TMPG 0 decreased following stent placement (25.2% (29/118) vs 14.3% (16/118), p = 0.03) and the incidence of a stain in the myocardium (TMPG 1) increased (13.5% (16/118) vs 28.6% (34/118), p = 0.004).
Conclusion:
Adjunctive stenting following thrombolytic administration in AMI improves epicardial TIMI 3 flow and TIMI frame counts as well as dye inflow into the myocardium: TMPG 0 is reduced and myocardial blush measured quantitatively by DSA tends to be brighter. However, more TMPG 1 or dye staining was present on next injection, suggesting dye outflow may be impaired.
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