Is PCI necessary for AMI related artery with TIMI 3 flow ? Donghoon Choi Yonsei Cardiovascular Center Yonsei University College of Medicine

M/63 Chest pain of 1 hour

Coronary Angiography Coronary Angiography

What do you think the fate of m-LAD after primary PCI will be ?

Primary PTCA VS Thrombolysis Weaver WD et al. JAMA 1997;278: TIMI 3 FlowDeathDeath or MICVAICH PTCAThrombolysis * * * ** * p<0.001 (%)

TIMI Flow Grades at Initial Angiography Stone GW et al. Circulation 2001;104:636 % patients n=2507

Survival after Primary PTCA in AMI by Initial TIMI Flow TIMI 3 TIMI 2 TIMI 0/1 Stone GW et al. Circulation 2001;104:636

Final TIMI Flow after Primary PCI and 30-day Mortality in AMI GUSTO IIb NEJM 1997;336:1621

Final TIMI 3 Flow !!!

Primary PCI PrePost ballon angioplasty M/63

Primary PCI After IC Verapmil Post stenting (GFX 3.0 x 24) M/63

Pathophysiology of AMI Ruptured fibrous cap with thrombus

Embolized Platelet Aggregate in a Small Myocardial Arteriole

Likelihood of Distal Embolization Spontaneous reperfusion (endogenous thrombolysis) Thrombolytic therapy PTCA Stenting more less

STENT- PAMI 6 month mortality Final TIMI 3 flow Grines CL et al. NEJM 1999;341:1949 p=0.10 p=0.27

Cura et al. JACC 2001;88:124 Final TIMI Flow in Relation to Initial TIMI Flow Pre TIMI 0,1 (n = 649) Pre TIMI 2 (n = 166) Pre TIMI 3 (n = 76) Final TIMI Flow : TIMI 3TIMI 0, 1, 2

Impact of Stenting on Coronary Blood Flow after Balloon angioplasty in Primary PCI Escobar et al. AJC 2001;88:1410 based on frame count patients

Effects of Adjuvant Balloon on CT-Frame Count Increased CTFC : 20 pts(43.5%) Decreased CTFC : 15 pts(32.6%) No change in CTFC : 11pts(23.9%) Change in CTFC % of total pts 43.5 % 32.6 % 23.9 % Koo BG et al. Korean Circulation in Press

TIMI 3 Flow !!!

Survival by Initial and Final Procedural TIMI flow % 80% 85% 90% 95% 100% TIMI Flow N (%) 6 month pre post patients mortality (15.8%) 0% 0~2 3 1,786(76.8%) 3.6% 0~2 0~2 166 (7.1%) 8.6% 3 0~2 7 (0.3%) 20.0% Stone GW et al. Circulation 2001;104:636

CADILLAC P = NS Stone GW et al. NEJM 2002;346:957

Conclusion Primary PCI can harm coronary blood flow in AMI. Therefore, PCI is neccesary only in AMI with impaired initial coronary perfusion.