1. Dye strongly persistent
Other Angiographic Efficacy Endpoint: 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%
Mortality (%)
p = 0.05
4.4%
Lecture Notes:
While the TIMI flow grades and the TIMI frame count assess flow in the epicardial arteries, the TIMI Myocardial Perfusion Grades (TMPG) assesses flow at the tissue level. Views are chosen to minimize superimposition of non-infarcted territories in the assessment of the culprit artery’s TMP Grade. The duration of cinefilming should be equal to or exceed 3 cardiac cycles in the washout phase to assess the washout of the myocardial blush. Care should be taken not to mistake filling of the venous system such as the great cardiac vein as blush. Blush is assessed during the same phase of the cardiac cycle as it may be less intense during diastole.
TIMI Myocardial Perfusion Grade 0: Failure of dye to enter the microvasculature. Either minimal or no ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit artery indicating lack of tissue level perfusion.
TIMI Myocardial Perfusion Grade 1: Dye slowly enters but fails to exit the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that fails to clear from the microvasculature, and dye staining is present on the next injection (approximately 30 seconds between injections).
TIMI Myocardial Perfusion Grade 2: Delayed entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that is strongly persistent at the end of the washout phase (i.e. dye is strongly persistent after 3 cardiac cycles of the washout phase and either does not or only minimally diminishes in intensity during washout).
TIMI Myocardial Perfusion Grade 3: Normal entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that clears normally, and is either gone or only mildly/moderately persistent at the end of the washout phase (i.e. dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery. Blush that is of only mild intensity throughout the washout phase but fades minimally is also classified as grade 3.
References:
Gibson CM, et al. Circulation. 2000;101:
2.0%
n = 203
n = 46
n = 79
n = 434
Gibson et al, Circulation 2000
© Gibson CM 2004
Neumann F-J, Blasini R, Schmitt C, et al. Effect of glycoprotein IIb/IIIa receptor blockade on recovery of coronary flow and left ventricular function after the placement of coronary-artery stents in acute myocardial infarction. Circulation. 1998;98:

2. 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%
Lecture Notes
This slide illustrates that not all TIMI Grade 3 flow is created equally. Every patient shown here had successful reperfusion with TIMI Grade 3 Flow. However, if the myocardium was occluded (TMPG Grades 0/1 on the right), the mortality remained elevated at 5.4%. It is not until both the epicardial artery and the myocardium are open (TMPG 3 shown on the far left), that the mortality was lowest in acute MI, below 1%.
References:
Gibson CM, et al. Circulation. 2000;101:
N = 278
N = 136
N = 34
Myocardial
Perfusion
Grade 3
Myocardial
Perfusion
Grade 2
Myocardial
Perfusion
Grades 0/1
© Gibson CM 2004
Gibson CM, et al. Circulation. 2000;101: