C. Thrombus burden according to TIMI thrombus grading system

Transcription

1 The Supplementary appendix A. TIMI flow grading system B. Coronary lesions classification C. Thrombus burden according to TIMI thrombus grading system D. TIMI frame count E. Myocardial blush grade

2 A. TIMI flow grades: 6 Grade 0: no perfusion (no antegrade flow beyond the point of occlusion) Grade 1: penetration without perfusion (contrast material passes beyond the area of obstruction but fails to opacify the entire coronary bed distal to the obstruction for the duration of the cineangiographic filming sequence) Grade 2: partial perfusion (contrast material passes across the obstruction and opacifies the coronary artery distal to the obstruction however, the rate of entry of contrast material into the vessel distal to the obstruction or its rate of clearance from the distal bed (or both) is perceptibly slower than its flow into or clearance from comparable areas not perfused by the previously occluded vessel) Grade 3: complete perfusion (antegrade flow into the bed distal to the obstruction occurs as promptly as antegrade flow into the bed proximal to the obstruction, and clearance of contrast material from the involved bed is as rapid as clearance from an uninvolved bed in the same vessel or the opposite artery). B. Coronary lesions classification according to ACC/AHA guidelines: Type A lesions (Minimally complex high success > 85%, low risk): Discrete (length <10 mm) Concentric Readily accessible. Non angulated segment (<45 o ). Smooth contour.

3 Little or no calcification. Less than totally occlusive. Not ostial in location. No major side branch involvement. Absence of thrombus. 2. Type B lesions (moderately complex moderate success 60-85%, moderate risk): Tubular (length 10 to 20 mm). Eccentric. Moderate tortuosity of proximal segment. Moderately angulated segment (>45 o, <90 o ). Irregular contour. Moderate or heavy calcification. Total occlusions <3 months old. Ostial in location. Bifurcation lesions requiring double guide wires. Some thrombus present. 3. Type C lesions (severely complex low success < 60%, high risk): Diffuse (length >2 cm). Excessive tortuosity of proximal segment. Extremely angulated segments >90 o Total occlusions >3 month old and/or bridging collaterals. Inability to protect major side branches. Degenerated vein grafts with friable lesions.

4 C. Thrombus burden according to TIMI thrombus grading system: 15 Grade 0= no thrombus. Grade 1= intraluminal haziness. Grade 2= definite thrombus < 1/2 vessel diameter. Grade 3= definite thrombus vessel diameter. Grade 4= definite thrombus > 2 vessel diameters. Grade 5= there is total recent thrombotic occlusion occlusion if they ended abruptly with a squared-off or an upstream convex termination. D. TIMI frame count: 16 It is a simple count of the number of cineframes required for contrast to first reach standardized distal coronary landmarks in the infarct-related artery (the TIMI frame count) by means of an automated frame counter. The first frame used for TIMI frame counting is the first frame in which dye fully enters the artery. This occurs when three criteria are met: (1) A column of nearly full or fully concentrated dye must extend across the entire width of the origin of the artery; (2) Dye must touch both borders of the origin of the artery; and (3) There must be antegrade motion to the dye. The following distal landmark branches are used for analysis: the distal bifurcation of the LAD (ie, the "mustache," "pitchfork," or "whale's tail"); in the LCX system, the distal bifurcation of the segment with the longest total distance that includes the culprit lesion; and in the RCA, the first branch of the posterolateral artery.

5 Coronary angiography was filmed at 12.5 frames/s. The original TFC is described for a cinefilm speed of 30 frames/s. To make the results of TFC analysis comparable between different studies, an adaptation to the cinefilm speed of 30 frames/s was performed as previously described. Therefore, the frame counts were multiplied by 2.4 (correction factor). LAD frame counts were corrected by dividing by 1.7 to derive the corrected TIMI frame count (ctfc). E. Myocardial blush Grade: 17 Grade 0: no myocardial blush or contrast density. Grade 1: minimal myocardial blush or contrast density. Grade 2: moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non infarctrelated coronary artery. Grade 3: normal myocardial blush or contrast density, comparable with that obtained during angiography of a contralateral or ipsilateral non infarctrelated coronary artery. Notes: 1. The washout phase is the time after the end of dye injection during which dye would normally be expected to clear from the epicardial vessels during opacification of the myocardium, followed by clearing from the myocardium. 2. The left lateral view for the LAD and LCX, and the left anterior oblique with cranial tilt view for the RCA were chosen to assess the MBG.

6 3. The duration of cinefilming should exceed 3 cardiac cycles in the washout phase to assess the washout of the myocardial blush. This would require filming for approximately 5 to 6 cardiac cycles (5 to 6 seconds). 4. MBG 2 or 3 will be defined as good myocardial tissue-level perfusion. 5. All cineangiograms were taken at a speed of 25 frames/s