**2.2 Echocardiography**

All patients had complete Doppler echcardiographic studies, within the first 6 hours after primary PCI, 48 hours later, and 5 days after the intervention.

Siemens, Acuson Sequoia echocardiographic system, California, equipped with 3.5-7MHZ transducers was used. All patients had complete Doppler echcardiographic studies, within the first 6 hours after primary PCI, 48 hours after primary PCI, and 5 days after primary PCI.

In order to obtain LAD flows, the color Doppler Nyquist limit was set at 17 cm/sec or power Doppler modality was applied. Systematic attempt to get LAD-color flow were performed. From low parasternal short axis view, search for diastolic color flow in the anterior interventricular groove followed by clockwise rotation was performed, while form apical foreshortened two chamber views LAD diastolic flow was located in the interventricular groove and the counterclockwise rotation of the transducer was performed. Colour Doppler sampling was easy to achieve, branches could be seen (figure 1) and margins of colour jet well delineated allowing measurement of jet width (figure 2).

Fig. 1. Colour Doppler of the LAD and diagonal branch

Fig. 2. Colour Doppler of the LAD allowing measurement of jet width

Pulsed-wave Doppler sampling was consistent (figure 3), with dominant diastolic component and clear envelope easy to trace (figure 4) and well demonstrated systolic component (figure 5).

All patients had complete Doppler echcardiographic studies, within the first 6 hours after

Siemens, Acuson Sequoia echocardiographic system, California, equipped with 3.5-7MHZ transducers was used. All patients had complete Doppler echcardiographic studies, within the first 6 hours after primary PCI, 48 hours after primary PCI, and 5 days after primary

In order to obtain LAD flows, the color Doppler Nyquist limit was set at 17 cm/sec or power Doppler modality was applied. Systematic attempt to get LAD-color flow were performed. From low parasternal short axis view, search for diastolic color flow in the anterior interventricular groove followed by clockwise rotation was performed, while form apical foreshortened two chamber views LAD diastolic flow was located in the interventricular groove and the counterclockwise rotation of the transducer was performed. Colour Doppler sampling was easy to achieve, branches could be seen (figure 1) and

margins of colour jet well delineated allowing measurement of jet width (figure 2).

primary PCI, 48 hours later, and 5 days after the intervention.

Fig. 1. Colour Doppler of the LAD and diagonal branch

Fig. 2. Colour Doppler of the LAD allowing measurement of jet width

component (figure 5).

Pulsed-wave Doppler sampling was consistent (figure 3), with dominant diastolic component and clear envelope easy to trace (figure 4) and well demonstrated systolic

**2.2 Echocardiography** 

PCI.

Fig. 3. Consistent pulsed-wave Doppler sampling of LAD blood velocity

Fig. 4. Pulsed-wave Doppler of LAD blood velocity with dominant, easy to trace diastolic component

Fig. 5. Pulsed-wave Doppler of LAD blood velocity with prominent systolic flow

Effects of Eptifibatide on the Microcirculation After Primary Angioplasty in

(van't Hof, 1998; Gibson et al, 2000; Stone et al, 2002).

treated with epifibatide, however, MBG was not different.

**TIMI p- (Pre/Post)** 

Table 1. Pre and Post PCI, TIMI and MBG and Diastolic LAD Flow

**3.2 Feasibility and examples of LAD Doppler velocity sampling** 

**EPT-Yes** 1.07±1.07 2.43±0.5 0.0004 0.71±1.07 1.93±0.73 0.002 49±26 **EPT-NO** 0.94±1.2 2.28±0.6 1.3×10-9 0.52±1.06 2.25±0.9 6×10-9 35±17

**(Yes/No)** 0.7 0.049 0.57 0.22 0.09

Sampling of LAD blood velocities was possible at all occasions in all the patients. Colour-Doppler jet of blood velocity through the LAD had distinct boarders and measurement of diameters was possible with inter and intra-observer variability of 0.1±0.05mm and 0.15±0.07mm. Inter and intra-observer variability of LAD velocities were 2±0.4 and 1.5±0.2 cm/sec and of time velocity integrals 0.4±0.1 and 0.3±0.1cm, and of pressure half time 10±3 and 8±3 msec In figure 6, an example of a patient with acute anterior STEMI after primary angioplasty and bare metal stent implantation in the LAD. The velocity profile demonstrates prolonged diastolic deceleration time (more than 600msec) and forward systolic flow. In this patient left ventricular systolic function improved and left ventricular ejection fraction at

**TIMI Post-PPCI** 

**2.7 Statistical analysis** 

**3.1 Angiographic results** 

**TIMI Pre-PPCI** 

**3. Results** 

**P** 

Acute ST-Elevation Myocardial Infarction: A Trans-Thoracic Coronary Artery Doppler Study 65

myocardial blush; MBG-1: myocardial staining persists on the next injection; MBG-2: myocardial staining with slow washout and persists markedly at the end of injection; MBG-3: normal myocardial staining and clearance with only mild staining at end of injection

Statistical analyses wee conducted using SPSS software version 13. All values were expressed as means and standard deviations. Two-tailed student's-t test was performed to compare changes in DDT and P1/2T, considering p<0.05 as statistically significant. Assessment of clinical utility of flow parameters was done by calculating sensitivity, specificity, positive and negative predictive values as well as diagnostic accuracy. Correlation coefficients and their p value were calculated to evaluate the relation of LAD flow parameters with LV systolic function parameters pre-discharge (5 days after PCI).

Average TIMI and myocardial blush grades (MBG) before angioplasty were not different between patient who were treated with epitifibatide compared to those in whom the medicine was not administrated (table 1). However, TIMI=0, was observed in 33% with eptifibatide compared to 55% in those without. In both groups TIMI and MBG grades improved after the PCI. TIMI grade after the intervention was higher in subjects who were

> **MBG Pre-PPCI**

**MBG Post-PPCI** 

**MBG p- (Pre/Post)** **Diastolic LAD Flow (ml/min)** 

#### **2.3 Echocardiographic measurements**

Chamber diameters and usual measurements were performed according to recommendations of American Society of Echocardiography. Ejection fraction of LV (LVEF) was measured from biplane apical views.

For the calculation of wall motion score index

$$LPV - V\text{MSI} = \frac{\sum \text{score of 16 segments}}{16} \tag{1}$$

assigning a value of 1 for normal LV wall motion, 2 for hypokinesis and 3 for akinesis. Using the same values of wall motion scores, LAD 9 segmental score index was calculated as:

$$LAD - V\text{MSI} = \frac{\sum \text{score of 9 segments}}{9} \tag{2}$$

#### **2.4 Velocity of the LAD and measurements**

In order to obtain LAD flows, the color Doppler Nyquist limit was set at 17 cm/sec. From low parasternal short axis view, search for diastolic color flow in the anterior interventricular groove followed by clockwise rotation was performed, while form apical foreshortened two chamber views LAD diastolic flow was located in the interventricular groove and the counterclockwise rotation of the transducer was performed.

Parameters of LAD velocity patterns were averaged from 3 beats, all in sinus rhythm. Diastolic LAD deceleration Time (DDT) was measured as the time from peak diastolic velocity to the intercept of tangent of the velocity envelope with baseline. Pressure half time (P1/2T) (msec) was determined as the time for peak diastolic velocity to decrease to 1 <sup>2</sup> of its initial value. In addition, search for LAD early systolic flow reversal with early systolic negative velocity (ESFR) was performed.

#### **2.5 LAD Flow measurements**

Diameter of the jet of blood velocity through the LAD (D), heart rate (HR) and diastolic time velocity integral (TVIDiastole) of the pulsed-wave Doppler were used to calculate blood flow in the LAD according to the following formula (3):

$$\text{Diastolic LAD Flow} = \pi \frac{D^2}{4} \times HR \times TVI\_{\text{Dair stroke}} \tag{3}$$

#### **2.6 Angiographic analysis**

Coronary angiograms were reviewed by two experienced interventional cardiologists. TIMI (thrombolysis in myocardial infarction) and MBG (myocardial blush grade) were evaluated pre and post- PCI. TIMI-0: no antigrade flow beyond the occlusion; TIMI-1: contrast passes through the occlusion but do not opacify the distality entirely; TIMI-2: contrast passes through the obstruction and opacify the distal coronary bed slower than normal or clears slower than normal; TIMI-3: prompt contrast opacification and clearance of the distal coronary bed (Chesebro et al, 1987). MBG was evaluated as: MBG-0: minimal or no myocardial blush; MBG-1: myocardial staining persists on the next injection; MBG-2: myocardial staining with slow washout and persists markedly at the end of injection; MBG-3: normal myocardial staining and clearance with only mild staining at end of injection (van't Hof, 1998; Gibson et al, 2000; Stone et al, 2002).
