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Verheijen DB, Egorova AD, Jongbloed MR, van der Kley F, Koolbergen DR, Hazekamp MG, Lamb HJ, Jukema JW, Kiès P, Vliegen HW. Anomalous Aortic Origin of the Right Coronary Artery: Invasive Haemodynamic Assessment in Adult Patients With High-Risk Anatomic Features. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:124-133. [PMID: 37969355 PMCID: PMC10642095 DOI: 10.1016/j.cjcpc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/01/2023] [Indexed: 11/17/2023]
Abstract
Background Anomalous aortic origin of a right coronary artery (AAORCA) with an interarterial course merits further evaluation; however, robust risk assessment strategies for myocardial ischemia and sudden cardiac death are currently lacking. The aim of this study is to explore the potential role of fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and intravascular ultrasound (IVUS) in patients with AAORCA. Methods Consecutive adult patients with AAORCA with an interarterial course were included. Computed tomography angiography, noninvasive ischemia detection, and FFR, iFR, and IVUS were performed at baseline and during adrenaline-induced stress. External compression was evaluated with IVUS. Results Eight patients (63% female, mean age: 53 ± 9.5 years) were included. Five patients (63%) were symptomatic, and computed tomography angiography revealed high-risk anatomy of the AAORCA in all patients. Only in 1 (12.5%) patient FFR and iFR were positive; however, this was attributed at large to concomitant diffuse atherosclerosis. In 2 of 8 (25%), IVUS revealed external compression; however, the ostial coronary surface area remained unchanged. In all patients, a conservative treatment strategy was pursued. During a mean follow-up of 29.3 months (standard deviation ±2.6 months), symptoms spontaneously disappeared in 4 of 5 (80%) and no adverse cardiac events occurred in any of the patients. Conclusions Despite the presence of high-risk anatomy in all patients, none had proven ischemia prompting a conservative treatment strategy. No adverse cardiac events occurred during follow-up, and in the majority of patients, symptoms spontaneously disappeared. Therefore, FFR, iFR, and IVUS with pharmacologic stress merit further investigation and might contribute to ischemia-based risk stratification and management strategies in adult patients with AAORCA.
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Affiliation(s)
- Diederick B.H. Verheijen
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anastasia D. Egorova
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique R.M. Jongbloed
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frank van der Kley
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Dave R. Koolbergen
- Department of Cardiothoracic Surgery, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J. Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Philippine Kiès
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hubert W. Vliegen
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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Tune JD, Goodwill AG, Kiel AM, Baker HE, Bender SB, Merkus D, Duncker DJ. Disentangling the Gordian knot of local metabolic control of coronary blood flow. Am J Physiol Heart Circ Physiol 2019; 318:H11-H24. [PMID: 31702972 DOI: 10.1152/ajpheart.00325.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recognition that coronary blood flow is tightly coupled with myocardial metabolism has been appreciated for well over half a century. However, exactly how coronary microvascular resistance is tightly coupled with myocardial oxygen consumption (MV̇o2) remains one of the most highly contested mysteries of the coronary circulation to this day. Understanding the mechanisms responsible for local metabolic control of coronary blood flow has been confounded by continued debate regarding both anticipated experimental outcomes and data interpretation. For a number of years, coronary venous Po2 has been generally accepted as a measure of myocardial tissue oxygenation and thus the classically proposed error signal for the generation of vasodilator metabolites in the heart. However, interpretation of changes in coronary venous Po2 relative to MV̇o2 are quite nuanced, inherently circular in nature, and subject to confounding influences that remain largely unaccounted for. The purpose of this review is to highlight difficulties in interpreting the complex interrelationship between key coronary outcome variables and the arguments that emerge from prior studies performed during exercise, hemodilution, hypoxemia, and alterations in perfusion pressure. Furthermore, potential paths forward are proposed to help to facilitate further dialogue and study to ultimately unravel what has become the Gordian knot of the coronary circulation.
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Affiliation(s)
- Johnathan D Tune
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam G Goodwill
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alexander M Kiel
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - Hana E Baker
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shawn B Bender
- Biomedical Sciences, University of Missouri, Columbia, Missouri.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri.,Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School Erasmus University Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Walter-Brendel Center of Experimental Medicine, University Hospital, Ludwig Maximilian University Munich, Munich, Germany.,German Centre for Cardiovascular Research, Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research School Erasmus University Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Yu X, Konstantinov IE, Kantoch MJ, Rebeyka IM, Li J. Dynamic changes of myocardial oxygen consumption at pacing increased heart rate - the first observation by the continuous measurement of systemic oxygen consumption. SCAND CARDIOVASC J 2011; 45:301-6. [PMID: 21707326 DOI: 10.3109/14017431.2011.589470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess dynamic changes in myocardial oxygen consumption (myoVO(2)) during atrial pacing increased heart rate by continuous measurement of systemic oxygen consumption (sysVO(2)). METHODS Six mechanically ventilated pigs were atrially paced to increase heart rate from baseline 98 ± 9 to 120-140-160-180 bpm for 10 minutes at each stage, with 10 minute intervals without pacing between stages. sysVO(2) was continuously measured with a respiratory mass spectrometer. Left anterior descending coronary arterial flow, aorta and coronary sinus blood gases were measured to calculate index of whole heart myoVO(2). RESULTS sysVO(2) peaked at the initiation of pacing in the first two to three minutes, followed by a decrease and subsequent stabilization. As heart rate increased, sysVO(2) increased by 0.08 ± 0.06 ml/kg/min, 0.14 ± 0.05 ml/kg/min and 0.17 ± 0.10 ml/kg/min, representing a 1.2 ± 0.9%, 2.1 ± 0.7% and 3.0 ± 1.8% increase of sysVO(2) respectively; myoVO(2) increased by 0.16 ± 0.12 to 0.31 ± 0.14 to 0.36 ± 0.24 ml/100 g/min, representing a 11 ± 9%, 21 ± 9% and 26 ± 12% increase of myoVO(2), respectively. The absolute and relative increases in sysVO(2) were significantly correlated with the increases in myoVO(2). CONCLUSIONS On-line continuous sysVO(2) monitoring by respiratory mass spectrometry allows non-invasive assessments of dynamic changes in myoVO(2) in vivo. The mechanism for the peaked increase in sysVO(2) at the initiation of pacing remains to be explored.
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Affiliation(s)
- Xiaoyang Yu
- Division of Pediatric Cardiology, Stollery Children's Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Westerhof N, Boer C, Lamberts RR, Sipkema P. Cross-Talk Between Cardiac Muscle and Coronary Vasculature. Physiol Rev 2006; 86:1263-308. [PMID: 17015490 DOI: 10.1152/physrev.00029.2005] [Citation(s) in RCA: 175] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The cardiac muscle and the coronary vasculature are in close proximity to each other, and a two-way interaction, called cross-talk, exists. Here we focus on the mechanical aspects of cross-talk including the role of the extracellular matrix. Cardiac muscle affects the coronary vasculature. In diastole, the effect of the cardiac muscle on the coronary vasculature depends on the (changes in) muscle length but appears to be small. In systole, coronary artery inflow is impeded, or even reversed, and venous outflow is augmented. These systolic effects are explained by two mechanisms. The waterfall model and the intramyocardial pump model are based on an intramyocardial pressure, assumed to be proportional to ventricular pressure. They explain the global effects of contraction on coronary flow and the effects of contraction in the layers of the heart wall. The varying elastance model, the muscle shortening and thickening model, and the vascular deformation model are based on direct contact between muscles and vessels. They predict global effects as well as differences on flow in layers and flow heterogeneity due to contraction. The relative contributions of these two mechanisms depend on the wall layer (epi- or endocardial) and type of contraction (isovolumic or shortening). Intramyocardial pressure results from (local) muscle contraction and to what extent the interstitial cavity contracts isovolumically. This explains why small arterioles and venules do not collapse in systole. Coronary vasculature affects the cardiac muscle. In diastole, at physiological ventricular volumes, an increase in coronary perfusion pressure increases ventricular stiffness, but the effect is small. In systole, there are two mechanisms by which coronary perfusion affects cardiac contractility. Increased perfusion pressure increases microvascular volume, thereby opening stretch-activated ion channels, resulting in an increased intracellular Ca2+transient, which is followed by an increase in Ca2+sensitivity and higher muscle contractility (Gregg effect). Thickening of the shortening cardiac muscle takes place at the expense of the vascular volume, which causes build-up of intracellular pressure. The intracellular pressure counteracts the tension generated by the contractile apparatus, leading to lower net force. Therefore, cardiac muscle contraction is augmented when vascular emptying is facilitated. During autoregulation, the microvasculature is protected against volume changes, and the Gregg effect is negligible. However, the effect is present in the right ventricle, as well as in pathological conditions with ineffective autoregulation. The beneficial effect of vascular emptying may be reduced in the presence of a stenosis. Thus cardiac contraction affects vascular diameters thereby reducing coronary inflow and enhancing venous outflow. Emptying of the vasculature, however, enhances muscle contraction. The extracellular matrix exerts its effect mainly on cardiac properties rather than on the cross-talk between cardiac muscle and coronary circulation.
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Affiliation(s)
- Nico Westerhof
- Laboratory of Physiology and Department of Anesthesiology, Institute for Cardiovascular Research Vrije Universiteit, VU University Medical Center, Amsterdam, The Netherlands
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