Coronary flow velocity waveforms in aortic stenosis and the effects of valve replacement

Association between coronary flow and aortic stenosis during transcatheter aortic valve implantation

AIMS

In patients with aortic stenosis (AS), the coronary flow reserve decreases even in the absence of epicardial coronary artery stenosis. Systolic coronary flow reversal (SFR) reflecting reduced coronary microcirculation, often seen in patients with severe AS, has a potential negative impact on the pathogenesis of cardiac dysfunction. However, there are limited data on the relationship between the severity of AS and SFR, as well as on the benefits of transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the relationship between the severity of AS and efficacy of TAVI in improving SFR.

METHODS AND RESULTS

Consecutive patients with AS who had undergone TAVI using transoesophageal echocardiography (TEE) from November 2020 to February 2022 were prospectively enrolled. Coronary flow in the left anterior descending artery as well as the aortic valve peak velocities, and the mean aortic valve pressure gradients (AVPGs), indicating the severity of AS, were measured using intraprocedural TEE before and after TAVI. The following parameters were measured as coronary flow: systolic and diastolic peak velocity (cm/s) and systolic and diastolic velocity-time integral (VTI) (cm). SFR was defined as the presence of a reversal coronary flow component in systole. The enrolled patients were classified into two groups according to the presence or absence of SFR before TAVI. A total of 25 patients were included: 13 had SFR and 12 who had no SFR, before TAVI. Patients with SFR had significantly higher aortic valve peak velocities (451.1 ± 45.9 vs. 372.1 ± 52.1 cm/s; P < 0.001) and mean AVPGs (49.2 ± 14.5 vs. 30.3 ± 11.6 mmHg; P = 0.002) than those without. The optimal binary cut-off aortic valve peak velocity values and the mean AVPG associated with the presence of SFR before TAVI were >410.0 cm/s (specificity, 75.0%; sensitivity, 92.3%) and >37.4 mmHg (specificity, 83.3%; sensitivity, 92.3%), respectively. After TAVI, SFR immediately disappeared in 11 of 13 patients with SFR (84.6%). Overall, the systolic coronary VTI significantly increased after TAVI (2.0 ± 4.7 vs. 6.4 ± 3.2 cm, P < 0.001), and this increase was greater in patients with SFR than in those without SFR before TAVI (interaction P = 0.035).

CONCLUSIONS

SFR was found to be associated with the severity of AS and with a greater increase in systolic coronary flow immediately after TAVI.

Hemodynamic changes during aortic valve surgery among patients with aortic stenosis

Introduction. Patients with severe aortic stenosis (AS) undergoing surgery are at increased risk of hypotension and hypoperfusion. Although treatable with inotropic agents or fluid, little is known about how these therapies affect central hemodynamics in AS patients under general anesthesia. We measured changes in central hemodynamics after dobutamine infusion and fluid bolus among patients with severe AS and associated these changes with preoperative echocardiography. Methods. We included 33 patients with severe AS undergoing surgical AVR. After induction of general anesthesia, hemodynamic measurements were obtained with a pulmonary artery catheter, including Cardiac index (CI), stroke volume index (SVi) and pulmonary capillary wedge pressure (PCWP). Measurements were repeated during dobutamine infusion, after fluid bolus and lastly after sternotomy. Results. General anesthesia resulted in a decrease in CI and SVi compared to preoperative values. During dobutamine infusion CI increased but mean SVi did not (38 ± 12 vs 37 ± 13 ml/m², p = .90). Higher EF and SVi before surgery and a larger decrease in SVi after induction of general anesthesia were associated with an increase in SVi during dobutamine infusion. After fluid bolus both CI, SVi (48 ± 12 vs 37 ± 13 ml/min/m², p < .0001) and PCWP increased. PCWP increased mostly among patients with a larger LA volume index. Conclusion. In patients with AS, CI can be increased with both dobutamine and fluid during surgery. Dobutamine's effect on SVI was highly variable and associated with baseline LVEF, and an increase in CI was mostly driven by an increase in heart rate. Fluid increased SVi at the cost of an increase in PCWP.

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

Aortic Stenosis: What Risks Do the Stresses of Noncardiac Surgery or Pregnancy Pose and How Should They Be Managed?

Studies suggest that patients with aortic stenosis have increased risk in pregnancy and delivery and during anesthesia and surgery, although there are significant degrees of uncertainty as to the exact risks and best way to manage such patients. This article reviews current literature regarding impact of aortic stenosis on pregnancy and anesthesia during noncardiac surgery. There are shortcomings in the scientific evidence. Most of the available studies are observational and often retrospective and therefore there is a great deal of bias. This leads to difficulty in drawing conclusions in terms of how to apply the published information to clinical management.

Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity

OBJECTIVES

In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve.

BACKGROUND

A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied.

METHODS

Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR.

RESULTS

Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001).

CONCLUSIONS

Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.

Impaired coronary circulation in patients with apical hypertrophic cardiomyopathy: noninvasive analysis by transthoracic Doppler echocardiography

OBJECTIVES

We designed this study to examine the characteristics of coronary circulation in patients with apical hypertrophic cardiomyopathy (ApHCM) using noninvasive transthoracic Doppler echocardiography (TTDE).

BACKGROUND

Recent advances in TTDE have allowed noninvasive assessment of coronary circulation by the measurement of coronary flow velocity (CFV) patterns and coronary flow velocity reserve (CFVR). However, there have been no previous studies evaluating coronary circulation in ApHCM.

METHODS

We analyzed CFV and CFVR in the left anterior descending coronary artery (LAD), and apical wall thickness in the left ventricle, in 10 ApHCM subjects and 10 control subjects. Mean diastolic velocity (MDV) and time from the beginning of diastole to peak velocity (TPV), and CFVR, defined as a ratio of drug-induced hyperemic to basal MDV, were measured.

RESULTS

At baseline, MDV was higher, and TPV was longer, in ApHCM subjects than in control subjects (29 +/- 5.7 versus 19 +/- 6.5 cm/sec; p < 0.01 and 5.2 +/- 1.0 versus 3.5 +/- 0.6 msec; p < 0.005, respectively). CFVR in ApHCM subjects was significantly lower than in control subjects (1.9 +/- 0.4 versus 3.1 +/- 0.8; p < 0.005). CFVR and basal MDV in ApHCM subjects showed significant correlations with apical/posterior wall thickness ratio [CFVR; r =-0.84, p < 0.01 and MDV; r = 0.74, p < 0.05, respectively].

CONCLUSION

Noninvasive coronary flow assessment by TTDE revealed an impaired coronary circulation with reduced CFVR, high MDV at baseline and prolonged TPV. These results suggest that these characteristics of coronary circulation may provide an additional index for the assessment of ApHCM.

Difference in coronary blood flow dynamics between patients with hypertension and those with hypertrophic cardiomyopathy

We studied twelve patients with hypertensive left ventricular hypertrophy (LVH), 10 patients with hypertrophic cardiomyopathy (HCM) and 10 control subjects to examine the differences in coronary blood flow (CBF) dynamics between patients with hypertensive LVH and those with HCM. All subjects had normal coronary arteriograms. Measurements of CBF using Doppler Flo-Wire were performed at rest, and after infusions of acetylcholine and papaverine. The baseline CBF was significantly increased in both hypertensive LVH patients and HCM patients compared to that noted in control subjects (64.1+/-36.9, 80.0+/-38.1, 32.3+/-8.0 ml/min, respectively, p<0.01). Coronary flow reserve and endothelium-dependent vasodilatation were significantly lower in hypertensive LVH patients and HCM patients than in control subjects, but there was no significant difference between the hypertensive LVH and HCM patients themselves. In contrast, the diastolic/systolic velocity ratio at baseline was significantly lower in hypertensive LVH patients than in HCM patients (1.53+/-0.40, 6.31+/-7.50, p<0.05). Although CBF and coronary flow reserve correlated positively and negatively, respectively, with left ventricular mass index (r=0.51, -0.59, respectively), the diastolic/systolic velocity ratio at baseline did not show a significant correlation to left ventricular mass index. In conclusion, the diastolic/systolic velocity ratio differed between hypertensive LVH and HCM patients, independent of left ventricular mass. These results suggest that the difference of phasic pattern of CBF may be essential for coronary circulation in patients with hypertensive LVH and in those with HCM.

Coronary flow reserve improves after aortic valve replacement for aortic stenosis: an adenosine transthoracic echocardiography study

OBJECTIVES

The goal of this study was to assess coronary flow reserve (CFR) before and after aortic valve replacement (AVR).

BACKGROUND

Coronary flow reserve is impaired under conditions of left ventricular (LV) hypertrophy. It is not known whether CFR improves with regression of LV hypertrophy in humans.

METHODS

We investigated 35 patients with pure aortic stenosis, LV hypertrophy and normal coronary arteriograms. Patients underwent adenosine transthoracic echocardiography on two occasions--immediately before AVR and six months postoperatively. Left ventricular mass, distal left anterior descending coronary artery (LAD) diameter, flow and CFR were assessed on each occasion.

RESULTS

Distal LAD diameter was successfully imaged in 30 patients (86%), and blood flow was successfully imaged in 27 (77%). Paired data were subsequently available in 24 patients, of whom 14 were men, mean age 68.1+/-12.5 years, body mass index 24.5+/-2.0 kg/m2, aortic valve gradient 93+/-32 mm Hg. Pre- to post-AVR a significant decrease was seen in LV mass (271+/-38 vs. 236+/-32g, p<0.01) and LV mass index (154+/-21 vs. 134+/-21 g/m2, p< 0.01). Distal LAD diameter fell from 2.27+/-0.37 to 2.23+/-0.35 mm, p = 0.08). Pre- to post-AVR there was no significant change in resting parameters of peak diastolic velocity (0.43+/-0.16 vs. 0.41+/-0.11 m/s), distal LAD flow 23.3+/-10.1 vs. 20.9+/-5.2 ml/min or distal LAD flow scaled for LV mass (8.7+/-3.8 vs. 9.0+/-2.5 ml/min/100 g LV mass), but there was significant increase in hyperemic peak diastolic velocity (0.71+/-0.26 vs. 1.08+/-0.24 m/s; p<0.01), distal LAD flow (37.8+/-11.3 vs. 53.5+/-16.1 ml/min; p<0.01) and distal LAD flow scaled for LV mass (14.3+/-5.0 vs. 23.3+/-8.5 ml/min/100 g LV mass; p<0.01). Coronary flow reserve, therefore, increased from 1.76+/-0.5 to 2.61+/-0.7.

CONCLUSIONS

Coronary flow reserve increases after AVR for aortic stenosis. This increase occurs in tandem with regression of LV hypertrophy.

The effects of cardioplegia on coronary pressure-flow velocity relationships during aortic valve replacement

OBJECTIVE

The acute physiological response of the coronary circulation to aortic valve replacement (AVR) has not been fully elucidated. This study aimed to characterize the changes in coronary perfusion pressure-flow velocity relationships, and to test whether this relationship is affected by cardioplegic method.

METHODS

Nineteen patients (mean age 67 +/- 12 (SD) years, 9 males) undergoing aortic valve replacement who received either cold blood cardioplegia (CBC, n = 9) or warm blood cardioplegia (WBC, n = 10), were prospectively studied before and 30 min after the operation, using transesophageal Doppler echocardiography combined with high fidelity left ventricular (LV) and aortic pressures. We thus determined: (1) Diastolic flow velocities in proximal anterior descending coronary artery (LAD), and simultaneous aorta to LV pressure differences. (2) The slope (LAD proximal linear resistance) and pressure intercept (zero flow pressure) of this relationship. (3) Overall LAD linear resistance as the ratio of mean diastolic flow velocity to mean pressure difference between aorta and left ventricle. (4) LV myocardial stroke work.

RESULTS

Following operation, myocardial stroke work fell from 5.2 +/- 2.7 to 3.0 +/- 1.7, mJ cm(-3) (P = 0.001), LAD mean diastolic flow velocity increased from 47 +/- 19 to 74 +/- 21, cm s(-1) (P = 0.0002). LAD overall linear resistance fell (0.75 +/- 0.24 vs. 1.26 +/- 0.26, mmHg cm(-1) s, P = 0.001). LAD proximal linear resistance, however, remained unchanged (P = 0.21), but the zero flow pressure fell (18 +/- 12.6 vs. 27 +/- 12.2, mmHg above LV end diastolic pressure, P = 0.013). With similar fall in myocardial work postoperatively, there was a greater fall in zero flow pressure after WBC than CBC (48 +/- 28 vs. 19 +/- 13,% of pre-op, P = 0.012), and a greater increase in flow velocity time integral (127 +/- 81 vs. 53 +/- 59,%, P = 0.039).

CONCLUSION

Instantaneous diastolic LAD pressure-flow velocity relations in the early postoperative period can be explained more satisfactorily in terms of zero flow pressure and proximal linear resistance than simple resistance alone. The fall in zero flow pressure alone explains the increase in LAD flow velocity immediately after aortic valve replacement. The extent of this fall is greater after warm rather than cold blood cardioplegia.

The relationship of myocardial stroke work to coronary flow velocity immediately after aortic valve replacement

BACKGROUND

The interrelations between myocardial stroke work and coronary flow velocity have not been fully defined during aortic valve replacement or with different cardioplegias.

METHODS

Twenty-six patients (15 men age 63+/-13 years) who had elective isolated aortic valve replacement were studied by transesophageal Doppler echocardiography with simultaneous high fidelity left ventricular pressure. Fifteen patients received cold blood cardioplegia and 11 had warm blood cardioplegia. Myocardial stroke work and flow velocities in proximal left anterior descending coronary artery were quantified simultaneously before cardiopulmonary bypass and at 1, 6, 12, and 20 hours afterwards.

RESULTS

Myocardial stroke work decreased postoperatively in both groups (160+/-19 versus 228+/-19 mJ/cm3 per minute, with cold blood cardioplegia; 135+/-22 versus 227+/-22 mJ/cm3 per minute with warm blood cardioplegia; both p<0.001 versus time, but p>0.05 versus cardioplegia, by two-way analysis of variance). Left anterior descending artery flow velocity-time integral per minute increased significantly in both groups (26.1+/-2.1 versus 15.0+/-2.1 m/min with cold blood cardioplegia; 32.8+/-2.5 versus 14.4+/-2.5 m/min with warm blood cardioplegia; both p<0.001 versus time, but p>0.05 versus cardioplegia). Thus, at 1 hour postoperatively the mJ x cm(-3) x m(-1) x min ratio of myocardial stroke work to left anterior descending artery flow velocity-time integral decreased significantly in both groups (4.3+/-1.6 versus 16.3+/-1.7 mJ x cm(-3) x m(-1) x min with warm blood cardioplegia, and 7.4+/-1.4 versus 17.9+/-1.4 J x cm(-3) x m(-1) x min with cold blood cardioplegia; both p<0.001 versus time). Warm blood cardioplegia was also associated with a lower mean ratio perioperatively than that with cold blood cardioplegia (7.8+/-0.9 versus 10.9+/-0.7 mJ x cm(-3) x m(-1) x min, p = 0.014).

CONCLUSIONS

Coronary hyperemia occurs for at least 20 hours postoperatively when myocardial stoke work has decreased. The ratio of myocardial stroke work to coronary flow velocity appears to be more sensitive than either alone in differentiating the effect of warm versus cold blood cardioplegia.

Effect of aortic valve replacement on coronary flow velocity during metabolic stress in a patient with aortic stenosis

The effect of aortic valve replacement on coronary flow velocity during atrial pacing and papaverine-induced-resistance vessel dilatation was tested in a patient with aortic stenosis. Although systolic flow reversal disappeared early after the valve replacement, rapid atrial pacing caused myocardial ischemia with lactate production. The coronary flow reserve also remained depressed. These results suggest that the alteration in the coronary flow profile early after the aortic valve replacement does not reflect an improvement in the flow increase during metabolic stress in a patient with aortic stenosis.

Influences of aortic pressure gradient and ventricular septal thickness with systolic coronary flow in aortic valve stenosis

This study evaluates flow patterns of the left anterior descending and circumflex coronary arteries by multiplane transesophageal echocardiography in 25 patients with aortic valve stenosis, and assesses the relation between coronary flow characteristics and anatomic and hemodynamic parameters.

Relation between symptoms and profiles of coronary artery blood flow velocities in patients with aortic valve stenosis: a study using transoesophageal Doppler echocardiography

OBJECTIVE

To analyse profiles of coronary artery flow velocity at rest in patients with aortic stenosis and to determine whether changes of the coronary artery flow velocities are related to symptoms in patients with aortic stenosis.

DESIGN

A prospective study investigating the significance of aortic valve area, pressure gradient across the aortic valve, systolic left ventricular wall stress index, ejection fraction, and left ventricular mass index in the coronary flow velocity profile of aortic stenosis; and comparing flow velocity profiles between symptomatic and asymptomatic patients with aortic stenosis using transoesophageal Doppler echocardiography to obtain coronary artery flow velocities of the left anterior descending coronary artery.

SETTING

Tertiary referral cardiac centre.

PATIENTS

Fifty eight patients with aortic stenosis and 15 controls with normal coronary arteries.

RESULTS

Adequate recordings of the profile of coronary artery flow velocities were obtained in 46 patients (79%). Left ventricular wall stress was the only significant haemodynamic variable for determining peak systolic velocity (r = -0.83, F = 88.5, P < 0.001). The pressure gradient across the aortic valve was the only contributor for explaining peak diastolic velocity (r = 0.56, F = 20.9, P < 0.001). Controls and asymptomatic patients with aortic stenosis (n = 12) did not differ for peak systolic velocity [32.8 (SEM 9.7) v 27.0 (8.7) cm/s, NS] and peak diastolic velocity [58.3 (18.7) v 61.9 (13.5) cm/s, NS]. In contrast, patients with angina (n = 12) or syncope (n = 8) had lower peak systolic velocities and higher peak diastolic velocities than asymptomatic patients (P < 0.01). Peak systolic and diastolic velocities were -7.7 (22.5) cm/s and 81.7 (17.6) cm/s for patients with angina, and -19.5 (22.3) cm/s and 94.0 (20.9) cm/s for patients with syncope. Asymptomatic patients and patients with dyspnoea (n = 14) did not differ.

CONCLUSIONS

Increased pressure gradient across the aortic valve and enhanced systolic wall stress result in characteristic changes of the profile of coronary flow velocities in patients with aortic stenosis. Decreased or reversed systolic flow velocities are compensated by enhanced diastolic flow velocities, particularly in patients with angina and syncope. This characteristic pattern of the profile of coronary artery flow velocities in patients with angina or syncope may be useful for differentiating those patients from asymptomatic patients.

Changes in phasic coronary blood flow velocity profile in relation to changes in hemodynamic parameters during stress in patients with aortic valve stenosis

BACKGROUND

Alterations in phasic coronary flow profile have been demonstrated at rest in patients with aortic valve stenosis (AVS) but have never been studied under conditions of hemodynamic stress.

METHODS AND RESULTS

Thirty-four patients with significant pure AVS (21 with exertional symptoms [group 1], 13 asymptomatic [group 2]) and 9 control subjects (group 3), all with normal coronary arteries, were studied successively at rest, during rapid atrial pacing, and after dobutamine infusion (5 to 30 micrograms.kg-1.min-1 i.v.) by proximal left anterior descending (LAD) intracoronary Doppler flow velocimetry concomitant with hemodynamic measurements. Systolic retrograde coronary flow velocity (CFV) was recorded only in patients with AVS, and its resting peak value was positively correlated with peak aortic pressure gradient (APG) (r = .63, P < .001). In group 1, there was lower aortic valve area (0.58 +/- 0.10 versus 0.75 +/- 0.08 cm2, P < .001) and higher resting APG and peak systolic retrograde CFV than in group 2, and also higher resting peak diastolic and mean CFV than in groups 2 and 3. In the two AVS groups, there were no changes from rest in APG and retrograde CFV at peak pacing rate; however, these parameters increased concomitantly and significantly at peak dobutamine stress. The ratio of the resting systolic to diastolic CFV curve area was inversely correlated with mean APG (r = -.54, P < .001); it was significantly lower in group 1 than in groups 2 and 3 (0.19 +/- 0.07 versus 0.29 +/- 0.10 and 0.30 +/- 0.04, respectively, both P < .005) and increased at peak pacing (group 1, to 0.29 +/- 0.14; group 2, to 0.39 +/- 0.12; group 3, to 0.38 +/- 0.07; all P < .001). At peak dobutamine stress, it decreased in patients with AVS (group 1, to 0.05 +/- 0.05; group 2, to 0.08 +/- 0.03; both P < .001) but did not change in group 3 (0.25 +/- 0.05). From rest to peak dobutamine stress, in both AVS groups there was increased retrograde systolic (group 1, 441 +/- 483%; group 2, 681 +/- 356%; both P < .001), decreased total systolic (group 1, -66 +/- 25%, P < .001; group 2, -19 +/- 24%; P = NS), and increased diastolic (group 1, 33.4 +/- 31.7%; group 2, 197.7 +/- 105.1%; both P < .001; group 1 versus group 2, P < .001) CFV curve area. In contrast, group 3 showed comparable increases in both systolic (143.5 +/- 44.4%) and diastolic (197.1 +/- 75.2%) CFV area (both P < .001). The stress-induced increases in the mean CFV and blood flow exceeded or were comparable with the concomitant increases in the estimated myocardial metabolic demand in groups 2 and 3 but were significantly lower in group 1.

CONCLUSIONS

Stress-induced changes in LAD phasic CFV profile differ significantly between patients with and without AVS. In AVS, these changes are closely related to the concomitant stress-induced changes in hemodynamic parameters.

Coronary flow dynamics and reserve assessed by transesophageal echocardiography in obstructive hypertrophic cardiomyopathy

Myocardial ischemia is frequently associated with left ventricular outflow obstruction. To assess coronary flow impairment in obstructive hypertrophic cardiomyopathy (HC), 10 patients with echo-Doppler-detected obstructive HC and normal coronary arteries underwent transesophageal echo-Doppler examination of both coronary flow velocity (CFV) at rest, recorded in the proximal left anterior descending coronary artery, and coronary flow reserve (CFR) evaluated by means of dipyridamole infusion response. Ten normal patients were similarly studied and served as a control group. Two relevant alterations in coronary flow dynamics were detected in patients with HC: (1) a significantly increased diastolic/systolic CFV ratio, and (2) a significantly reduced dipyridamole/baseline CFV ratio. Compared with normal subjects, the CFV pattern showed a significantly greater diastolic and a significantly lower systolic component at rest (in some patients it was reversed). Diastolic/systolic CFV ratio was significantly higher in patients with HC at baseline (3.1 +/- 1 vs 1.6 +/- 0.5; p < 0.01) and increased further after dipyridamole infusion (4.9 +/- 2 vs 2.2 +/- 0.7; p < 0.01). In addition, CFR was impaired in patients with HC (1.8 +/- 0.3 vs 3.1 +/- 0.5; p < 0.01). Furthermore, a significant correlation between CFR and intraventricular pressure gradient was found. Thus, transesophageal echo-Doppler examination is a useful tool for evaluating CFV dynamics and CFR as demonstrated in patients with obstructive HC.

Quantitative sorting of normal and abnormal coronary flow wave form shapes

The normal phasic flow wave form in an epicardial coronary artery has a distinct characteristic shape, which reflects the interaction between the coronary tree, myocardial function and hemodynamic conditions. Since clinical measurements of phasic coronary wave forms are becoming available, determination of abnormal coronary flow wave forms is important. We suggest here an objective and automatic method to discriminate between normal and abnormal flow wave forms based on the Karhunen-Loève Transform (KLT), and experimentally tested it. The normal flow domain was represented by the resting flow waves measured in the left anterior descending arteries in 31 anesthetized dogs. The abnormal flow conditions, imposed and tested experimentally, were varying stenosis severity and severely reduced left ventricular pressure. In addition, the effects of reactive hyperemia on the shape of the flow were examined. The sorting index was based on the mean-square error (MSE) calculated for each flow signal based on a truncated KLT expansion. The results show excellent discrimination between the normal and the abnormal groups. During reactive hyperemia, however, MSE did not change significantly. These results indicate that the shape of abnormal coronary flow wave forms can be identified and discriminated from normal wave forms.

Profiles of coronary blood flow velocity in patients with aortic stenosis and the effect of valve replacement: a transthoracic echocardiographic study

OBJECTIVE

To report the first non-invasive assessment by transthoracic Doppler echocardiography of coronary blood flow in patients with aortic stenosis and of the effects of valve replacement.

DESIGN

High frequency transthoracic Doppler echocardiography was used to examine resting phasic flow in the left anterior descending coronary artery before and after replacement of the aortic valve in awake, unsedated patients with pure aortic stenosis and normal coronary arteries.

SETTING

A tertiary referral cardiothoracic centre.

METHODS

Eleven patients with pure aortic stenosis and normal coronary arteries (six men, five women, mean (range) age 69 (50-82) years), were studied the day before and 1 week after replacement of the aortic valve. These patients were selected from a cohort of 15 due to ease of imaging of the left anterior descending coronary artery. Seven had a history of angina. Haemodynamics, peak transvalvar aortic gradient, left ventricular mass index, ventricular dimensions, and profiles of coronary flow velocity were measured. Profiles of coronary flow velocity were also measured in a control population of 10 normal subjects (five men, five women, mean (range) age 58 (34-66) years).

RESULTS

The control population showed forward flow throughout systole, but reversed early systolic flow (mean velocity 20.6 (3.6) cm/s) was seen in six patients with aortic stenosis. Only three of these patients had a clinical history of angina. Peak and mean systolic and diastolic forward flow velocities were not significantly different in the control group and in patients with aortic stenosis. The time from the start of systole to the onset of forward systolic flow was significantly longer in patients with aortic stenosis than in the control population (185 (8.5) v 85 (10) ms, p < 0.01). The time from the onset of diastolic flow to peak diastolic velocity was also significantly longer in the aortic stenosis group (146 (16) v 74 (13) ms, p < 0.01). These abnormalities in profiles of coronary flow were reversed by replacement of the aortic valve. There was no correlation between changes in flow profiles in patients with aortic stenosis and preoperative clinical history, transvalvar gradient, left ventricular mass index, or ventricular dimensions.

CONCLUSIONS

Coronary flow profiles in patients with aortic stenosis were characterised by reversed early systolic flow and delayed forward systolic flow and attainment of peak diastolic velocity. Reversal of these abnormalities by replacement of the aortic valve may reflect altered left ventricular and aortic haemodynamics and contribute to the relief of angina when left ventricular hypertrophy persists. Further studies may correlate abnormalities of coronary flow with preoperative clinical and haemodynamic state.

Phasic coronary flow characteristics in patients with hypertrophic cardiomyopathy: a study by coronary Doppler catheter

Abnormal patterns of coronary flow velocity have been observed in patients with symmetric left ventricular hypertrophy in conditions such as aortic stenosis and systemic hypertension. However, phasic coronary flow characteristics have not been investigated in patients with asymmetric left ventricular hypertrophy in hypertrophic cardiomyopathy. The purpose of this study was to assess phasic coronary flow characteristics and their relation to echocardiographic and hemodynamic parameters in patients with hypertrophic cardiomyopathy. Coronary flow velocity was recorded in the left anterior descending artery with a 20 MHz Doppler catheter in eight patients with hypertrophic nonobstructive cardiomyopathy and eight control subjects with normal coronary arteries. Flow reversals observed in systole in all patients with hypertrophic cardiomyopathy, and the time velocity integrals of systolic flow were significantly smaller in patients with hypertrophic cardiomyopathy than in control subjects (-1.5 +/- 1.7 versus 4.3 +/- 1.2 cm; p < 0.01). The time from the beginning of diastole to peak diastolic velocity corrected by the square root of R-R interval (square root of RR) was prolonged significantly, and the velocity half-time from peak diastolic velocity corrected by square root of RR was shorter in the patients with hypertrophic cardiomyopathy compared with those in the control subjects (6.8 +/- 2.0 msec versus 4.0 +/- 0.6 msec [p < 0.01] and 9.2 +/- 4.9 msec versus 13.9 +/- 2.0 msec [p < 0.05], respectively). Peak velocity and time velocity integral of flow reversal showed significant correlations with anterior ventricular septal thickness (y = -0.5x + 13.5, r = 0.8, and p < 0.01; y = -1.3 +/- 16.8, r = 0.8, and p = 0.024, respectively), the septal/free wall thickness ratio (y = -0.1x + 1.1, r = 0.8, and p < 0.01; y = -0.2x + 1.4, r = 0.9, and p < 0.01, respectively), and the degree of narrowing of the first septal perforator arteries (y = 1.9x + 91.6, r = 0.8, and p = 0.012; y = 6.1x + 80.6, r = 0.9, and p < 0.01, respectively). In conclusion, flow reversal in systole and slow acceleration and rapid deceleration in diastole were characteristics in patients with hypertrophic cardiomyopathy. Flow reversal might be related to the degree of left ventricular asymmetry and compression of the septal perforator arteries.

Relation of phasic coronary flow velocity profile to clinical and hemodynamic characteristics of patients with aortic valve disease

BACKGROUND

Our objective was to assess phasic coronary blood flow and velocity characteristics of the proximal portion of the left anterior descending artery and to evaluate their relation to the clinical and hemodynamic manifestations in patients with aortic valve disease.

METHODS AND RESULTS

We examined 26 patients with chronic aortic regurgitation (AR), 12 patients with predominant aortic stenosis (AS), and 11 control subjects using an intravascular Doppler catheter with spectral analysis. Angiographic assessment of AR identified 10 patients with mild regurgitation and 16 with severe regurgitation. The resting systolic coronary flow velocity-time integral (VTI) was significantly higher and the diastolic VTI was slightly but significantly higher in patients with severe regurgitation than in those with mild regurgitation (11.8 +/- 4.2 vs 4.1 +/- 1.1 cm, P < .001; 18.5 +/- 5.8 vs 13.2 +/- 3.2 cm, P < .05) and control subjects (4.0 +/- 1.0 cm, P < .001 and 13.3 +/- 3.6 cm, P < .05), respectively. Patients with AS had a slightly lower resting systolic VTI (3.8 +/- 1.4 cm) and a higher diastolic VTI (14.6 +/- 3.7 cm) than control subjects. Resting coronary blood flow was greater in patients with aortic valve disease than in control subjects. There was a significant correlation between the ratio of the resting systolic to diastolic VTI (S/D ratio) and the ratio of the aortic systolic to diastolic pressure (r = .75, P < .001) in patients with AR. The S/D ratio was inversely correlated with left ventricular systolic pressure (r = -.92, P < .001) and positively correlated with the ratio of the aortic systolic to diastolic pressure (r = .68, P < .05) in patients with AS.

CONCLUSIONS

Our results indicate that hemodynamic changes related to aortic valve disease contribute to alterations in the resting phasic coronary blood flow and velocity profiles observed in these patients.

Systolic coronary flow reversal and abnormal diastolic flow patterns in patients with aortic stenosis: assessment with an intracoronary Doppler catheter

Decreased left ventricular coronary flow reserve has been reported in patients with normal coronary arteries and left ventricular hypertrophy in association with aortic stenosis. However, phasic coronary flow characteristics have not been analyzed in detail in similar patients. The purpose of this study is to assess phasic coronary flow characteristics and their relation to hemodynamic parameters in patients with aortic stenosis. Coronary flow velocities were recorded in the left anterior descending artery with a 20 MHz Doppler catheter in nine patients with aortic stenosis and nine control subjects with normal coronary arteries. Patient aortic valve area ranged from 0.34 to 0.51 cm2. Flow reversal was observed in systole in all patients with aortic stenosis, and time velocity integrals of systolic flow were significantly smaller in patients with aortic stenosis than in controls (-0.3 +/- 2.3 vs 4.0 +/- 1.1 cm, p < 0.01). The time to peak diastolic velocity corrected by square root R-R interval was prolonged and the velocity half-time from peak diastolic velocity corrected by square root R-R interval was shorter in patients with aortic stenosis than in controls (5.3 +/- 1.1 vs 4.0 +/- 0.5, p < 0.01, 8.0 +/- 2.6 vs 13.0 +/- 3.3, p < 0.01, respectively). Peak velocity and time velocity integral of flow reversal showed significant correlations with mean pressure gradient across the aortic valve (y = 1.3x + 37.3, r = 0.72, p = 0.03, y = 11.3x + 41.2, r = 0.81, p < 0.01, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)