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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Garber L, Khodaei S, Maftoon N, Keshavarz-Motamed Z. Impact of TAVR on coronary artery hemodynamics using clinical measurements and image-based patient-specific in silico modeling. Sci Rep 2023; 13:8948. [PMID: 37268642 DOI: 10.1038/s41598-023-31987-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/21/2023] [Indexed: 06/04/2023] Open
Abstract
In recent years, transcatheter aortic valve replacement (TAVR) has become the leading method for treating aortic stenosis. While the procedure has improved dramatically in the past decade, there are still uncertainties about the impact of TAVR on coronary blood flow. Recent research has indicated that negative coronary events after TAVR may be partially driven by impaired coronary blood flow dynamics. Furthermore, the current technologies to rapidly obtain non-invasive coronary blood flow data are relatively limited. Herein, we present a lumped parameter computational model to simulate coronary blood flow in the main arteries as well as a series of cardiovascular hemodynamic metrics. The model was designed to only use a few inputs parameters from echocardiography, computed tomography and a sphygmomanometer. The novel computational model was then validated and applied to 19 patients undergoing TAVR to examine the impact of the procedure on coronary blood flow in the left anterior descending (LAD) artery, left circumflex (LCX) artery and right coronary artery (RCA) and various global hemodynamics metrics. Based on our findings, the changes in coronary blood flow after TAVR varied and were subject specific (37% had increased flow in all three coronary arteries, 32% had decreased flow in all coronary arteries, and 31% had both increased and decreased flow in different coronary arteries). Additionally, valvular pressure gradient, left ventricle (LV) workload and maximum LV pressure decreased by 61.5%, 4.5% and 13.0% respectively, while mean arterial pressure and cardiac output increased by 6.9% and 9.9% after TAVR. By applying this proof-of-concept computational model, a series of hemodynamic metrics were generated non-invasively which can help to better understand the individual relationships between TAVR and mean and peak coronary flow rates. In the future, tools such as these may play a vital role by providing clinicians with rapid insight into various cardiac and coronary metrics, rendering the planning for TAVR and other cardiovascular procedures more personalized.
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Affiliation(s)
- Louis Garber
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
| | - Seyedvahid Khodaei
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, ON, Canada
| | - Zahra Keshavarz-Motamed
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada.
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada.
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada.
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Ciampi Q, Cortigiani L, Rivadeneira Ruiz M, Barbieri A, Manganelli F, Mori F, D’Alfonso MG, Bursi F, Villari B. ABCDEG Stress Echocardiography in Aortic Stenosis. Diagnostics (Basel) 2023; 13:1727. [PMID: 37238211 PMCID: PMC10217228 DOI: 10.3390/diagnostics13101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | | | | | - Andrea Barbieri
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Fiore Manganelli
- Cardiology Division, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Fabio Mori
- Cardiology Division, Careggi Hospital, 50134 Florence, Italy; (F.M.); (M.G.D.)
| | | | - Francesca Bursi
- Department of Health Science, University of Milan, Cardiology Division, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy;
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
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Sabbah M, Olsen NT, Holmvang L, Tilsted HH, Pedersen F, Joshi FR, Sørensen R, Jabbari R, Arslani K, Sondergaard L, Engstrøm T, Lønborg JT. Long-term changes in coronary physiology after aortic valve replacement. EUROINTERVENTION 2023; 18:1156-1164. [PMID: 36239118 PMCID: PMC9940233 DOI: 10.4244/eij-d-22-00621] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/01/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND The detrimental effects of long-standing severe aortic stenosis (AS) often include left ventricular hypertrophy (LVH) and exhaustion of coronary flow reserve (CFR), the reversibility of which is unclear after valve replacement. AIMS Our aims were to 1) investigate whether CFR in the left anterior descending artery (LAD) would improve following valve replacement, and if the change was related to changes in hyperaemic coronary flow (QLAD) and minimal microvascular resistance (Rμ,LAD); and 2) investigate the relationship between changes in CFR and changes in left ventricular mass (LVM) and stroke work (LVSW). METHODS We measured intracoronary bolus thermodilution-derived CFR, and continuous thermodilution-derived QLAD and Rμ,LAD before and 6 months after aortic valve replacement. Cardiac magnetic resonance imaging was used to quantify left ventricular anatomy and function for the calculation of LVM and LVSW. Results: Thirty-four patients were included (17 patients had transcatheter aortic valve implantation; 14 had surgical valve replacement with a bioprosthesis and 3 with a mechanical prosthesis) who underwent invasive assessment in the LAD. CFR increased from 2.5 (interquartile range [IQR] 1.5-3.3) at baseline to 3.1 (IQR 2.2-5.1) at follow-up (p=0.005), despite no significant change in QLAD (230±106 mL/min to 250±101 mL/min; p=0.26) or Rμ,LAD (347 [IQR 247-463] to 287 [IQR 230-456]; p=0.20). When indexed for LVM, QLAD was 39% (IQR 8-98%) higher at follow-up compared with baseline (p<0.001). The improvement in CFR was correlated with ΔLVSW, r= -0.39; p=0.047. Conclusions: CFR in the LAD increased significantly at follow-up although global hyperaemic flow and minimal microvascular resistance remained unchanged. Thus, a decrease in resting flow was the cause of CFR improvement. CFR improvement was associated with reduction in LVSW.
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Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niels T Olsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hans-Henrik Tilsted
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Francis Richard Joshi
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ketina Arslani
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Sondergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Thomsen Lønborg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Civieri G, Montisci R, Kerkhof PLM, Iliceto S, Tona F. Coronary Flow Velocity Reserve by Echocardiography: Beyond Atherosclerotic Disease. Diagnostics (Basel) 2023; 13:diagnostics13020193. [PMID: 36673004 PMCID: PMC9858233 DOI: 10.3390/diagnostics13020193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Coronary flow velocity reserve (CFVR) is defined as the ratio between coronary flow velocity during maximal hyperemia and coronary flow at rest. Gold-standard techniques to measure CFVR are either invasive or require radiation and are therefore inappropriate for large-scale adoption. More than 30 years ago, echocardiography was demonstrated to be a reliable tool to assess CFVR, and its field of application rapidly expanded. Although initially validated to assess the hemodynamic relevance of a coronary stenosis, CFVR by echocardiography was later used to investigate coronary microcirculation. Microvascular dysfunction was detected in many different conditions, ranging from organ transplantation to inflammatory disorders and from metabolic diseases to cardiomyopathies. Moreover, it has been proven that CFVR by echocardiography not only detects coronary microvascular involvement but is also an effective prognostic factor that allows a precise risk stratification of the patients. In this review, we will summarize the many applications of CFVR by echocardiography, focusing on the coronary involvement of systemic diseases.
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Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, 09124 Cagliari, Italy
| | - Peter L. M. Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, 1081 HV Amsterdam, The Netherlands
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
- Correspondence: ; Tel.: +39-049-8211844
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Gupta K, Dixit P, Ananthasubramaniam K. Cardiac PET in aortic stenosis: Potential role in risk refinement? J Nucl Cardiol 2022; 29:3474-3479. [PMID: 34228335 DOI: 10.1007/s12350-021-02714-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kartik Gupta
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | | - Karthik Ananthasubramaniam
- Department of Internal Medicine, Heart and Vascular Institute, Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA.
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Serial changes of coronary flow reserve over one year after transcatheter aortic valve implantation in patients with severe aortic stenosis. IJC HEART & VASCULATURE 2022; 42:101090. [PMID: 35873862 PMCID: PMC9304717 DOI: 10.1016/j.ijcha.2022.101090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 01/09/2023]
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Abstract
Purpose of Review
Stress echocardiography is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms during activities of daily living. We describe the current methodology and the evidence supporting these applications. Recent Findings The comprehensive stress echo assessment includes valve function (gradients and regurgitation), left ventricular global systolic and diastolic function, left atrial volume, pulmonary congestion, pulmonary arterial pressure, and right ventricular function, integrated with blood pressure response with cuff sphygmomanometer, chronotropic reserve with heart rate, and symptoms. Summary Recent guidelines recommend the evaluation of asymptomatic severe or symptomatic non-severe mitral regurgitation or stenosis with exercise stress and suspected low-flow, low-gradient severe aortic stenosis with reduced ejection fraction with low dose (up to 20 mcg, without atropine) dobutamine stress. Prospective, large-scale studies based on a comprehensive protocol (ABCDE +) capturing the multiplicity of clinical phenotypes are needed to support stress echo-driven treatment strategies.
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Affiliation(s)
- Rodolfo Citro
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni Di Dio E Ruggi d, Aragona University Hospital, Salerno, Italy
- Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Francesca Bursi
- Dipartimento Di Scienze Della Salute, ASST Santi Paolo E Carlo Milano, Università Degli Studi Statale Di Milano, Ospedale San Paolo, Milan, Italy
| | - Michele Bellino
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, CNR Research Campus, Via Moruzzi, 1, Building C, First floor, Room 130, 56124, Pisa, Italy.
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Sabbah M, Olsen NT, Minkkinen M, Holmvang L, Tilsted H, Pedersen F, Joshi FR, Ahtarovski K, Sørensen R, Linde JJ, Søndergaard L, Pijls N, Lønborg J, Engstrøm T. Microcirculatory Function in Nonhypertrophic and Hypertrophic Myocardium in Patients With Aortic Valve Stenosis. J Am Heart Assoc 2022; 11:e025381. [PMID: 35470693 PMCID: PMC9238586 DOI: 10.1161/jaha.122.025381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Left ventricular hypertrophy (LVH) has often been supposed to be associated with abnormal myocardial blood flow and resistance. The aim of this study was to evaluate and quantify the physiological and pathological changes in myocardial blood flow and microcirculatory resistance in patients with and without LVH attributable to severe aortic stenosis. Methods and Results Absolute coronary blood flow and microvascular resistance were measured using a novel technique with continuous thermodilution and infusion of saline. In addition, myocardial mass was assessed with cardiac magnetic resonance imaging. Fifty-three patients with aortic valve stenosis were enrolled in the study. In 32 patients with LVH, hyperemic blood flow per gram of tissue was significantly decreased compared with 21 patients without LVH (1.26±0.48 versus 1.66±0.65 mL·min-1·g-1; P=0.018), whereas minimal resistance indexed for left ventricular mass was significantly increased in patients with LVH (63 [47-82] versus 43 [35-63] Wood Units·kg; P=0.014). Conclusions Patients with LVH attributable to severe aortic stenosis had lower hyperemic blood flow per gram of myocardium and higher minimal myocardial resistance compared with patients without LVH.
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Affiliation(s)
- Muhammad Sabbah
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Niels Thue Olsen
- Department of CardiologyCopenhagen University Hospital–Herlev and GentofteGentofteDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Mikko Minkkinen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Hans‐Henrik Tilsted
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Frants Pedersen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Francis R. Joshi
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Kiril Ahtarovski
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Rikke Sørensen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Jesper James Linde
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lars Søndergaard
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nico Pijls
- Department of CardiologyCatharina HospitalEindhoventhe Netherlands
| | - Jacob Lønborg
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Thomas Engstrøm
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
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Munneke AG, Lumens J, Arts T, Delhaas T. A Closed-Loop Modeling Framework for Cardiac-to-Coronary Coupling. Front Physiol 2022; 13:830925. [PMID: 35295571 PMCID: PMC8919076 DOI: 10.3389/fphys.2022.830925] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/24/2022] [Indexed: 01/09/2023] Open
Abstract
The mechanisms by which cardiac mechanics effect coronary perfusion (cardiac-to-coronary coupling) remain incompletely understood. Several coronary models have been proposed to deepen our understanding of coronary hemodynamics, but possibilities for in-depth studies on cardiac-to-coronary coupling are limited as mechanical properties like myocardial stress and strain are most often neglected. To overcome this limitation, a mathematical model of coronary mechanics and hemodynamics was implemented in the previously published multi-scale CircAdapt model of the closed-loop cardiovascular system. The coronary model consisted of a relatively simple one-dimensional network of the major conduit arteries and veins as well as a lumped parameter model with three transmural layers for the microcirculation. Intramyocardial pressure was assumed to arise from transmission of ventricular cavity pressure into the myocardial wall as well as myocardial stiffness, based on global pump mechanics and local myofiber mechanics. Model-predicted waveforms of global epicardial flow velocity, as well as of intramyocardial flow and diameter were qualitatively and quantitatively compared with reported data. Versatility of the model was demonstrated in a case study of aortic valve stenosis. The reference simulation correctly described the phasic pattern of coronary flow velocity, arterial flow impediment, and intramyocardial differences in coronary flow and diameter. Predicted retrograde flow during early systole in aortic valve stenosis was in agreement with measurements obtained in patients. In conclusion, we presented a powerful multi-scale modeling framework that enables realistic simulation of coronary mechanics and hemodynamics. This modeling framework can be used as a research platform for in-depth studies of cardiac-to-coronary coupling, enabling study of the effect of abnormal myocardial tissue properties on coronary hemodynamics.
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Affiliation(s)
- Anneloes G Munneke
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Theo Arts
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
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Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Srdjan Aleksandric
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Sabbah M, Joshi FR, Minkkinen M, Holmvang L, Tilsted HH, Pedersen F, Ahtarovski K, Sørensen R, Thue Olsen N, Søndergaard L, De Backer O, Engstrøm T, Lønborg J. Long-Term Changes in Invasive Physiological Pressure Indices of Stenosis Severity Following Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2021; 15:e011331. [PMID: 34809440 DOI: 10.1161/circinterventions.121.011331] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with severe aortic stenosis frequently have coexisting coronary artery disease. Invasive hyperemic and nonhyperemic pressure indices are used to assess coronary artery disease severity but have not been evaluated in the context of severe aortic stenosis. METHODS We compared lesion reclassification rates of fractional flow reserve (FFR) and resting full-cycle ratio (RFR) measured before and 6 months after transcatheter aortic valve implantation using the conventional clinical cutoffs of ≤0.80 for FFR and ≤0.89 for RFR. This was a substudy of the ongoing NOTION-3 trial (Third Nordic Aortic Valve Intervention). Two-dimensional quantitative coronary analysis was used to assess changes in angiographic lesion severity. RESULTS Forty patients were included contributing 50 lesions in which FFR was measured. In 32 patients (36 lesions), RFR was also measured. There was no significant change in diameter stenosis from baseline to follow-up, 49.8% (42.9%-57.1%) versus 52.3% (43.2%-57.8%), P=0.50. RFR improved significantly from 0.88 (0.83%-0.93) at baseline to 0.92 (0.83-0.95) at follow-up, P=0.003, whereas FFR remained unchanged, 0.84 (0.81-0.89) versus 0.86 (0.78-0.90), P=0.72. At baseline, 11 out of 50 (22%) lesions were FFR-positive, whereas 15 out of 50 (30%) were positive at follow-up, P=0.219. Corresponding numbers for RFR were 23 out of 36 (64%) at baseline and 12 out of 36 (33%) at follow-up, P=0.003. CONCLUSIONS In patients with severe aortic stenosis, physiological assessment of coronary lesions with FFR before transcatheter aortic valve implantation leads to lower reclassification rate at 6-month follow-up, compared with RFR.
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Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Francis R Joshi
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Mikko Minkkinen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Hans-Henrik Tilsted
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Kiril Ahtarovski
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark (N.T.O.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Lars Søndergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Jacob Lønborg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
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13
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Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M, Kennon S, Forrest JK, Mathur A, Mullen MJ, Lansky A, Baumbach A. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:2083-2096. [PMID: 34620388 DOI: 10.1016/j.jcin.2021.07.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Michail
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Krishnaraj Rathod
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Daniel A Jones
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mick Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Mathur
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andreas Baumbach
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA.
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14
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El Kadi S, Qian L, Zeng P, Lof J, Stolze E, Xie F, van Rossum AC, Kamp O, Everbach C, Porter TR. Efficacy of Sonothrombolysis Using Acoustically Activated Perflutren Nanodroplets versus Perflutren Microbubbles. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1814-1825. [PMID: 33896679 DOI: 10.1016/j.ultrasmedbio.2021.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 06/12/2023]
Abstract
Nanoscale-diameter liquid droplets from commercially available microbubbles may optimize thrombus permeation and subsequent thrombus dissolution (TD). Thrombi were made using fresh porcine arterial whole blood and placed in an in vitro vascular simulation. A diagnostic ultrasound probe in contact with a tissue-mimicking phantom tested intermittent high-mechanical-index (HMI) fundamental multipulse (focused ultrasound [FUS], 1.8 MHz) versus harmonic single-pulse (HUS, 1.3 MHz) modes during a 10-min infusion of Definity nanodroplets (DNDs), Definity microbubbles (DMBs) or saline. The ability of FUS and intravenous DNDs to improve epicardial and microvascular flow was then tested in four pigs with left anterior descending thrombotic occlusion. Sixty in vitro thrombi were tested, 20 in each group. Percentage TD was significantly higher for DND-treated thrombi than DMB-treated thrombi and controls (DNDs: 42.4%, DMBs: 26.7%, saline: 15.0%; p < 0.0001 vs. control). The highest %TD was seen in the HMI FUS-treated DND group (51 ± 17% TD). HMI FUS detected droplet activation within the risk area in three of four pigs with left anterior descending thrombotic occlusion and re-canalized the epicardial vessel in two. DNDs with intermittent diagnostic HMI ultrasound resulted in significantly more intravascular TD than DMBs and have potential for coronary and risk area thrombolysis.
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Affiliation(s)
- Soufiane El Kadi
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands; Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lijun Qian
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA; Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ping Zeng
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - John Lof
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elizabeth Stolze
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Feng Xie
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Otto Kamp
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Carr Everbach
- Department of Engineering, Swarthmore College, Swarthmore, Pennsylvania, USA
| | - Thomas R Porter
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.
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15
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Coronary Microcirculation in Aortic Stenosis: Pathophysiology, Invasive Assessment, and Future Directions. J Interv Cardiol 2020; 2020:4603169. [PMID: 32774184 PMCID: PMC7396014 DOI: 10.1155/2020/4603169] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 01/09/2023] Open
Abstract
With the increasing prevalence of aortic stenosis (AS) due to a growing elderly population, a proper understanding of its physiology is paramount to guide therapy and define severity. A better understanding of the microvasculature in AS could improve clinical care by predicting left ventricular remodeling or anticipate the interplay between epicardial stenosis and myocardial dysfunction. In this review, we combine five decades of literature regarding microvascular, coronary, and aortic valve physiology with emerging insights from newly developed invasive tools for quantifying microcirculatory function. Furthermore, we describe the coupling between microcirculation and epicardial stenosis, which is currently under investigation in several randomized trials enrolling subjects with concomitant AS and coronary disease. To clarify the physiology explained previously, we present two instructive cases with invasive pressure measurements quantifying coexisting valve and coronary stenoses. Finally, we pose open clinical and research questions whose answers would further expand our knowledge of microvascular dysfunction in AS. These trials were registered with NCT03042104, NCT03094143, and NCT02436655.
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16
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Zelis JM, Tonino PAL, Johnson NP. Why Can Fractional Flow Reserve Decrease After Transcatheter Aortic Valve Implantation? J Am Heart Assoc 2020; 9:e04905. [PMID: 32102613 PMCID: PMC7335563 DOI: 10.1161/jaha.120.015806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jo M Zelis
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Pim A L Tonino
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Nils P Johnson
- Division of Cardiology Department of Medicine Weatherhead PET Center McGovern Medical School at UTHealth and Memorial Hermann Hospital Houston TX
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17
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Abstract
Regulation of coronary blood flow is maintained through a delicate balance of ventriculoarterial and neurohumoral mechanisms. The aortic valve is integral to the functions of these systems, and disease states that compromise aortic valve integrity have the potential to seriously disrupt coronary blood flow. Aortic stenosis (AS) is the most common cause of valvular heart disease requiring medical intervention, and the prevalence and associated socio-economic burden of AS are set to increase with population ageing. Valvular stenosis precipitates a cascade of structural, microcirculatory, and neurohumoral changes, which all lead to impairment of coronary flow reserve and myocardial ischaemia even in the absence of notable coronary stenosis. Coronary physiology can potentially be normalized through interventions that relieve severe AS, but normality is often not immediately achievable and probably requires continued adaptation. Finally, the physiological assessment of coronary artery disease in patients with AS represents an ongoing challenge, as the invasive physiological measures used in current cardiology practice are yet to be validated in this population. This Review discusses the key concepts of coronary pathophysiology in patients with AS through presentation of contemporary basic science and data from animal and human studies.
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18
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Abstract
Aortic stenosis is a heterogeneous disorder. Variations in the pathological and physiological responses to pressure overload are incompletely understood and generate a range of flow and pressure gradient patterns, which ultimately cause varying microvascular effects. The impact of cardiac-coronary coupling depends on these pressure and flow effects. In this article, we explore important concepts concerning cardiac physiology and the coronary microcirculation in aortic stenosis and their impact on myocardial remodeling, aortic valve flow patterns, and clinical progression.
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Affiliation(s)
- Hannah Z.R. McConkey
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Michael Marber
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Canada (P.P.)
| | - Simon R. Redwood
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Bernard D. Prendergast
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
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19
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Stoller M, Gloekler S, Zbinden R, Tueller D, Eberli F, Windecker S, Wenaweser P, Seiler C. Left ventricular afterload reduction by transcatheter aortic valve implantation in severe aortic stenosis and its prompt effects on comprehensive coronary haemodynamics. EUROINTERVENTION 2019; 14:166-173. [PMID: 29553941 DOI: 10.4244/eij-d-17-00719] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS In this study we aimed to test the hypothesis that left ventricular (LV) afterload reduction in severe aortic valve stenosis (AS) by transcatheter aortic valve implantation (TAVI) acutely improves coronary haemodynamics. METHODS AND RESULTS This was a prospective, pathophysiologic study in 40 patients with severe AS undergoing TAVI. Endpoints were determined invasively immediately before and after TAVI without altering coronary stenotic lesions if present. Myocardial hyperaemia was induced by intravenous adenosine. The primary study endpoints were coronary flow reserve (thermodilution-derived CFR), and fractional flow reserve (FFR). The secondary study endpoint was coronary collateral flow index (CFI) as obtained during a one-minute coronary balloon occlusion. CFR was 1.9±0.9 before TAVI and 2.0±1.0 after TAVI (p=0.72). FFR was 0.90±0.08 before TAVI and 0.93±0.08 after TAVI (p=0.0021). The TAVI-induced increase in FFR was related to a significant decrease in hyperaemic mean aortic pressure from 71±16 mmHg before TAVI to 67±15 mmHg after TAVI (p=0.0099). Hyperaemic CFI increased from 0.127±0.083 before to 0.146±0.090 after TAVI (p=0.0508). CONCLUSIONS CFR appears not to be acutely affected by LV afterload reduction among patients with severe AS in response to TAVI. However, it acutely improves FFR; this occurs via lowering of mean aortic pressure. Hyperaemic coronary collateral flow index tends to augment in response to TAVI.
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Affiliation(s)
- Michael Stoller
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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20
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Broyd CJ, Rigo F, Nijjer S, Sen S, Petraco R, Al-Lamee R, Foin N, Chukwuemeka A, Anderson J, Parker J, Malik IS, Mikhail GW, Francis DP, Parker K, Hughes AD, Mayet J, Davies JE. Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: Insights from serial coronary wave intensity analysis. Acta Physiol (Oxf) 2018; 224:e13109. [PMID: 29935058 DOI: 10.1111/apha.13109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 01/10/2023]
Abstract
AIM Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous haemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary "suction" force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave intensity analysis (WIA) to separate and measure the sequential effects of outflow tract obstruction relief and then LVH regression following intervention for aortic stenosis. METHODS Fifteen patients with unobstructed coronary arteries undergoing aortic valve intervention (11 surgical aortic valve replacement [SAVR], 4 TAVI) were successfully assessed before and after intervention, and at 6 and 12 months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial cuff system. RESULTS Immediately following intervention, a decline in the backward decompression wave (BDW) was noted (9.7 ± 5.7 vs 5.1 ± 3.6 × 103 W/m2 /s, P < 0.01). Over 12 months, LV mass index fell from 114 ± 19 to 82 ± 17 kg/m2 . Accompanying this, the BDW fraction increased to 32.8 ± 7.2% at 6 months (P = 0.01 vs post-procedure) and 34.7 ± 6.7% at 12 months (P < 0.001 vs post-procedure). CONCLUSION In aortic stenosis, both the outflow tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features.
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Affiliation(s)
| | - Fausto Rigo
- Division of Cardiology; dell'Angelo Hospital; Mestre-Venice Italy
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21
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Arashi H, Yamaguchi J, Ri T, Tanaka K, Otsuki H, Nakao M, Kamishima K, Jujo K, Minami Y, Ogawa H, Hagiwara N. Evaluation of the cut-off value for the instantaneous wave-free ratio of patients with aortic valve stenosis. Cardiovasc Interv Ther 2018; 34:269-274. [PMID: 30460666 DOI: 10.1007/s12928-018-0556-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/04/2018] [Indexed: 01/10/2023]
Abstract
The aim of this study was to examine the clinical value of iFR for AS patients. Functional evaluation of coronary stenosis in patients with aortic valve stenosis (AS) is challenging because the stress-induced test is often thought to be a contraindication. AS patients have a unique coronary flow pattern dependent on the diastolic phase. The instantaneous wave-free ratio (iFR) is a vasodilator-free, invasive pressure wire index of the functional severity of coronary stenosis and is calculated under resting conditions. And iFR calculated during a specific period of diastole may have the potential benefit to assess the functional severity of coronary stenosis in AS patients. We examined 158 consecutive patients (217 stenoses) whose iFR and fractional flow reserve (FFR) were measured simultaneously. Among the 158 patients, AS was observed in 13 (8.2%). The iFR showed good correlation with FFR in AS patients. The best cut-off value of iFR for the receiver-operator curve analysis to predict FFR of 0.8 was 0.9 for non-AS patients. However, it was 0.73 for AS patients. The present study demonstrated good correlation between iFR and FFR for AS patients. Vasodilator-free assessment using iFR may provide potential benefits when evaluating coronary stenosis in patients with AS. In AS patients, the best cut-off of iFR value predicting FFR value of 0.8 was lower than 0.9 that is the standard predictive value of iFR.
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Affiliation(s)
- Hiroyuki Arashi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Tonre Ri
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazuki Tanaka
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hisao Otsuki
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masashi Nakao
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazuho Kamishima
- Department of Cardiology, Rissho Kosei-kai Kosei General Hospital, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yuichiro Minami
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroshi Ogawa
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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22
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Mohammadi H, Cartier R, Mongrain R. 3D physiological model of the aortic valve incorporating small coronary arteries. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:e2829. [PMID: 27591390 DOI: 10.1002/cnm.2829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/04/2016] [Accepted: 08/26/2016] [Indexed: 06/06/2023]
Abstract
The diseases of the coronary arteries and the aortic root are still the leading causes of mortality and morbidity worldwide. In this study, a 3D global fluid-structure interaction of the aortic root with inclusion of anatomically inspired small coronary arteries using the finite element method is presented. This innovative model allows to study the impact and interaction of root biomechanics on coronary hemodynamics and brings a new understanding to small coronary vessels hemodynamics. For the first time, the velocity profiles and shear stresses are reported in distal coronary arteries as a result of the aortic flow conditions in a global fluid-structure interaction model.
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Affiliation(s)
- Hossein Mohammadi
- Mechanical Engineering Department, McGill University, Montreal, Quebec, H3A 0C3, Canada
| | - Raymond Cartier
- Department of Cardiovascular Surgery, Montreal Heart Institute, Montreal, Quebec, H1T 1C8, Canada
| | - Rosaire Mongrain
- Mechanical Engineering Department, McGill University, Montreal, Quebec, H3A 0C3, Canada
- Department of Cardiovascular Surgery, Montreal Heart Institute, Montreal, Quebec, H1T 1C8, Canada
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Broyd CJ, Davies JE, Escaned JE, Hughes A, Parker K. Wave intensity analysis and its application to the coronary circulation. Glob Cardiol Sci Pract 2017; 2017:e201705. [PMID: 28971104 PMCID: PMC5621714 DOI: 10.21542/gcsp.2017.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Wave intensity analysis (WIA) is a technique developed from the field of gas dynamics that is now being applied to assess cardiovascular physiology. It allows quantification of the forces acting to alter flow and pressure within a fluid system, and as such it is highly insightful in ascribing cause to dynamic blood pressure or velocity changes. When co-incident waves arrive at the same spatial location they exert either counteracting or summative effects on flow and pressure. WIA however allows waves of different origins to be measured uninfluenced by other simultaneously arriving waves. It therefore has found particular applicability within the coronary circulation where both proximal (aortic) and distal (myocardial) ends of the coronary artery can markedly influence blood flow. Using these concepts, a repeating pattern of 6 waves has been consistently identified within the coronary arteries, 3 originating proximally and 3 distally. Each has been associated with a particular part of the cardiac cycle. The most clinically relevant wave to date is the backward decompression wave, which causes the marked increase in coronary flow velocity observed at the start of the diastole. It has been proposed that this wave is generated by the elastic re-expansion of the intra-myocardial blood vessels that are compressed during systolic contraction. Particularly by quantifying this wave, WIA has been used to provide mechanistic and prognostic insight into a number of conditions including aortic stenosis, left ventricular hypertrophy, coronary artery disease and heart failure. It has proven itself to be highly sensitive and as such a number of novel research directions are encouraged where further insights would be beneficial.
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Affiliation(s)
- C J Broyd
- Imperial College London, London, UK.,Hospital Clinico San Carlos, Madrid, Spain
| | | | | | - A Hughes
- University College London, London, UK
| | - K Parker
- Imperial College London, London, UK
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24
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Nield LE, Dragulescu A, MacColl C, Manlhiot C, Brun H, McCrindle BW, Kuipers B, Caldarone CA, Miner SES, Mertens L. Coronary artery Doppler patterns are associated with clinical outcomes post-arterial switch operation for transposition of the great arteries. Eur Heart J Cardiovasc Imaging 2017; 19:461-468. [DOI: 10.1093/ehjci/jex050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lynne E Nield
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Andreea Dragulescu
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Christine MacColl
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Cedric Manlhiot
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Henrik Brun
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Bart Kuipers
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Christopher A Caldarone
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Steven E S Miner
- University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Luc Mertens
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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25
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Mirtschink P, Krek W. Hypoxia-driven glycolytic and fructolytic metabolic programs: Pivotal to hypertrophic heart disease. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2016; 1863:1822-8. [DOI: 10.1016/j.bbamcr.2016.02.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/28/2016] [Accepted: 02/13/2016] [Indexed: 01/21/2023]
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26
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Wiegerinck EMA, van de Hoef TP, Rolandi MC, Yong Z, van Kesteren F, Koch KT, Vis MM, de Mol BAJM, Piek JJ, Baan J. Impact of Aortic Valve Stenosis on Coronary Hemodynamics and the Instantaneous Effect of Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2016; 8:e002443. [PMID: 26245891 DOI: 10.1161/circinterventions.114.002443] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Aortic valve stenosis (AS) induces compensatory alterations in left ventricular hemodynamics, leading to physiological and pathological alterations in coronary hemodynamics. Relief of AS by transcatheter aortic valve implantation (TAVI) decreases ventricular afterload and is expected to improve microvascular function immediately. We evaluated the effect of AS on coronary hemodynamics and the immediate effect of TAVI. METHODS AND RESULTS Intracoronary pressure and flow velocity were simultaneously assessed at rest and at maximal hyperemia in an unobstructed coronary artery in 27 patients with AS before and immediately after TAVI and in 28 patients without AS. Baseline flow velocity was higher and baseline microvascular resistance was lower in patients with AS as compared with controls, which remained unaltered post-TAVI. In patients with AS, hyperemic flow velocity was significantly lower as compared with controls (44.5±14.5 versus 54.3±18.6 cm/s; P=0.04). Hyperemic microvascular resistance (expressed in mm Hg·cm·s(-1)) was 2.10±0.69 in patients with AS as compared with 1.80±0.60 in controls (P=0.096). Coronary flow velocity reserve in patients with AS was lower, 1.9±0.5 versus 2.7±0.7 in controls (P<0.001). Improvement in coronary hemodynamics after TAVI was most pronounced in patients without post-TAVI aortic regurgitation. In these patients (n=20), hyperemic flow velocity increased significantly from 46.24±15.47 pre-TAVI to 56.56±17.44 cm/s post-TAVI (P=0.003). Hyperemic microvascular resistance decreased from 2.03±0.71 to 1.66±0.45 (P=0.050). Coronary flow velocity reserve increased significantly from 1.9±0.4 to 2.2±0.6 (P=0.009). CONCLUSIONS The vasodilatory reserve capacity of the coronary circulation is reduced in AS. TAVI induces an immediate decrease in hyperemic microvascular resistance and a concomitant increase in hyperemic flow velocity, resulting in immediate improvement in coronary vasodilatory reserve.
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Affiliation(s)
- Esther M A Wiegerinck
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Cristina Rolandi
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - ZeYie Yong
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Floortje van Kesteren
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T Koch
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije M Vis
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas A J M de Mol
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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27
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Rolandi MC, Wiegerinck EM, Casadonte L, Yong ZY, Koch KT, Vis M, Piek JJ, Baan J, Spaan JA, Siebes M. Transcatheter Replacement of Stenotic Aortic Valve Normalizes Cardiac–Coronary Interaction by Restoration of Systolic Coronary Flow Dynamics as Assessed by Wave Intensity Analysis. Circ Cardiovasc Interv 2016; 9:e002356. [DOI: 10.1161/circinterventions.114.002356] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- M. Cristina Rolandi
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Esther M.A. Wiegerinck
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Lorena Casadonte
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ze-Yie Yong
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karel T. Koch
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marije Vis
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan J. Piek
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Baan
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jos A.E. Spaan
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Maria Siebes
- From the Departments of Biomedical Engineering and Physics (M.C.R., L.C., J.A.E.S., M.S.) and Cardiology (E.M.A.W., Z.-Y.Y., K.T.K., M.V., J.J.P., J.B.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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28
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Differences in coronary artery blood velocities in the setting of normal coronary angiography and normal stress echocardiography. Heart Int 2016; 10:e6-e11. [PMID: 27672435 PMCID: PMC4946382 DOI: 10.5301/heartint.5000221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2015] [Indexed: 12/13/2022] Open
Abstract
Background Normal left anterior descending (LAD) coronary artery as determined by coronary angiography is considered not only to reflect normal angiography but also to correlate with normal anatomy and function. However, subjects who undergo coronary angiography may differ from those who do not need to have invasive evaluation even if their functional noninvasive studies like dobutamine stress echocardiography (DSE) were normal. Aim LAD velocities in subjects with normal angiography and those with normal DSE are equal. Methods A total of 244 subjects were evaluated, 78 had normal LAD by angiography and 166 had normal LAD by DSE. All had Doppler sampling of LAD velocities by transthoracic echocardiography. Results Velocity was higher in the angiographic subgroup in diastole 41 ± 23 vs 33 ± 14 cm/s, p = 0.0078; systole 18 ± 14 vs 13 ± 7 cm/s, p = 0.012; diastolic integral 12.6 ± 5 vs 9.8 ± 3.8 cm, p = 3.15 × 10-5; systolic velocity integral 4 ± 2.9 vs 2.8 ± 1.9, p = 0.0014. While heart rate was similar in both groups, the product of diastolic velocity integral and heart rate of the LAD in the angiographic group was higher: 902 ± 450 vs 656 ± 394, p = 0.00599. Diastolic velocity deceleration time was similar in both groups. Coronary flow reserve defined as diastolic velocity ratio before and immediately after DSE correlated negatively with baseline velocity, r = -0.4. Conclusions Mode of defining normality of coronary artery affects velocity behavior of the vessel, reflecting functional differences possibly related to microvasculature and vasodilatation.
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29
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Abstract
Left ventricular hypertrophy (LVH) is growth in left ventricular mass caused by increased cardiomyocyte size. LVH can be a physiological adaptation to strenuous physical exercise, as in athletes, or it can be a pathological condition, which is either genetic or secondary to LV overload. Physiological LVH is usually benign and regresses upon reduction/cessation of physical activity. Pathological LVH is a compensatory phenomenon, which eventually may become maladaptive and evolve towards progressive LV dysfunction and heart failure (HF). Both interstitial and replacement fibrosis play a major role in the progressive decompensation of the hypertrophied LV. Coronary microvascular dysfunction (CMD) and myocardial ischemia, which have been demonstrated in most forms of pathological LVH, have an important pathogenetic role in the formation of replacement fibrosis and both contribute to the evolution towards LV dysfunction and HF. Noninvasive imaging allows detection of myocardial fibrosis and CMD, thus providing unique information for the stratification of patients with LVH. (Circ J 2016; 80: 555-564).
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Affiliation(s)
- Davide Lazzeroni
- Prevention and Rehabilitation Unit, Don Gnocchi Foundation & University of Parma
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30
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Broyd C, Davies J, Escaned J, Hughes A, Parker K. Wave intensity analysis and its application to the coronary circulation. Glob Cardiol Sci Pract 2015. [DOI: 10.5339/gcsp.2015.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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31
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Simova I. Coronary Flow Velocity Reserve Assessment with Transthoracic Doppler Echocardiography. Eur Cardiol 2015; 10:12-18. [PMID: 30310417 PMCID: PMC6159450 DOI: 10.15420/ecr.2015.10.01.12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/23/2015] [Indexed: 11/04/2022] Open
Abstract
Coronary flow velocity reserve (CFVR) reflects global coronary atherosclerotic burden, endothelial function and state of the microvasculature. It could be measured using transthoracic Doppler echocardiography in a non-invasive, feasible, reliable and reproducible fashion, following a standardised protocol with different vasodilatory stimuli. CFVR measurement is a recommended complement to vasodilator stress echocardiography. It could serve as a diagnostic tool for coronary microvascular dysfunction and in the setting of epicardial coronary artery stenoses could help in identification and assessment of functional significance of coronary lesions and follow-up of patients after coronary interventions. CFVR has also a prognostic significance in different clinical situations.
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Affiliation(s)
- Iana Simova
- National Cardiology Hospital, Sofia, Bulgaria
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32
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Meimoun P, Czitrom D. [Coronary microvascular dysfunction and aortic stenosis: an update]. Ann Cardiol Angeiol (Paris) 2014; 63:353-361. [PMID: 25261167 DOI: 10.1016/j.ancard.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 06/03/2023]
Abstract
The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - D Czitrom
- Service de cardiologie, institut mutualiste Montsouris, 75014 Paris, France
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33
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Coronary blood flow in patients with severe aortic stenosis before and after transcatheter aortic valve implantation. Am J Cardiol 2014; 114:1264-8. [PMID: 25173443 DOI: 10.1016/j.amjcard.2014.07.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 07/16/2014] [Accepted: 07/16/2014] [Indexed: 11/21/2022]
Abstract
Patients with severe aortic stenosis and no obstructed coronary arteries are reported to have reduced coronary flow. Doppler evaluation of proximal coronary flow is feasible using transesophageal echocardiography. The present study aimed to assess the change in coronary flow in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The left main coronary artery was visualized using transesophageal echocardiography in 90 patients undergoing TAVI using the Edwards SAPIEN valve. The peak systolic and diastolic velocities of the coronary flow and the time-velocity integral were obtained before and after TAVI using pulse-wave Doppler. Mean aortic gradients decreased from 47.1 ± 15.7 mm Hg before TAVI to 3.6 ± 2.6 mm Hg after TAVI (p <0.001). The aortic valve area increased from 0.58 ± 0.17 to 1.99 ± 0.35 cm(2) (p <0.001). The cardiac output increased from 3.4 ± 1.1 to 3.8 ± 1.0 L/min (p <0.001). Left ventricular end-diastolic pressure (LVEDP) decreased from 19.8 ± 5.4 to 17.3 ± 4.1 mm Hg (p <0.001). The following coronary flow parameters increased significantly after TAVI: peak systolic velocity 24.2 ± 9.3 to 30.5 ± 14.9 cm/s (p <0.001), peak diastolic velocity 49.8 ± 16.9 to 53.7 ± 22.3 cm/s (p = 0.04), total velocity-time integral 26.7 ± 10.5 to 29.7 ± 14.1 cm (p = 0.002), and systolic velocity-time integral 6.1 ± 3.7 to 7.7 ± 5.0 cm (p = 0.001). Diastolic time-velocity integral increased from 20.6 ± 8.7 to 22.0 ± 10.1 cm (p = 0.04). Total velocity-time integral increased >10% in 43 patients (47.2%). Pearson's correlation coefficient revealed the change in LVEDP as the best correlate of change in coronary flow (R = -0.41, p = 0.003). In conclusion, TAVI resulted in a significant increase in coronary flow. The change in coronary flow was associated mostly with a decrease in LVEDP.
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34
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Wu J, Xie F, Kumar T, Liu J, Lof J, Shi W, Everbach EC, Porter TR. Improved sonothrombolysis from a modified diagnostic transducer delivering impulses containing a longer pulse duration. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1545-53. [PMID: 24613551 PMCID: PMC4048784 DOI: 10.1016/j.ultrasmedbio.2014.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/06/2014] [Accepted: 01/13/2014] [Indexed: 05/11/2023]
Abstract
Although guided high-mechanical-index (MI) impulses from a diagnostic ultrasound transducer have been used in preclinical studies to dissolve coronary arterial and microvascular thrombi in the presence of intravenously infused microbubbles, it is possible that pulse durations (PDs) longer than that used for diagnostic imaging may further improve the effectiveness of this approach. By use of an established in vitro model flow system, a total of 90 occlusive porcine arterial thrombi (thrombus age: 3-4 h) within a vascular mimicking system were randomized to 10-min treatments with two different PDs (5 and 20 μs) using a Philips S5-1 transducer (1.6-MHz center frequency) at a range of MIs (from 0.2 to 1.4). All impulses were delivered in an intermittent fashion to permit microbubble replenishment within the thrombosed vessel. Diluted lipid-encapsulated microbubbles (0.5% Definity) were infused during the entire treatment period. A tissue-mimicking phantom 5 cm thick was placed between the transducer and thrombosed vessel to mimic transthoracic attenuation. Two 20-MHz passive cavitation detection systems were placed confocal to the insonified vessel to assess for inertial cavitational activity. Percentage thrombus dissolution was calculated by weighing the thrombi before and after each treatment. Percentage thrombus dissolution was significantly higher with a 20-μs PD already at the 0.2 and 0.4 MI therapeutic impulses (54 ± 12% vs. 33 ± 17% and 54 ± 22% vs. 34 ± 17%, p < 0.05 compared with the 5-μs PD group, respectively), and where passive cavitation detection systems detected only low intensities of inertial cavitation. At higher MI settings and 20-μs PDs, percentage thrombus dissolution decreased most likely from high-intensity cavitation shielding of the thrombus. Slightly prolonging the PD on a diagnostic transducer improves the degree of sonothrombolysis that can be achieved without fibrinolytic agents at a lower mechanical index.
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Affiliation(s)
- Juefei Wu
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Feng Xie
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tanmay Kumar
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jinjin Liu
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John Lof
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - William Shi
- Philips Research North America, Briarcliff, New York, USA
| | | | - Thomas R Porter
- University of Nebraska Medical Center, Omaha, Nebraska, USA.
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35
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Takata M, Amiya E, Watanabe M, Ozeki A, Watanabe A, Kawarasaki S, Nakao T, Hosoya Y, Uno K, Saito A, Murasawa T, Ono M, Nagai R, Komuro I. Brachial artery diameter has a predictive value in the improvement of flow-mediated dilation after aortic valve replacement for aortic stenosis. Heart Vessels 2014; 30:218-26. [DOI: 10.1007/s00380-014-0475-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/17/2014] [Indexed: 11/24/2022]
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36
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Sharif D, Sharif-Rasslan A, Khalil A, Rosenschein U. Left anterior descending coronary artery flow after primary angioplasty in acute anterior ST-elevation myocardial infarction: How much flow is needed for left ventricular functional recovery? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:223-8. [DOI: 10.1177/2048872614521763] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dawod Sharif
- Department of Cardiology, Bnai Zion Medical Center, Israel
- Technion – Israel Institute of Technology, Israel
| | - Amal Sharif-Rasslan
- Technion – Israel Institute of Technology, Israel
- The Academic Arab College, Mathematics Department, Haifa, Israel
| | - Amin Khalil
- Department of Cardiology, Bnai Zion Medical Center, Israel
| | - Uri Rosenschein
- Department of Cardiology, Bnai Zion Medical Center, Israel
- Technion – Israel Institute of Technology, Israel
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37
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Camuglia AC, Syed J, Garg P, Kiaii B, Chu MW, Jones PM, Bainbridge D, Teefy PJ. Invasively assessed coronary flow dynamics improve following relief of aortic stenosis with transcatheter aortic valve implantation. J Am Coll Cardiol 2013; 63:1808-9. [PMID: 24370439 DOI: 10.1016/j.jacc.2013.11.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Anthony C Camuglia
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Jaffer Syed
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Pallav Garg
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Bob Kiaii
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Michael W Chu
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Philip M Jones
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Daniel Bainbridge
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada
| | - Patrick J Teefy
- London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada.
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38
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Sharif D, Sharif-Rasslan A, Makhoul N, Shefer A, Hassan A, Rosenschein U. Sequential Evaluation of Coronary Flow Patterns after Primary Angioplasty in Acute Anterior ST-Elevation Myocardial Infarction Predicts Recovery of Left Ventricular Systolic Function. Echocardiography 2013; 31:644-653. [DOI: 10.1111/echo.12446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Dawod Sharif
- Department of Cardiology; Bnai Zion Medical Center; Haifa Israel
- Technion - Israel Institute of Technology; Haifa Israel
| | | | - Nabeel Makhoul
- Department of Cardiology; Bnai Zion Medical Center; Haifa Israel
| | - Arie Shefer
- Department of Cardiology; Bnai Zion Medical Center; Haifa Israel
| | - Amin Hassan
- Department of Cardiology; Bnai Zion Medical Center; Haifa Israel
| | - Uri Rosenschein
- Department of Cardiology; Bnai Zion Medical Center; Haifa Israel
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39
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Towards patient-specific modeling of coronary hemodynamics in healthy and diseased state. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2013; 2013:393792. [PMID: 23533537 PMCID: PMC3603622 DOI: 10.1155/2013/393792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/25/2012] [Accepted: 01/03/2013] [Indexed: 01/09/2023]
Abstract
A model describing the primary relations between the cardiac muscle and coronary circulation might be useful for interpreting coronary hemodynamics in case multiple types of coronary circulatory disease are present. The main contribution of the present study is the coupling of a microstructure-based heart contraction model with a 1D wave propagation model. The 1D representation of the vessels enables patient-specific modeling of the arteries and/or can serve as boundary conditions for detailed 3D models, while the heart model enables the simulation of cardiac disease, with physiology-based parameter changes. Here, the different components of the model are explained and the ability of the model to describe coronary hemodynamics in health and disease is evaluated. Two disease types are modeled: coronary epicardial stenoses and left ventricular hypertrophy with an aortic valve stenosis. In all simulations (healthy and diseased), the dynamics of pressure and flow qualitatively agreed with observations described in literature. We conclude that the model adequately can predict coronary hemodynamics in both normal and diseased state based on patient-specific clinical data.
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Broyd CJ, Sen S, Mikhail GW, Francis DP, Mayet J, Davies JE. Myocardial ischemia in aortic stenosis: insights from arterial pulse-wave dynamics after percutaneous aortic valve replacement. Trends Cardiovasc Med 2013; 23:185-91. [PMID: 23395429 DOI: 10.1016/j.tcm.2012.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/01/2012] [Accepted: 12/03/2012] [Indexed: 01/09/2023]
Abstract
Wave-intensity analysis is a technique that can qualify both the direction and magnitude of the forces accelerating and decelerating coronary blood flow and is derived from simultaneously acquired measures of coronary pressure and velocity using invasive intracoronary wires. Using this technique during TAVI, the dominant force (or 'wave') acting to increase the coronary blood flow which originates from microvascular relaxation is shown to be elevated in severe aortic stenosis and decreased post-implantation. Additionally, with increasing heart rate a progressive fall in the magnitude of this wave is noted and after TAVI this effect is reversed (returning towards the physiological norm). The potential causes of myocardial ischemia in aortic stenosis are clearly multi-factorial but this observation suggests a decoupling between the aorta and myocardium in aortic stenosis, the effects of which are magnified during increased heart rate.
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Affiliation(s)
- Christopher J Broyd
- International Centre for Circulatory Health, National Heart and Lung Institute, 59-61 North Wharf Road, London W2 1LA, UK.
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Jelenc M, Juvan KA, Medvešček NTR, Geršak B. Influence of type of aortic valve prosthesis on coronary blood flow velocity. Heart Surg Forum 2013; 16:E8-E14. [PMID: 23439362 DOI: 10.1532/hsf98.20121073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Severe aortic valve stenosis is associated with high resting and reduced hyperemic coronary blood flow. Coronary blood flow increases after aortic valve replacement (AVR); however, the increase depends on the type of prosthesis used. The present study investigates the influence of type of aortic valve prosthesis on coronary blood flow velocity. METHODS The blood flow velocity in the left anterior descending coronary artery (LAD) and the right coronary artery (RCA) was measured intraoperatively before and after AVR with a stentless bioprosthesis (Sorin Freedom Solo; n = 11) or a bileaflet mechanical prosthesis (St. Jude Medical Regent; n = 11). Measurements were made with an X-Plore epicardial Doppler probe (Medistim, Oslo, Norway) following induction of hyperemia with an adenosine infusion. Preoperative and postoperative echocardiography evaluations were used to assess valvular and ventricular function. Velocity time integrals (VTI) were measured from the Doppler signals and used to calculate the proportion of systolic VTI (SF), diastolic VTI (DF), and normalized systolic coronary blood flow velocities (NSF) and normalized diastolic coronary blood flow velocities (NDF). RESULTS The systolic proportion of the LAD VTI increased after AVR with the St. Jude Medical Regent prosthesis, which produced higher LAD SF and NSF values than the Sorin Freedom Solo prosthesis (SF, 0.41 ± 0.09 versus 0.29 ± 0.13 [P = .04]; NSF, 0.88 ± 0.24 versus 0.55 ± 0.17 [P = .01]). No significant changes in the LAD velocity profile were noted after valve replacement with the Sorin Freedom Solo, despite a significant reduction in transvalvular gradient and an increase in the effective orifice area. AVR had no effect on the RCA flow velocity profile. CONCLUSION The coronary flow velocity profile in the LAD was significantly influenced by the type of aortic valve prosthesis used. The differences in the LAD velocity profile probably reflect differences in valve design and the systolic transvalvular flow pattern.
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Affiliation(s)
- Matija Jelenc
- Department of Cardiovascular Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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Meimoun P, Germain AL, Elmkies F, Benali T, Boulanger J, Espanel C, Clerc J, Zemir H, Luycx-Bore A, Tribouilloy C. Factors Associated with Noninvasive Coronary Flow Reserve in Severe Aortic Stenosis. J Am Soc Echocardiogr 2012; 25:835-41. [DOI: 10.1016/j.echo.2012.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Indexed: 01/27/2023]
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Coronary perfusion: Impact of flow dynamics and geometric design of 2 different aortic prostheses of similar size. J Thorac Cardiovasc Surg 2012; 143:1030-5. [DOI: 10.1016/j.jtcvs.2011.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/12/2011] [Accepted: 06/07/2011] [Indexed: 11/19/2022]
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Clinical Applications of Transthoracic Doppler Echocardiographic Coronary Flow Reserve Measurements in the Left Anterior Descending Coronary Artery. J Med Ultrasound 2011. [DOI: 10.1016/j.jmu.2011.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sharif D, Sharif-Rasslan A, Shahla C, Khalil A, Rosenschein U. Coronary Flow Reserve of the Non-Ischemia Related Coronary Artery During Dobutamine Stress Echocardiography. Cardiol Res 2011; 2:174-180. [PMID: 28352387 PMCID: PMC5358225 DOI: 10.4021/cr57w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2011] [Indexed: 11/14/2022] Open
Abstract
Background Incorporation of analysis of coronary velocities in stress studies adds diagnostic value to both clinical variables and dobutamine echocardiography. Micorcirculatory abnormalities may precede obstructive corornary disease. Therefore the aim of this study was to assess Doppler derived coronary velocity and flow of the left anterior descending coronary artery (LAD) during dobutamine stress echocardiography (DSE) in patients without LAD-related ischemia. Methods Sixty nine patients with chest pain underwent DSE studies to evaluate myocardial ischemia. All had trans-thoracic Doppler interrogation of the distal LAD before and just after termination of the DSE. Coronary velocity reserves (CFR) were calculated as the ratios of post-DSE/baseline diastolic velocities. Volumetric flow in the distal LAD was calculated from the diameter of LAD color jet and velocity integral. Volumetric flow reserve was calculated as the ratio of post-DSE baseline LAD flows. Results At rest all subjects had left ventricular wall motion score index (WMSI) = 1, while in 28, wall motion abnormality appeared in non-LAD territory with WMSI = 1.17 ± 0.08. Peak diastolic velocity after DSE increased form 28.5 ± 13.6 to 52.4 ± 23.7 cm/sec, P = 9.5 × 10-11, and velocity-CFR was 2.08 ± 0.7. Diastolic LAD flow increased from 36.5 ± 23.8 to 75.75 ± 48.7 mL/min, P = 1.21 × 10-7 and volumetric-CFR was 2.6 ± 2.8. Peak diastolic velocity-CFR in patients without LV wall motion abnormality was 2.4 ± 0.7 while in those with motion abnormality 1.77 ± 0.56, P = 0.00008. Flow-derived LAD-CFR was 3.3 ± 3.7 in those without compared to 1.88 ± 0.57 in patients with wall motion abnormality, P < 0.05. Conclusion LAD velocity and flow reserves are reduced in patients with remote myocardial ischemia, which may indicate early atherosclerotic involvement.
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Affiliation(s)
- Dawod Sharif
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
| | | | - Camilia Shahla
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | - Amin Khalil
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | - Uri Rosenschein
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
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Nemes A, Forster T. [Functional vascular alterations associated with aortic valve stenosis]. Orv Hetil 2011; 152:993-9. [PMID: 21642051 DOI: 10.1556/oh.2011.29145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Degenerative changes, atherosclerotic process and calcification of valvular leaflets are mostly responsible for valvular aortic valve stenosis, but congenital bicuspid aortic valve and rheumatic fever in history are also known predisposing factors. Aortic valve stenosis is frequently associated with different functional vascular alterations. The aim of this review is to demonstrate these vascular alterations evaluated by non-invasive methods and underlying physiologic and pathophysiologic processes.
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Affiliation(s)
- Attila Nemes
- Szegedi Tudományegyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika és Kardiológiai Központ Szeged Korányi.
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Timmer SAJ, Knaapen P, Germans T, Dijkmans PA, Lubberink M, Ten Berg JM, Ten Cate FJ, Rüssel IK, Götte MJW, Lammertsma AA, van Rossum AC. Effects of alcohol septal ablation on coronary microvascular function and myocardial energetics in hypertrophic obstructive cardiomyopathy. Am J Physiol Heart Circ Physiol 2011; 301:H129-37. [PMID: 21490327 DOI: 10.1152/ajpheart.00077.2011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study investigated the effects of alcohol septal ablation (ASA) on microcirculatory function and myocardial energetics in patients with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction. In 15 HCM patients who underwent ASA, echocardiography was performed before and 6 mo after the procedure to assess the LVOT gradient (LVOTG). Additionally, [(15)O]water PET was performed to obtain resting myocardial blood flow (MBF) and coronary vasodilator reserve (CVR). Changes in LV mass (LVM) and volumes were assessed by cardiovascular magnetic resonance imaging. Myocardial oxygen consumption (MVo(2)) was evaluated by [(11)C]acetate PET in a subset of seven patients to calculate myocardial external efficiency (MEE). After ASA, peak LVOTG decreased from 41 ± 32 to 23 ± 19 mmHg (P = 0.04), as well as LVM (215 ± 74 to 169 ± 63 g; P < 0.001). MBF remained unchanged (0.94 ± 0.23 to 0.98 ± 0.15 ml·min(-1)·g(-1); P = 0.45), whereas CVR increased (2.55 ± 1.23 to 3.05 ± 1.24; P = 0.05). Preoperatively, the endo-to-epicardial MBF ratio was lower during hyperemia compared with rest (0.80 ± 0.18 vs. 1.18 ± 0.15; P < 0.001). After ASA, the endo-to-epicardial hyperemic (h)MBF ratio increased to 1.03 ± 0.26 (P = 0.02). ΔCVR was correlated to ΔLVOTG (r = -0.82; P < 0.001) and ΔLVM (r = -0.54; P = 0.04). MEE increased from 15 ± 6 to 20 ± 9% (P = 0.04). Coronary microvascular dysfunction in obstructive HCM is at least in part reversible by relief of LVOT obstruction. After ASA, hMBF and CVR increased predominantly in the subendocardium. The improvement in CVR was closely correlated to the absolute reduction in peak LVOTG, suggesting a pronounced effect of LV loading conditions on microvascular function of the subendocardium. Furthermore, ASA has favorable effects on myocardial energetics.
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Affiliation(s)
- Stefan A J Timmer
- Dept. of Cardiology, 5F, VU Univ. Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Xie F, Everbach EC, Gao S, Drvol LK, Shi WT, Vignon F, Powers JE, Lof J, Porter TR. Effects of attenuation and thrombus age on the success of ultrasound and microbubble-mediated thrombus dissolution. ULTRASOUND IN MEDICINE & BIOLOGY 2011; 37:280-8. [PMID: 21208727 PMCID: PMC3059129 DOI: 10.1016/j.ultrasmedbio.2010.10.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 09/17/2010] [Accepted: 10/20/2010] [Indexed: 05/09/2023]
Abstract
The purpose of this study was to examine the effects of applied mechanical index, incident angle, attenuation and thrombus age on the ability of 2-D vs. 3-D diagnostic ultrasound and microbubbles to dissolve thrombi. A total of 180 occlusive porcine arterial thrombi of varying age (3 or 6 h) were examined in a flow system. A tissue-mimicking phantom of varying thickness (5 to 10 cm) was placed over the thrombosed vessel and the 2-D or 3-D diagnostic transducer aligned with the thrombosed vessel using a positioning system. Diluted lipid-encapsulated microbubbles were infused during ultrasound application. Percent thrombus dissolution (%TD) was calculated by comparison of clot mass before and after treatment. Both 2-D and 3-D-guided ultrasound increased %TD compared with microbubbles alone, but %TD achieved with 6-h-old thrombi was significantly less than 3-h-old thrombi. Thrombus dissolution was achieved at 10 cm tissue-mimicking depths, even without inertial cavitation. In conclusion, diagnostic 2-D or 3-D ultrasound can dissolve thrombi with intravenous nontargeted microbubbles, even at tissue attenuation distances of up to 10 cm. This treatment modality is less effective, however, for older aged thrombi.
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Affiliation(s)
- Feng Xie
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198-2265, USA.
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Enhanced left ventricular mass regression after aortic valve replacement in patients with aortic stenosis is associated with improved long-term survival. J Thorac Cardiovasc Surg 2011; 142:285-91. [PMID: 21272899 DOI: 10.1016/j.jtcvs.2010.08.084] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 07/29/2010] [Accepted: 08/31/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Aortic valve replacement in patients with aortic stenosis is usually followed by regression of left ventricular hypertrophy. More complete resolution of left ventricular hypertrophy is suggested to be associated with superior clinical outcomes; however, its translational impact on long-term survival after aortic valve replacement has not been investigated. METHODS Demographic, operative, and clinical data were obtained retrospectively through case note review. Transthoracic echocardiography was used to measure left ventricular mass preoperatively and at annual follow-up visits. Patients were classified according to their reduction in left ventricular mass at 1 year after the operation: group 1, less than 25 g; group 2, 25 to 150 g; and group 3, more than 150 g. Kaplan-Meier and multivariable Cox regression were used. RESULTS A total of 147 patients were discharged from the hospital after aortic valve replacement for aortic stenosis between 1991 and 2001. Preoperative left ventricular mass was 279 ± 98 g in group 1 (n = 47), 347 ± 104 g in group 2 (n = 62), and 491 ± 183 g in group 3 (n = 38) (P < .001). Mean time to last echocardiogram was 6.2 ± 3.2 years. Left ventricular mass at late follow-up was 310 ± 119 g in group 1, 267 ± 107 g in group 2, and 259 ± 96 g in group 3 (P = .05). Transvalvular gradients at follow-up were not significantly different among the groups (group 1, 24.8 ± 23 mm Hg; group 2, 21.4 ± 16 mm Hg; group 3, 14.7 ± 9 mm Hg) (P = .31). There was no difference in the prevalence of other factors influencing left ventricular mass regression such as ischemic heart disease or hypertension, valve type, or valve size used. Ten-year actuarial survival was not statistically different in patients with enhanced left ventricular mass regression when compared with the log-rank test (group 1, 51% ± 9%; group 2, 54% ± 8%; and group 3, 72% ± 10%) (P = .26). After adjustment, left ventricular mass reduction of more than 150 g was demonstrated as an independent predictor of improved long-term survival on multivariate analysis (P = .02). CONCLUSIONS Our study is the first to suggest that enhanced postoperative left ventricular mass regression, specifically in patients undergoing aortic valve replacement for aortic stenosis, may be associated with improved long-term survival. In view of these findings, strategies purported to be associated with superior left ventricular mass regression should be considered when undertaking aortic valve replacement.
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Sharif D, Sharif-Rasslan A, Shahla C, Abinader EG. Detection of severe left anterior descending coronary artery stenosis by transthoracic evaluation of resting coronary flow velocity dynamics. Heart Int 2010; 5:e10. [PMID: 21977295 PMCID: PMC3184686 DOI: 10.4081/hi.2010.e10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 06/23/2010] [Accepted: 08/03/2010] [Indexed: 11/23/2022] Open
Abstract
In the presence of severe stenosis, coronary artery flow may be reduced at rest. Recent advances in echocardiography have made non-invasive sampling of velocities in the left anterior descending coronary artery (LAD) possible. The aim of our study was to evaluate feasibility and capability of transthoracic Doppler to detect severe stenosis of the LAD. The study population consisted of 42 subjects with suspected coronary artery disease scheduled for coronary angiography. All had complete transthoracic echocardiography and Doppler sampling of LAD velocities. Quantitative coronary angiography was performed within 24 hours of the echocardiogram. Correlations between LAD velocity profile, measurements and calculations, and the angiographic results were performed. Six subjects had LAD occlusion, 10 had severe (>80% diameter) LAD stenosis, and 26 had normal or non-occlusive LAD disease. In all six subjects with LAD occlusion, distal LAD velocities were not detectable, while in the other 36 subjects, LAD velocities were recorded indicating the vessels were patent. In the 10 subjects with severe LAD stenosis, the diastolic/systolic velocity ratio was <1.5, while in those with non-significant LAD disease, the diastolic/systolic velocity ratio was >1.5 (P<0.005). Diastolic LAD flow was 21.8±13 mL/min in the presence of severe stenosis as compared to 48.5±20 mL/min in subjects without severe stenosis (P<0.0013). LAD velocities had high sensitivity and specificity for the prediction of severe angiographic stenosis. Thus transthoracic Doppler measurement of LAD velocities is feasible and can predict the presence of severe LAD stenosis or occlusion.
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Affiliation(s)
- Dawod Sharif
- Department of Cardiology, Bnai Zion Medical Center, Haifa
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