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Inoue K, Sonoda S, Naka Y, Okabe H, Setoyama K, Miura T, Anai R, Araki M, Kataoka M. Clinical Efficacy of Intracoronary Papaverine After Nicorandil Administration for Safe and Optimal Fractional Flow Reserve Measurement. Int Heart J 2021; 62:962-969. [PMID: 34544970 DOI: 10.1536/ihj.21-010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Fractional flow reserve (FFR) is considered the standard for assessment of the physiological significance of coronary artery stenosis. Intracoronary papaverine (PAP) is the most potent vasodilator used for the achievement of maximal hyperemia. However, its use can provoke ventricular tachycardia (VT) due to excessive QT prolongation. We evaluated the clinical efficacy and safety of the administration of PAP after nicorandil (NIC), a potassium channel opener that prevents VT, for optimal FFR measurement.A total of 127 patients with 178 stenoses were enrolled. The FFR values were measured using NIC (NIC-FFR) and PAP (PAP-FFR). We administered PAP following NIC (NIC-PAP). Changes in the FFR and electrogram parameters (baseline versus NIC versus PAP) were assessed and the incidence of arrhythmias after PAP was evaluated. In addition, we analyzed another 41 patients with 51 stenoses by assessing the FFR using PAP before NIC (PAP-NIC). After propensity score matching, the electrogram parameters between 2 groups were compared.The mean PAP-FFR was significantly lower than the mean NIC-FFR (0.82 ± 0.11 versus 0.81 ± 0.11, P < 0.05). The mean baseline-QTc, NIC-QTc, and PAP-QTc values were 425 ± 37 ms1/2, 424 ± 41 ms1/2, and 483 ± 54 ms1/2, respectively. VT occurred in only 1 patient (0.6%). Although PAP induced QTc prolongation (P < 0.05), the PAP-QTc duration was significantly shorter in NIC-PAP compared to PAP-NIC (P < 0.05).The administration of PAP with NIC may induce sufficient hyperemia and prevent fatal arrhythmia through reductions in the PAP-induced QTc prolongation during FFR measurement.
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Affiliation(s)
- Konosuke Inoue
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Shinjo Sonoda
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Yutaro Naka
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Hiroki Okabe
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Koshi Setoyama
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Toshiya Miura
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Reo Anai
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Masaru Araki
- Second Department of Internal Medicine, University of Occupational and Environmental Health
| | - Masaharu Kataoka
- Second Department of Internal Medicine, University of Occupational and Environmental Health
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Shaik FA, Slotwiner DJ, Gustafson GM, Dai X. Intra-procedural arrhythmia during cardiac catheterization: A systematic review of literature. World J Cardiol 2020; 12:269-284. [PMID: 32774779 PMCID: PMC7383354 DOI: 10.4330/wjc.v12.i6.269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cardiac catheterization is among the most performed medical procedures in the modern era. There were sporadic reports indicating that cardiac arrhythmias are common during cardiac catheterization, and there are risks of developing serious and potentially life-threatening arrhythmias, such as sustained ventricular tachycardia (VT), ventricular fibrillation (VF) and high-grade conduction disturbances such as complete heart block (CHB), requiring immediate interventions. However, there is lack of systematic overview of these conditions.
AIM To systematically review existing literature and gain better understanding of the incidence of cardiac arrhythmias during cardiac catheterization, and their impact on outcomes, as well as potential approaches to minimize this risk.
METHODS We applied a combination of terms potentially used in reports describing various cardiac arrhythmias during common cardiac catheterization procedures to systematically search PubMed, EMBASE and Cochrane databases, as well as references of full-length articles.
RESULTS During right heart catheterization (RHC), the incidence of atrial arrhythmias (premature atrial complexes, atrial fibrillation and flutter) was low (< 1%); these arrhythmias were usually transient and self-limited. RHC associated with the development of a new RBBB at a rate of 0.1%-0.3% in individuals with normal conduction system but up to 6.3% in individuals with pre-existing left bundle branch block. These patients may require temporary pacing due to transient CHB. Isolated premature ventricular complexes or non-sustained VT are common during RHC (up to 20% of cases). Sustained ventricular arrhythmias (VT and/or VF) requiring either withdrawal of catheter or cardioversion occurred infrequently (1%-1.3%). During left heart catheterizations (LHC), the incidence of ventricular arrhythmias has declined significantly over the last few decades, from 1.1% historically to 0.1% currently. The overall reported rate of VT/VF in diagnostic LHC and coronary angiography is 0.8%. The risk of VT/VF was higher during percutaneous coronary interventions for stable coronary artery disease (1.1%) and even higher for patients with acute myocardial infarctions (4.1%-4.3%). Intravenous adenosine and papaverine bolus for fractional flow reserve measurement, as well as intracoronary imaging using optical coherence tomography have been reported to induce VF. Although uncommon, LHC and coronary angiography were also reported to induce conduction disturbances including CHB.
CONCLUSION Cardiac arrhythmias are common and potentially serious complications of cardiac catheterization procedures, and it demands constant vigilance and readiness to intervene during procedures.
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Affiliation(s)
- Fatima A Shaik
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - David J Slotwiner
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - Gregory M Gustafson
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - Xuming Dai
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
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Matsumoto H, Mikuri M, Masaki R, Tanaka H, Ogura K, Arai T, Sakai R, Oishi Y, Okada N, Shinke T. Feasibility of intracoronary nicorandil for inducing hyperemia on fractional flow reserve measurement: Comparison with intracoronary papaverine. Int J Cardiol 2020; 314:1-6. [PMID: 32387252 DOI: 10.1016/j.ijcard.2020.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/22/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adenosine and adenosine triphosphate (ATP) are widely used to induce hyperemia for fractional flow reserve (FFR) measurements. Caffeine attenuates their hyperemic effects, but not those of nicorandil and papaverine. No studies have systematically compared the hyperemic efficacies of nicorandil, papaverine, and ATP with and without caffeine abstention. METHODS FFRs were measured using nicorandil 2 mg (FFRNC2), nicorandil 4 mg (FFRNC4), and papaverine (FFRPAP) in 40 patients (group 1), and using nicorandil 2 mg, ATP (FFRATP), ATP plus nicorandil (FFRATP+NC2), and papaverine in 20 patients with (group 2) and in 20 patients without caffeine abstention (group 3). RESULTS In group 1, FFRNC2 and FFRNC4 did not differ (p = 0.321) and were higher than FFRPAP (p < 0.001 and p = 0.0026). Likewise, FFRNC2 was higher than FFRPAP in groups 2 (p = 0.049) and 3 (p < 0.010). In the whole group, Bland-Altman analysis showed a modest mean difference (0.015, p < 0.001) and narrow 95% limits of agreement (-0.025 and 0.056). FFRNC2 and FFRPAP strongly correlated (r = 0.975, p < 0.001). Compared with FFRPAP, FFRATP and FFRATP+NC2 did not differ in group 2 (p = 1.0 and p = 0.780), but they were higher (p = 0.002 and p = 0.02) in group 3. Adjunctive nicorandil did not decline FFR further in groups 2 (p = 0.942) and 3 (p = 0.294). CONCLUSIONS Nicorandil 2 mg is a safe and practical alternative for patients who consume caffeine-containing products before the test or have contraindications for adenosine/ATP. Increasing the nicorandil dose to 4 mg or administering adjunctive nicorandil during ATP infusions does not offer any clinical advantages compared with administering nicorandil 2 mg alone.
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan.
| | - Mikiko Mikuri
- Department of Cardiology, Kyojinkai Komatsu Hospital, Neyagawa, Japan
| | - Ryota Masaki
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hideaki Tanaka
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ogura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Taitou Arai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Rikuo Sakai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Oishi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Natsumi Okada
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
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Summary of Torsades de Pointes (TdP) Reports Associated with Intravenous Drug Formulations Containing the Preservative Chlorobutanol. Drug Saf 2020; 42:907-913. [PMID: 30888625 DOI: 10.1007/s40264-019-00804-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Drug-induced torsades de pointes (TdP) is a potentially lethal ventricular arrhythmia that is associated with drugs that prolong the QT interval on the electrocardiogram (ECG) due to their interference with the cardiac potassium current, IKR. Intravenous (IV) formulations of methadone have been associated with TdP and contain the preservative chlorobutanol, which, like methadone, blocks IKR. The combinations of chlorobutanol with methadone or terfenadine, another IKR blocker, produce synergistic IKR block. OBJECTIVE The aim of this study was to examine and summarize the evidence available to address the question: what other IV drug formulations contain chlorobutanol and are they associated with TdP? METHODS IV drug products containing the preservative chlorobutanol were identified by searching the websites DailyMed ( https://dailymed.nlm.nih.gov/dailymed/index.cfm ) and Drugs@FDA ( https://www.accessdata.fda.gov/scripts/cder/daf/ ). For each drug identified, PubMed and the FDA's Adverse Event Reporting System (FAERS) were searched for reports of TdP and/or QT prolongation and FAERS data were analyzed for disproportionality of reports. RESULTS The search found nine drugs (methadone, epinephrine, papaverine, oxytocin, vasopressin, testosterone, estradiol, isoniazid, and desmopressin) that contain chlorobutanol 2.5 (n = 1) or 5.0 mg/mL. All nine drugs had reports of QT prolongation or TdP reported in FAERS and all but estradiol, testosterone, desmopressin, and isoniazid had reports of QT prolongation or TdP in PubMed. Two of the nine drugs (epinephrine and methadone) had positive signals (by disproportionality analysis) for TdP in FAERS (EB05 2.88 and 23.81, respectively) and four (methadone, epinephrine, papaverine, and vasopressin) were reported in published articles as the suspect drugs in cases of TdP. CONCLUSION The pharmacologic profile of chlorobutanol (synergistic IKR block) and its association with reports of TdP and QT prolongation suggest the need for a full evaluation of its cardiac safety when used as a preservative in IV drug and vitamin formulations.
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Nakayama M, Tanaka N, Yamashita J, Iwasaki K. Confirmation of maximal hyperemia by the incremental dose of intracoronary papaverine. Cardiovasc Interv Ther 2020; 35:371-378. [DOI: 10.1007/s12928-020-00641-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/08/2020] [Indexed: 12/30/2022]
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Ishibuchi K, Fujii K, Otsuji S, Takiuchi S, Hasegawa K, Tamaru H, Ishii R, Yasuda S, Nakabayashi S, Yamamoto W, Kusumoto H, Taniguchi Y, Kakishita M, Shimatani Y, Higashino Y. Utility and Validity of Intracoronary Administration of Nicorandil Alone for the Measurement of Fractional Flow Reserve in Patients With Intermediate Coronary Stenosis. Circ J 2019; 83:2010-2016. [PMID: 31413232 DOI: 10.1253/circj.cj-19-0421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intracoronary (IC) administration of nicorandil has been proposed as an alternative choice of hyperemic agent for fractional flow reserve (FFR) measurements. This study evaluated the utility and validity of IC nicorandil administration alone to induce maximal hyperemia.Methods and Results:Two-hundred-seven patients with coronary artery disease listed for coronary angiography with FFR were prospectively enrolled. FFR was measured after (1) IC administration of nicorandil 2 mg (ICNIC2 mg); (2) continuous intravenous (IV) adenosine triphosphatase (ATP) infusion at 150 μg/kg/min (IVATP150); (3) IV ATP infusion at 210 μg/kg/min (IVATP210); (4) IC administration of 0.5 mg nicorandil during IVATP150 (ICNIC0.5 mg+IVATP150); (5) IC administration of 1 mg nicorandil during IVATP150 (ICNIC1 mg+IVATP150); and (6) IC administration of 2 mg nicorandil during IVATP150 (ICNIC2 mg+IVATP150). The average FFR values and the rate of achieving maximum hyperemia after ICNIC2 mg, IVATP150, IVATP210, ICNIC0.5 mg+IVATP150, ICNIC1 mg+IVATP150, and ICNIC2 mg+IVATP150 were 0.85±0.08, 0.89±0.08, 0.85±0.09, 0.84±0.08, 0.83±0.08, 0.83±0.08 (P<0.01), and 92%, 54%, 91%, 96%, 99%, 99% (P<0.01), respectively. The incidence of systolic aortic pressure drop, chest discomfort, and transient atrioventricular block increased in a dose-dependent manner after IV ATP infusion, but almost no adverse effects were observed after ICNIC2 mg. CONCLUSIONS ICNIC2 mg produced a more pronounced hyperemia than continuous IV ATP, and might be the preferred method for assessment of FFR.
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Affiliation(s)
| | - Kenichi Fujii
- Department of Cardiology, Higashi Takarazuka Satoh Hospital.,Department of Medicine II, Kansai Medical University
| | - Satoru Otsuji
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
| | - Shin Takiuchi
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
| | | | - Hiroto Tamaru
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
| | - Rui Ishii
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
| | - Shingo Yasuda
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
| | | | | | | | | | | | - Yuji Shimatani
- Department of Cardiology, Higashi Takarazuka Satoh Hospital
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Nauchi M, Sakai T, Yamawaki M, Ito Y. Sinus Standstill in a Patient after Intracoronary Papaverine Administration for a Coronary Fractional Flow Reserve. Int Heart J 2018; 59:630-633. [DOI: 10.1536/ihj.17-294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Masahiro Nauchi
- Department of Cardiology, Saiseikai Yokohamashi Tobu Hospital
| | - Tsuyoshi Sakai
- Department of Cardiology, Saiseikai Yokohamashi Tobu Hospital
| | | | - Yoshiaki Ito
- Department of Cardiology, Saiseikai Yokohamashi Tobu Hospital
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Okabe Y, Otowa K, Mitamura Y, Murai H, Usui S, Kaneko S, Takamura M. Evaluation of the risk factors for ventricular arrhythmias secondary to QT prolongation induced by papaverine injection during coronary flow reserve studies using a 4 Fr angio-catheter. Heart Vessels 2018; 33:1358-1364. [PMID: 29713819 DOI: 10.1007/s00380-018-1175-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Estimation of the fractional flow reserve (FFR) is considered to be an established method by which to assess stable coronary artery stenosis. Induction of maximal coronary hyperemia is important during the FFR procedure. Papaverine has been reported to increase the risk of ventricular arrhythmia (VA). The purpose of the present study was to discover predictors of papaverine-induced VAs developing during FFR measurement. A total of 213 clinically stable patients were included in the study. FFRs were determined after intracoronary papaverine administration (12 mg into the left and 8 mg into the right coronary arteries). We compared patients in whom VA did and did not develop in terms of clinical and electrocardiogram characteristics. FFR measurements were performed on 244 lesions (133 in the left anterior descending arteries, 43 in the left circumflex arteries, and 68 in the right coronary arteries). We found that the QTc interval was prolonged in all patients after papaverine administration (average post-administration QTc interval = 569 ± 89 ms; average ΔQTc interval = 144 ± 80 ms). VA developed in three patients with significantly prolonged QT intervals (average post-administration QTc interval = 639 ± 19 ms, average ΔQTc interval = 220 ± 64 ms, p < 0.02) and transitioned from torsade de pointes to ventricular fibrillation. Bradycardia (< 50 beats/min), hypokalemia (serum K < 3.5 mEp/L), and low left ventricular function (ejection fraction (EF) < 50%) were associated with VA (bradycardia, p < 0.01; hypokalemia, p < 0.01; low left ventricular function, p < 0.01). Three-vessel disease was significantly predictive of VA (p < 0.003). In the three-vessel group, the complications of low left ventricular function, hypokalemia, and bradycardia were significantly associated with VA (p < 0.045). Three-vessel disease is a predictor of the development of VA during FFR measurement performed with the aid of papaverine, especially if accompanied by one or more of the following: low left ventricular function, hypokalemia, or bradycardia.
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Affiliation(s)
- Yoshitaka Okabe
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Kanichi Otowa
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Yasuhito Mitamura
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Hisayoshi Murai
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Soichiro Usui
- Municipal Tsuruga Hospital, 6-60, 1-chome Mishima cho, Tsuruga, Fukui, Japan
| | - Shuichi Kaneko
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Johnson NP, Kirkeeide RL, Gould KL. History and Development of Coronary Flow Reserve and Fractional Flow Reserve for Clinical Applications. Interv Cardiol Clin 2015; 4:397-410. [PMID: 28581927 DOI: 10.1016/j.iccl.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We discuss the historical development of clinical coronary physiology, emphasizing coronary flow reserve (CFR) and fractional flow reserve (FFR). Our analysis focuses on the clinical motivations and technologic advances that prompted and enabled the application of physiology for patient diagnosis. CFR grew from the general concepts of physiologic and coronary reserve, linking the anatomic severity of a lesion to its impact on hyperemic flow. FFR developed from existing models relating pressure measurements to the potential for flow to increase after removing a stenosis. Because pressure measurements have proved easier and more robust than flow measurements, FFR has become the dominant metric.
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Affiliation(s)
- Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA.
| | - Richard L Kirkeeide
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
| | - K Lance Gould
- Division of Cardiology, Department of Medicine, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Memorial Hermann Hospital, University of Texas Medical School at Houston, 6431 Fannin Street, Room MSB 4.256, Houston, TX 77030, USA
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Nakayama M, Tanaka N, Sakoda K, Hokama Y, Hoshino K, Kimura Y, Ogawa M, Yamashita J, Kobori Y, Uchiyama T, Aizawa Y, Yamashina A. Papaverine-induced polymorphic ventricular tachycardia during coronary flow reserve study of patients with moderate coronary artery disease. Circ J 2015; 79:530-6. [PMID: 25746536 DOI: 10.1253/circj.cj-14-1118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Papaverine is useful for evaluating the functional status of a coronary artery, but it may provoke malignant ventricular arrhythmia (VA). The aim of this study was to investigate the incidence, and clinical and ECG characteristics of patients with papaverine-induced VAs. METHODS AND RESULTS: The 182 consecutive patients underwent fractional flow reserve (FFR) measurement of 277 lesions. FFR was determined after intracoronary papaverine administration by standard procedures. The clinical and ECG characteristics were compared between patients with and without ventricular tachycardia (VT: ≥3 successive premature ventricular beats (PVBs), or ventricular fibrillation (VF)). After papaverine administration, the QTc interval, QTUc interval, and T-peak to U-end interval were prolonged significantly. Single PVBs on the T-wave or U-wave type developed in 29 patients (15.9%). Polymorphic VT (torsade de pointes) occurred in 5 patients (2.8%), and of those, VF developed in 3 patients (1.7%). No clinical and baseline ECG parameters were predictors for VT or VF except for sex and administration of papaverine into the left coronary artery. Excessive prolongation of QT (or QTU), T-peak to U-end intervals and giant T-U waves were found immediately prior to the ventricular tachyarrhythmias (VTAs), which were unpredictable from the baseline data. CONCLUSIONS Intracoronary administration of papaverine induced fatal VTAs, although the incidence is rare. Excessive prolongation of the QT (and QTU) interval appeared prior to VTAs; however, they were unpredictable.
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Affiliation(s)
- Masafumi Nakayama
- Department of Cardiology, Tokyo Medical University; Cardiovascular Center, Toda Central General Hospital, Saitama, Japan.
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Arumugham P, Figueredo VM, Patel PB, Morris DL. Comparison of intravenous adenosine and intravenous regadenoson for the measurement of pressure-derived coronary fractional flow reserve. EUROINTERVENTION 2013; 8:1166-71. [PMID: 23164748 DOI: 10.4244/eijv8i10a180] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Defining the clinical and physiologic significance of an intermediate coronary artery stenosis is aided by measurement of fractional flow reserve (FFR). Adenosine is the most common agent used in the cardiac catheterisation laboratory for the measurement of FFR. Regadenoson, a selective adenosine receptor agonist, with fewer side effects than adenosine has been used extensively in stress testing to induce hyperaemia. We postulated that FFR measurements would be equivalent following administration of regadenoson and adenosine. METHODS AND RESULTS Twenty patients with an angiographic intermediate coronary artery stenosis (50% to 80%) were included in the study. FFR was measured during three minutes of intravenous (IV) adenosine infusion and for five minutes after an injection of regadenoson. The mean difference between the FFR measured by IV adenosine and IV regadenoson was 0.0040 (min -0.04, max +0.04, standard deviation [SD] 0.025). There was a strong linear correlation between the FFR measured by IV adenosine and IV regadenoson (R2 linear=0.933). The FFR at maximum hyperaemia was achieved earlier using regadenoson than adenosine (59±24.5 sec vs. 93±44.5 sec, p=0.01). CONCLUSIONS Regadenoson produces similar pressure-derived FFR compared to IV adenosine infusion.
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Affiliation(s)
- Pradeep Arumugham
- Cardiovascular Diseases, Cardiac Catherization Laboratory, Albert Einstein Medical Center and the Einstein Institute for Heart and Vascular Health, Philadelphia, PA 19141, USA
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Nakayama M, Saito A, Kitazawa H, Takahashi M, Sato M, Fuse K, Okabe M, Hoshino K, Tanaka N, Yamashina A, Aizawa Y. Papaverine-induced polymorphic ventricular tachycardia in relation to QTU and giant T-U waves in four cases. Intern Med 2012; 51:351-6. [PMID: 22333368 DOI: 10.2169/internalmedicine.51.6567] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Papaverine is used for the evaluation of functional status of the coronary arteries but it may provoke severe ventricular tachyarrhythmias (VTAs). This study compared the clinical and ECG characteristic of patients with papaverine-induced VTAs. MATERIALS AND METHODS The study involved 25 patients who underwent a fractional flow reserve (FFR) study. FFR was determined as the ratio of blood pressure at the distal and the proximal site of stenosis after intracoronary papaverine administration at 12 mg into the left and 8 mg into the right coronary artery. The QT and QTU intervals were measured manually in the limb leads and in the precordial leads, respectively and corrected by the R-R interval to obtain QTc and QTUc. The clinical and ECG data were compared between the patient groups with and without VTAs. RESULTS After papaverine administration into the left (20), right (3) or both coronary arteries (2), the RR interval shortened, but non-significantly however, the QT interval (and QTc) and the QTU interval (and QTUc) were significantly prolonged. VTAs developed in four women: torsade de pointes in 3 followed by ventricular fibrillation and ventricular premature beats in 1 patient. After papaverine administration, QTU and QTUc were more prolonged in women than men and in patients with VTAs compared to those without. Just prior to VTAs, giant T-U waves were observed. CONCLUSION Intracoronary papaverine was used to determine FFR which may induce VTAs. VTAs developed only in women and they were closely related to prolongation of the QTU intervals with prominent T-U waves.
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Kapoor N, Fahsah I, Karim R, Jevans AJ, Leesar MA. Physiological assessment of renal artery stenosis: Comparisons of resting with hyperemic renal pressure measurements. Catheter Cardiovasc Interv 2010; 76:726-32. [DOI: 10.1002/ccd.22731] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Affiliation(s)
- R B Naidu
- Department of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Qian J, Ge J, Baumgart D, Oldenburg O, Haude M, Sack S, Erbel R. Safety of intracoronary Doppler flow measurement. Am Heart J 2000; 140:502-10. [PMID: 10966554 DOI: 10.1067/mhj.2000.109221] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND With the introduction of Doppler-tipped guide wires, intracoronary Doppler flow measurement has been increasingly accepted as an additional diagnostic approach in the catheterization laboratory. However, the safety of intracoronary Doppler flow measurement has not been well-investigated. The purpose of our study was to evaluate the safety of intracoronary Doppler flow measurement using the Doppler FloWire (Cardiometrics, Mountain View, Calif). METHODS AND RESULTS A total of 906 patients were examined by intracoronary Doppler with a 0.014-inch or an 0.018-inch Doppler FloWire. For coronary flow reserve measurement, intracoronary injection of adenosine or papaverine was used. Of the patients studied, 77 were cardiac transplant recipients and 829 were patients who had not received a transplant, of whom 617 had undergone diagnostic coronary procedures and 212 had coronary interventions. In 27 (2.98%) of 906 patients adverse cardiac events were observed. Fifteen (1.66%) of 906 patients had severe transient bradycardia develop (asystole or second- to third-degree atrioventricular block) after intracoronary administration of adenosine, 14 of which occurred in the right coronary artery and 1 in the left anterior descending artery. Nine (0.99%) of 906 patients had coronary spasm during the passage of the Doppler wire (5 in the right coronary artery, 4 in the left anterior descending artery). Two (0.22%) of 906 patients had ventricular fibrillation during the procedure. Hypotension with bradycardia and ventricular extrasystole each occurred in 1 (0.11%) of 906 patients. The incidence of complication was significantly higher in transplant recipients than in patients who underwent either diagnostic or interventional procedures (12.99% vs 2.43% vs 0.94%, P <.001). The Doppler measurements in the right coronary artery were associated with a higher incidence of complications, especially bradycardia, compared with the left anterior descending and the left circumflex arteries (right coronary, 5.87% vs left anterior descending, 1.05% vs left circumflex, 0.17%; P <.001). All complications were cured medically. CONCLUSION Intracoronary Doppler flow measurement with Doppler wires and intracoronary administration of adenosine is a safe method. However, severe complications such as bradycardia and coronary spasm can occur. Attention should be paid to the examination of the right coronary artery, especially in heart transplant recipients.
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Affiliation(s)
- J Qian
- Department of Cardiology, Zhongshan Hospital, Shanghai Medical University, Shanghai, China
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Sonoda S, Takeuchi M, Nakashima Y, Kuroiwa A. Safety and optimal dose of intracoronary adenosine 5'-triphosphate for the measurement of coronary flow reserve. Am Heart J 1998; 135:621-7. [PMID: 9539477 DOI: 10.1016/s0002-8703(98)70277-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adenosine 5'-triphosphate (ATP) has been demonstrated to have similar vasodilator potency and fewer hemodynamic or electrocardiographic derangements compared with papaverine in the measurement of coronary flow reserve. However, there is little data about its optimal dose and the effect on myocardial lactate metabolism. METHODS Under continuous monitoring of the left anterior descending coronary flow velocity with a Doppler guide wire, we investigated the changes of hemodynamics, electrocardiogram, and myocardial lactate metabolism before and after the administration of 50 microg ATP and 10 mg papaverine into the left coronary artery in 18 patients with normal coronary arteries. To determine the optimal dose of ATP for the coronary flow reserve in the left coronary artery, we measured coronary flow velocity with five incremental doses of intracoronary ATP (0.5, 5, 15, 30, and 50 microg) and 10 mg of papaverine in another seven patients. RESULTS In contrast to papaverine, ATP did not produce any significant changes in hemodynamics or the electrocardiogram. The increase in the coronary flow velocity of the two agents was similar. Although all patients showed lactate production after the administration of papaverine, only three patients showed lactate production after ATP (p < 0.001). The coronary flow reserve derived from > or = 215 microg of ATP was similar to that derived from papaverine. There was a significant correlation between the coronary flow reserve obtained with > or = 5 microg of ATP and that obtained with papaverine. CONCLUSIONS These results suggest that maximal coronary vasodilation in the left coronary artery can be safely obtained with doses > or = 15 microg of intracoronary ATP in patients with normal coronary arteries.
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Affiliation(s)
- S Sonoda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
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Takeuchi M, Himeno E, Sonoda S, Nakashima Y, Kuroiwa A. Measurement of myocardial fractional flow reserve during coronary angioplasty in patients with old myocardial infarction. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 42:19-25. [PMID: 9286532 DOI: 10.1002/(sici)1097-0304(199709)42:1<19::aid-ccd6>3.0.co;2-c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although myocardial fractional flow reserve (FFRmyo) has been demonstrated to be a useful index for determining functional significance of coronary stenosis, the data in previous studies was derived from a highly selected group of patients. The aim of this study was to investigate the value of FFRmyo in a more clinically relevant group of patients, especially in patients who also had resistance vessel dysfunction. We measured FFRmyo in 20 consecutive patients who had undergone elective coronary angioplasty. FFRmyo was calculated by the ratio of Pc/Pa during intracoronary adenosine 5'-triphosphate (ATP; 50 micrograms in the left coronary and 20 micrograms in the right coronary artery) induced maximal hyperemia, where Pa represents mean aortic pressure obtained by the guiding catheter and Pc represents mean distal coronary pressure measured by a 2.1 F infusion catheter. In total, 21 vessels were dilated and 14 of them were infarct-related arteries. The percent diameter stenosis significantly decreased from 80 +/- 14% to 27 +/- 17%, and the FFRmyo increased significantly from 0.46 +/- 0.18 to 0.77 +/- 0.15 after angioplasty. There was no significant differences in the FFRmyo between vessels with previous myocardial infarction and those without, after angioplasty (0.78 +/- 0.18 vs. 0.76 +/- 0.08). There was a significant correlation between the percent diameter stenosis and FFRmyo before (r = 0.83, P < 0.001) and after (r = 0.64, P < 0.01) angioplasty. In conclusion, FFRmyo significantly improved immediately after angioplasty in vessels with myocardial infarction as well as those without. These results led us to suggest the usefulness of FFRmyo in patients who had both epicardial stenosis and resistance vessel dysfunction. The significant correlation between FFRmyo and quantitative coronary arterial diameter stenosis would further support the more widespread use of FFRmyo in the clinical setting.
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Affiliation(s)
- M Takeuchi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Takeuchi M, Nohtomi Y, Kuroiwa A. Intracoronary papaverine induced myocardial lactate production in patients with angiographically normal coronary arteries. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 39:126-30. [PMID: 8922310 DOI: 10.1002/(sici)1097-0304(199610)39:2<126::aid-ccd4>3.0.co;2-h] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although intracoronary papaverine has been widely used for the measurement of coronary flow reserve, little is known concerning whether papaverine may produce deleterious metabolic changes in humans. We investigated the effect of papaverine on lactate metabolism in 28 patients with normal coronary arteries. We continuously monitored phasic coronary flow velocity in the proximal left anterior descending coronary artery using Doppler guidewire. We also obtained paired samples of arterial and coronary sinus blood for the measurement of lactate at control and at 1 min after administration of 10 mg of intracoronary papaverine. There were no serious side effects during papaverine infusion. Sixteen patients showed ST-T abnormalities after papaverine. The QTc interval increased from 450 +/- 42 msec to 571 +/- 58 msec (P < 0.001). Average peak velocity increased significantly (% increase: 198.5 +/- 87.8%, range: 27.8-374.1%) after papaverine. Although intracoronary papaverine produced no significant change in arterial lactate levels (8.5 +/- 4.0-8.8 +/- 5.0 mg/ml), it induced a significant increase in coronary sinus lactate levels (5.4 +/- 3.2-15.3 +/- 8.2 mg/ml, P < 0.001). Lactate extraction ratio decreased significantly (36.4 +/- 18.4--82.2 +/- 58.4%, P < 0.001), and all patients showed net lactate production (-3.9--198.0%) after papaverine. There was weak but significant correlation between lactate extraction ratio after papaverine and coronary flow reserve (R2 = 0.15, P < 0.05). There was no correlation between lactate extraction ratio and QTc interval after papaverine. The mean value of lactate extraction ratio was not different in patients with ST-T abnormalities induced by papaverine compared to those without. These results demonstrate that intracoronary papaverine induces myocardial lactate production irrespective of the degree of coronary flow reserve and electrocardiographic changes in patients with normal coronary arteries. A safer and more reliable agent is needed for the measurement of coronary flow reserve.
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Affiliation(s)
- M Takeuchi
- Second Department of Internal Medicine, University of Occupational and Environment Health, Kitakyushu, Japan
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van der Voort PH, van Hagen E, Hendrix G, van Gelder B, Bech JW, Pijls NH. Comparison of intravenous adenosine to intracoronary papaverine for calculation of pressure-derived fractional flow reserve. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 39:120-5. [PMID: 8922309 DOI: 10.1002/(sici)1097-0304(199610)39:2<120::aid-ccd3>3.0.co;2-h] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
For calculation of fractional flow reserve (FFR), simultaneous registration of both aortic pressure (Pa) and transstenotic distal coronary pressure (Pd) is necessary at steady-state maximum coronary hyperemia. The aim of the present study was to compare the maximum transstenotic gradient (delta Pmax) and pressure-derived myocardial fractional flow reserve (FFRmyo), observed during intravenous adenosine infusion, to delta Pmax and FFRmyo induced by intracoronary papaverine, which is considered to be the gold standard for induction of coronary hyperemia, but acts too short for steady-state hyperemic pressure recordings and is associated with QT-prolongation. In 24 patients with coronary stenoses of various degrees, Pa and Pd were measured simultaneously by the diagnostic catheter and a high fidelity 0.018" fiberoptic pressure monitoring guide wire, respectively. Excellent steady-state phasic intracoronary pressure recordings were obtained in all patients within 1 min after start of intravenous adenosine infusion at a rate of 140 micrograms/kg/min, and compared to delta Pmax obtained 30 sec after intracoronary administration of papaverine (12 mg LCA, 10 mg RCA). Delta Pmax was 24 +/- 15 mmHg during adenosine infusion and 24 +/- 15 mmHg after papaverine administration. Myocardial fractional flow reserve, calculated from these pressure recordings, was 0.75 +/- 0.16 and 0.75 +/- 0.15, respectively, with an individual difference of 0.02 +/- 0.01 between both values (r = 0.99). No important side effects by intravenous infusion of adenosine were observed. Thus intravenous adenosine infusion at a rate of 140 micrograms/kg/min is an excellent and safe alternative for induction of steady-state maximum coronary hyperemia and therefore is an ideal vasodilator for determination of fractional flow reserve based upon pressure recordings.
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Affiliation(s)
- P H van der Voort
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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Takeuchi M, Nohtomi Y, Kuroiwa A. Does coronary flow reserve assessed by blood flow velocity analysis reflect absolute coronary flow reserve? CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 38:251-4. [PMID: 8804781 DOI: 10.1002/(sici)1097-0304(199607)38:3<251::aid-ccd6>3.0.co;2-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Doppler guidewire enables us to measure phasic coronary velocity and has been used for the measurement of coronary flow reserve (CFR). Although CFR is usually calculated by the quotient of peak flow velocity during papaverine infusion and flow velocity at rest, this assumption is true only if conduit vessel size is constant. To determine the accuracy of measurement of CFR using average peak velocity (APV) with Doppler guidewire, we investigated the influence of intracoronary papaverine on coronary flow velocity and coronary arterial diameter (CAD) and examined the correlation between CFR derived using APV and that derived using coronary blood flow (CBF) in 26 patients with normal coronary arteries. We measured phasic coronary flow velocity, and performed quantitative coronary angiography in the proximal left coronary artery at control and during 10 mg of intracoronary papaverine. Compared to control value, papaverine induced a significant increase in APV (% increase: 182 +/- 101%; P < 0.001). Papaverine also significantly increased CAD (16 +/- 10%; P < 0.001). Thus, CFR derived from APV was significantly lower than that derived from CBF (2.8 +/- 1.0 vs. 4.0 +/- 1.5, P < 0.001). Although there was a significantly strong positive correlation between these two methods (R2 = 0.83, P < 0.001), there was also considerable variability with regard to predicting one variable from the other. These results suggest the importance of standardizing the conditions in which coronary flow velocity is measured with regard to either controlling or measuring changes in epicardial coronary arterial diameter during changes in distal resistance vessel tone.
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Affiliation(s)
- M Takeuchi
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Chauhan DA, Mullins PA, Thuraisingham ST, Schofield PM. Intracoronary papaverine and complete atrioventricular block. BMJ (CLINICAL RESEARCH ED.) 1992; 305:870. [PMID: 1422403 PMCID: PMC1883043 DOI: 10.1136/bmj.305.6858.870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Mullins PA, Chauhan A, Sharples L, Cary NR, Large SR, Wallwork J, Schofield PM. Impairment of coronary flow reserve in orthotopic cardiac transplant recipients with minor coronary occlusive disease. BRITISH HEART JOURNAL 1992; 68:266-71. [PMID: 1389756 PMCID: PMC1025068 DOI: 10.1136/hrt.68.9.266] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Coronary occlusive disease is the major long-term complication after cardiac transplantation. The relation between minor angiographic abnormalities and myocardial perfusion has not been previously assessed in a large number of cardiac transplant patients. DESIGN Prospective study. Coronary flow reserve was measured with an intracoronary Doppler flow probe in the proximal left anterior descending coronary artery in each patient. A dose of intracoronary papaverine producing maximal vasodilation was then administered. SETTING A regional cardiothoracic centre and a supraregional transplant unit. PATIENTS Seven patients with chest pain but normal coronary anatomy (controls), and 61 cardiac transplant patients between three months and 10 years after operation (median 4.5 years). Twenty one cardiac transplant patients had angiographic evidence of minor coronary occlusive disease (mean (SD) percentage stenosis diameter 23% (6%)) in a primary or secondary coronary vessel (group 1), with 12 of these in the left anterior descending coronary artery (stenosis diameter (mean (SD) 24% (8%)). The remaining 40 transplant patients had normal coronary angiograms (group 2). MAIN OUTCOME MEASURE Coronary flow reserve was defined as the ratio of the peak flow velocity after papaverine to the resting flow velocity. RESULTS Group 1 patients had a noticeably impaired coronary flow reserve (2.6 (1.1)) compared with control patients (3.9 (0.4), p = 0.05) and, after adjusting for year after operation, compared with group 2 patients (3.8 (1.0), p < 0.001). No other variables were associated with a reduction in coronary flow reserve. Mean resting flow velocity was similar in all three groups (controls, 7.4 (4.6) cm/s; group 1, 7.5 (5.9) cm/s; and group 2, 7.3 (3.9) cm/s). Mean peak flow velocity response to papaverine was reduced in group 1 patients (18.1 (13.5) cm/s) relative to group 2 patients (27.5 (15.4) cm/s, p = 0.05) but not controls (28.4 (15.1) cm/s, p = 0.1). CONCLUSIONS Coronary flow reserve and the peak flow response to the coronary vascular smooth muscle relaxant papaverine are impaired in cardiac transplant patients with minor coronary occlusive disease. This disturbance of cardiac microvascular function may contribute to the late morbidity and mortality seen in cardiac transplant patients with coronary occlusive disease.
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Affiliation(s)
- P A Mullins
- Transplant Unit, Papworth Hospital, Huntingdon, Cambridge
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Mullins PA, Scott JP, Aravot DJ, Dennis C, Large SR, Wallwork J, Schofield PM. Coronary flow reserve and coronary occlusive disease. Transpl Int 1992. [DOI: 10.1111/tri.1992.5.s1.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mullins PA, Scott JP, Aravot DJ, Dennis C, Large SR, Wallwork J, Schofield PM. Coronary flow reserve and coronary occlusive disease. Transpl Int 1992; 5 Suppl 1:S252-4. [PMID: 14621793 DOI: 10.1007/978-3-642-77423-2_80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
The functional effects of coronary occlusive disease (COD) in cardiac transplant patients on small-resistance coronary vessels are unclear. We investigated the changes in coronary flow reserve (CFR) in response to the non-specific smooth muscle vasodilator papaverine. A 3F Doppler probe was inserted into the left anterior descending (LAD) coronary artery in 61 patients following orthotopic heart transplantation. Studies were performed in 57 males and 4 females with a mean age of 46 years (range 20-61 years). The median time from operation was 4 years (range 3 months to 10 years). Coronary blood velocity was measured at rest (RFV) and maximum hyperaemia (PFV) produced by intracoronary papaverine. Coronary flow reserve (CFR) was defined as the ratio of PFV to RFV. Minor lesions in epicardial vessels were found in 23 transplant patients. The mean percentage diameter of the most severe lesion in the coronary tree was 23% SD 3% including 12 lesions in the LAD coronary artery itself (mean 24% SD 4%). Patients with COD had an impaired CFR (2.6 SEM 0.2) compared with normals (3.9 SEM 0.2, P = 0.0003), adjusting for year after operation. Mean resting flow velocity was similar in both groups (minor COD, 6.8 cm/s SEM 1.2; normals, 7.1 cm/s SEM 0.6), but mean peak flow velocity response to papverine was reduced (16.5 cm/s SEM 2.5 versus 27.3 cm/s SEM 2.6; P = 0.007). In the presence of minor epicardial disease, coronary flow reserve in resistance vessels was reduced due to impairment of peak flow. This demonstrates that non-endothelial-dependent coronary resistance vessel vasodilatation is abnormal and may be caused by a defect in vascular smooth muscle function.
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Affiliation(s)
- P A Mullins
- Transplant Unit, Papworth Hospital, Huntingdon, Cambridge, UK
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Kern MJ, Deligonul U, Tatineni S, Serota H, Aguirre F, Hilton TC. Intravenous adenosine: continuous infusion and low dose bolus administration for determination of coronary vasodilator reserve in patients with and without coronary artery disease. J Am Coll Cardiol 1991; 18:718-29. [PMID: 1869735 DOI: 10.1016/0735-1097(91)90795-b] [Citation(s) in RCA: 129] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To assess the use of adenosine as an alternative agent for determination of coronary vasodilator reserve, hemodynamics and coronary blood flow velocity were measured at rest and during peak hyperemic responses to continuous intravenous adenosine infusion (50, 100 and 150 micrograms/kg per min for 3 min) and intracoronary papaverine (10 mg) in 34 patients (17 without [group 1] and 17 with [group 2] significant left coronary artery disease), and in 17 patients (11 without and 6 with left coronary artery disease) after low dose (2.5 mg) intravenous bolus injection of adenosine. The maximal adenosine dose did not change mean arterial pressure (-10 +/- 14% and -6 +/- 12% for groups 1 and 2, respectively) but increased the heart rate (15 +/- 18% and 13 +/- 16, respectively). For continuous adenosine infusions, mean coronary flow velocity increased 64 +/- 104%, 122 +/- 94% and 198 +/- 59% and 15 +/- 51%, 110 +/- 95% and 109 +/- 86% in groups 1 and 2, respectively for each of the three doses. Mean coronary flow velocity increased significantly after 100 and 150 micrograms/kg of adenosine and 10 mg of intracoronary papaverine (48 +/- 25, 52 +/- 19 and 54 +/- 21 cm/s, respectively; all p less than 0.05 vs. baseline) and was significantly higher than in group 2 (37 +/- 24, 32 +/- 16, 41 +/- 23 cm/s; all p less than 0.05 vs. group 1). The coronary vasodilator reserve ratio (calculated as the ratio of hyperemic to basal mean flow velocity) for adenosine and papaverine was 2.94 +/- 1.50 and 2.94 +/- 1.00, respectively, in group 1 and was significantly and similarly reduced in group 2 (2.16 +/- 0.81 and 2.38 +/- 0.78, respectively; both p less than 0.05 vs. group 1). Low dose bolus injection of adenosine increased mean velocity equivalently to that after continuous infusion of 100 micrograms/kg, but less than after papaverine. There was a strong correlation between adenosine infusion and papaverine for both mean coronary flow velocity and coronary vasodilator reserve ratio (r2 = 0.871 and 0.325; SEE = 0.068 and 0.189, respectively; both p less than 0.0005). No patient had significant arrhythmias or prolongation of the corrected QT (QTc) interval with adenosine, but papaverine increased the QT (QTc) interval from 445 +/- 44 to 501 +/- 43 ms (p less than 0.001 vs. both maximal adenosine and baseline) and produced nonsustained ventricular tachycardia in one patient.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- M J Kern
- Cardiology Division, St. Louis University Hospital, Missouri 63110-0250
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