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Bucciarelli-Ducci C, Auger D, Di Mario C, Locca D, Petryka J, O'Hanlon R, Grasso A, Wright C, Symmonds K, Wage R, Asimacopoulos E, Del Furia F, Lyne JC, Gatehouse PD, Fox KM, Pennell DJ. CMR Guidance for Recanalization of Coronary Chronic Total Occlusion. JACC Cardiovasc Imaging 2016; 9:547-56. [PMID: 27085432 DOI: 10.1016/j.jcmg.2015.10.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 10/15/2015] [Accepted: 10/22/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES This study explored whether cardiac magnetic resonance (CMR) could help select patients who could benefit from revascularization by identifying inducible myocardial ischemia and viability in the perfusion territory of the artery with chronic total occlusion (CTO). BACKGROUND The benefit of revascularization using percutaneous coronary intervention (PCI) in CTO is controversial. CMR offers incomparable left ventricular (LV) systolic function assessment in addition to potent ischemic burden quantification and reliable myocardial viability analysis. Whether CMR guided CTO revascularization would be helpful to such patients has not yet been explored fully. METHODS A prospective study of 50 consecutive CTO patients was conducted. Of 50 patients undergoing baseline stress CMR, 32 (64%) were selected for recanalization based on the presence of significant inducible perfusion deficit and myocardial viability within the CTO arterial territory. Patients were rescanned 3 months after successful CTO recanalization. RESULTS At baseline, myocardial perfusion reserve (MPR) in the CTO territory was significantly reduced compared with the remote region (1.8 ± 0.72 vs. 2.2 ± 0.7; p = 0.01). MPR in the CTO region improved significantly after PCI (to 2.3 ± 0.9; p = 0.02 vs. baseline) with complete or near-complete resolution of CTO related perfusion defect in 90% of patients. Remote territory MPR was unchanged after PCI (2.5 ± 1.2; p = NS vs. baseline). The LV ejection fraction increased from 63 ± 13% to 67 ± 12% (p < 0.0001) and end-systolic volume decreased from 65 ± 38 to 56 ± 38 ml (p < 0.001) 3 months after CTO PCI. Importantly, despite minimal post-procedural infarction due to distal embolization and side branch occlusion in 8 of 32 patients (25%), the total Seattle Angina Questionnaire score improved from a median of 54 (range 45 to 74) at baseline to 89 (range 77 to 98) after CTO recanalization (p < 0.0001). CONCLUSIONS In this small group of patients showing CMR evidence of significant myocardial inducible perfusion defect and viability, CTO recanalization reduces ischemic burden, favors reverse remodeling, and ameliorates quality of life.
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Affiliation(s)
- Chiara Bucciarelli-Ducci
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom; Bristol Heart Institute, Bristol NIHR Cardiovascular Biomedical Research Unit, University of Bristol, Bristol, United Kingdom
| | - Dominique Auger
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Carlo Di Mario
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Didier Locca
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Joanna Petryka
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Rory O'Hanlon
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Agata Grasso
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Christine Wright
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Karen Symmonds
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Ricardo Wage
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | - Eleni Asimacopoulos
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Jonathan C Lyne
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Peter D Gatehouse
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Kim M Fox
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Dudley J Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Oostendorp M, Post MJ, Backes WH. Vessel growth and function: depiction with contrast-enhanced MR imaging. Radiology 2009; 251:317-35. [PMID: 19401568 DOI: 10.1148/radiol.2512080485] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Magnetic resonance (MR) imaging is a versatile noninvasive diagnostic tool that can be applied to the entire human body to revealing morphologic, functional, and metabolic information. The authors review how MR imaging can depict both the established and the developing vasculature with techniques involving intravenously administered contrast agents. In addition to macrovascular morphology and flow, MR imaging is able to exploit microvascular properties, including vessel size distribution, hyperpermeability, flow heterogeneity, and possibly also upregulation of endothelial biomarkers. For each MR method, the basic principles, potential acquisition and interpretation pitfalls, solutions, and applications are described. Furthermore, discussion includes current shortcomings and the impact of future developments (eg, higher magnetic field strength systems, targeted macromolecular contrast agents) on the visualization of blood vessel growth and function with contrast-enhanced MR imaging.
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Affiliation(s)
- Marlies Oostendorp
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
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Myocardial Perfusion in Patients With a Totally Occluded Left Anterior Descending Coronary Artery Reinjected by a Normal Right Coronary Artery: The Role of Collateral Circulation. Angiology 2008; 59:464-8. [DOI: 10.1177/0003319707309308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this article, myocardial perfusion in patients with a totally occluded left anterior descending artery reinjected by a normal right coronary artery is assessed using stress single photon emission computed tomography (SPECT). In all, 20 patients, with a totally occluded left anterior descending artery reinjected by normal right coronary artery, underwent myocardial single photon emission computed tomography imaging within 60 days of angiography. All patients had abnormal perfusion single photon emission computed tomography results and 70% had reversible defects. Perfusion defects at rest were present in 75% of patients, with perinecrotic residual ischemia in 45% of patients whereas for 30% of patients, no viable myocardium was detected in the collateral-dependent segments. In all, 25% of patients had no resting perfusion defects but all are presented with stress-induced ischemia. Collaterals are not protective against stress-induced ischemia, but they can preserve myocardial viability. This conclusion is highly supported by the presence of residual ischemia in the collateral-dependent segments.
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