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Eftekhari A, van de Hoef TP, Hoshino M, Lee JM, Boerhout CKM, de Waard GA, Jung JH, Lee SH, Mejia-Renteria H, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Effat MA, Marques K, Doh JH, Banerjee R, Nam CW, Niccoli G, Murai T, Nakayama M, Tanaka N, Shin ES, Knaapen P, van Royen N, Escaned J, Koo BK, Chamuleau SAJ, Kakuta T, Piek JJ, Christiansen EH. Changes in microvascular resistance following percutaneous coronary intervention - From the ILIAS global registry. Int J Cardiol 2023; 392:131296. [PMID: 37633364 DOI: 10.1016/j.ijcard.2023.131296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/08/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Microvascular resistance (MR) has prognostic value in acute and chronic coronary syndromes following percutaneous coronary intervention (PCI), however anatomic and physiologic determinants of the relative changes of MR and its association to target vessel failure (TVF) has not been investigated previously. This study aims to evaluate the association between changes in MR and TVF. METHODS This is a sub-study of the Inclusive Invasive Physiological Assessment in Angina Syndromes (ILIAS) registry which is a global multi-centre initiative pooling lesion-level coronary pressure and flow data. RESULTS Paired pre-post PCI haemodynamic data were available in n = 295 vessels out of n = 828 PCI treated patients and of these paired data on MR was present in n = 155 vessels. Vessels were divided according to increase vs. decrease % in microvascular resistance following PCI (ΔMR % ≤ 0 vs. ΔMR > 0%). Decreased microvascular resistance ΔMR % ≤ 0 occurred in vessels with lower pre-PCI fractional flow reserve (0.67 ± 0.15 vs. 0.72 ± 0.09 p = 0.051), coronary flow reserve (1.9 ± 0.8 vs. 2.6 ± 1.8 p < 0.0001) and higher hyperemic microvascular resistance (2.76 ± 1.3 vs. 1.62 ± 0.74 p = 0.001) and index of microvascular resistance (24.4 IQ (13.8) vs. 15. 8 IQ (13.2) p = 0.004). There was no difference in angiographic parameters between ΔMR % ≤ 0 vs. ΔMR > 0%. In a cox regression model ΔMR % > 0 was associated with increased rate of TVF (hazard ratio 95% CI 3.6 [1.2; 10.3] p = 0.018). CONCLUSION Increased MR post-PCI was associated with lesions of less severe hemodynamic influence at baseline and higher rates of TVF at follow-up.
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Affiliation(s)
- Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Masahiro Hoshino
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Department of Medicine Hearth Vascular Stroke Institute Seoul, Republic of Korea
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Ji-Hyun Jung
- Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Mauro Echavarria-Pinto
- Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estad Querétaro, Facultad de Medicina Universidad Autónoma de Querétaro, Querétaro, Mexico
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Hearth Center, Gifu, Japan
| | | | - Mohamed A Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Koen Marques
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Joon-Hyung Doh
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Rupak Banerjee
- Mechanical and Materials Engineering Department, University of Cincinnati, Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Chang-Wook Nam
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | | | - Tadashi Murai
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan; Cardiovascular Center, Toda Central General Hospital, Toda, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Javier Escaned
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Bon Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC- Location VUmc, Amsterdam, the Netherlands
| | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Tsuchiura City, Japan
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC - Location AMC, Amsterdam, the Netherlands
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Bradley C, Berry C. Definition and epidemiology of coronary microvascular disease. J Nucl Cardiol 2022; 29:1763-1775. [PMID: 35534718 PMCID: PMC9345825 DOI: 10.1007/s12350-022-02974-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/17/2022] [Indexed: 11/18/2022]
Abstract
Ischemic heart disease remains one of the leading causes of death and disability worldwide. However, most patients referred for a noninvasive computed tomography coronary angiogram (CTA) or invasive coronary angiogram for the investigation of angina do not have obstructive coronary artery disease (CAD). Approximately two in five referred patients have coronary microvascular disease (CMD) as a primary diagnosis and, in addition, CMD also associates with CAD and myocardial disease (dual pathology). CMD underpins excess morbidity, impaired quality of life, significant health resource utilization, and adverse cardiovascular events. However, CMD often passes undiagnosed and the onward management of these patients is uncertain and heterogeneous. International standardized diagnostic criteria allow for the accurate diagnosis of CMD, ensuring an often overlooked patient population can be diagnosed and stratified for targeted medical therapy. Key to this is assessing coronary microvascular function-including coronary flow reserve, coronary microvascular resistance, and coronary microvascular spasm. This can be done by invasive methods (intracoronary temperature-pressure wire, intracoronary Doppler flow-pressure wire, intracoronary provocation testing) and non-invasive methods [positron emission tomography (PET), cardiac magnetic resonance imaging (CMR), transthoracic Doppler echocardiography (TTDE), cardiac computed tomography (CT)]. Coronary CTA is insensitive for CMD. Functional coronary angiography represents the combination of CAD imaging and invasive diagnostic procedures.
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Affiliation(s)
- Conor Bradley
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- NHS Golden Jubilee Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
- NHS Golden Jubilee Hospital, Clydebank, United Kingdom.
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, Scotland, United Kingdom.
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3
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Three-Dimensional Angiographic Characteristics versus Functional Stenosis Severity in Fractional and Coronary Flow Reserve Discordance: A DEFINE FLOW Sub Study. Diagnostics (Basel) 2022; 12:diagnostics12071770. [PMID: 35885676 PMCID: PMC9323286 DOI: 10.3390/diagnostics12071770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Coronary angiography alone is insufficient to identify lesions associated with myocardial ischemia that may benefit from revascularization. Coronary physiology parameters may improve clinical decision making in addition to coronary angiography, but the association between 2D and 3D qualitative coronary angiography (QCA) and invasive pressure and flow measurements is yet to be elucidated. Methods: We associated invasive fractional flow reserve (FFR), coronary flow reserve (CFR) and coronary flow capacity (CFC) with 2D- and 3D-QCA in 430 intermediate lesions of 366 patients. Results: Overall, 2D-QCA analysis resulted in less severe stenosis severity compared with 3D-QCA analysis. FFR+/CFR− lesions had similar 3D-QCA characteristics as FFR+/CFR+ lesions. In contrast, vessels with FFR−/CFR+ discordance had 3D-QCA characteristics similar to those of vessels with concordant FFR−/CFR−. Contrarily, FFR+/CFR− lesions had CFC similar to that of as FFR-/CFR- lesions. Conclusions: Non-flow-limiting lesions (FFR+/CFR−) have 3D-QCA characteristics similar to those of FFR+/CFR+, but the majority are not associated with inducible myocardial ischemia as determined by invasive CFC. FFR−/CFR+ lesions have 3D-QCA characteristics similar to those of FFR−/CFR− lesions but are more frequently associated with a moderately to severely reduced CFC, illustrating the angiographic–functional mismatch in discordant lesions.
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4
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Geng Y, Liu H, Wang X, Zhang J, Gong Y, Zheng D, Jiang J, Xia L. Effect of microcirculatory dysfunction on coronary hemodynamics: A pilot study based on computational fluid dynamics simulation. Comput Biol Med 2022; 146:105583. [DOI: 10.1016/j.compbiomed.2022.105583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/21/2022] [Accepted: 04/30/2022] [Indexed: 01/09/2023]
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5
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Fernández-Peregrina E, Garcia-Garcia HM, Sans-Rosello J, Sanz-Sanchez J, Kotronias R, Scarsini R, Echavarria-Pinto M, Tebaldi M, De Maria GL. Angiography-derived versus invasively-determined index of microcirculatory resistance in the assessment of coronary microcirculation: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2022; 99:2018-2025. [PMID: 35366386 DOI: 10.1002/ccd.30174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/18/2022] [Accepted: 03/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The index of microvascular resistance (IMR) is an established tool to assess the status of coronary microcirculation. However, the need for a pressure wire and hyperemic agents have limited its routine use and have led to the development of angiography-derived pressure-wire-free methods (angiography-derived IMR [IMRAngio]). In this review and meta-analysis, we aim to assess the global diagnosis accuracy of IMRAngio versus IMR. METHODS A systematic review of the literature was performed. Studies directly evaluating IMRAngio versus IMR were considered eligible. Pooled values of diagnostic test and summary receiver operator curve were calculated. RESULTS Seven studies directly comparing IMRAngio versus IMR were included (687 patients; 807 vessels). Pooled sensitivity, specificity, +likelihood ratio (LR), and -LR were 82%, 83%, 4.5, and 0.26 respectively. Pooled accuracy was 83% while pooled positive predictive value and negative predictive value were 76% and 85%, respectively. Comparable results were obtained when analyzing by clinical scenario (acute and nonacute coronary syndromes). CONCLUSION IMRAngio shows a good diagnostic performance for the prediction of abnormal IMR.
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Affiliation(s)
- Estefania Fernández-Peregrina
- Division of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Hector M Garcia-Garcia
- Division of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Jordi Sans-Rosello
- Division of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jorge Sanz-Sanchez
- Departamento de Cardiología Intervencionista, Hospital de La Fe, Valencia, Spain.,Centro de Investigacion Biomedica en Red (CIBERCV), Madrid, Spain
| | - Rafail Kotronias
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Roberto Scarsini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Mauro Echavarria-Pinto
- Facultad de Medicina, Hospital General ISSSTE Querétano, Universidad Autónoma de Querétano, Santiago de Querétano, Mexico
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliera Univertaria S. Anna, Ferrara, Italy
| | - Giovanni L De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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6
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Scarsini R, Shanmuganathan M, Kotronias RA, Terentes-Printzios D, Borlotti A, Langrish JP, Lucking AJ, Ribichini F, Ferreira VM, Channon KM, Garcia-Garcia HM, Banning AP, De Maria GL. Angiography-derived index of microcirculatory resistance (IMRangio) as a novel pressure-wire-free tool to assess coronary microvascular dysfunction in acute coronary syndromes and stable coronary artery disease. Int J Cardiovasc Imaging 2021; 37:1801-1813. [DOI: 10.1007/s10554-021-02254-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/23/2021] [Indexed: 01/04/2023]
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7
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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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8
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Maznyczka AM, Oldroyd KG, McCartney P, McEntegart M, Berry C. The Potential Use of the Index of Microcirculatory Resistance to Guide Stratification of Patients for Adjunctive Therapy in Acute Myocardial Infarction. JACC Cardiovasc Interv 2020; 12:951-966. [PMID: 31122353 DOI: 10.1016/j.jcin.2019.01.246] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/20/2018] [Accepted: 01/03/2019] [Indexed: 12/31/2022]
Abstract
The goal of reperfusion therapies in ST-segment elevation myocardial infarction has evolved to include effective reperfusion of the microcirculation subtended by the culprit epicardial coronary artery. The index of microcirculatory resistance is measured using a pressure- and temperature-sensing coronary guidewire and quantifies microvascular dysfunction. The index of microcirculatory resistance is an independent predictor of microvascular obstruction, infarct size, and adverse clinical outcomes. It has the advantage of being immediately measurable in the catheterization laboratory, before the results of blood biomarkers or noninvasive imaging become available. This provides an opportunity for additional intervention that may alter outcomes. In this review, the authors provide a critical appraisal of the published research on the emerging role of the index of microcirculatory resistance as a tool to guide the stratification of patients for adjunctive therapeutic strategies in acute ST-segment elevation myocardial infarction.
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Affiliation(s)
- Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Peter McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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9
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Muroya T, Kawano H, Koga S, Ikeda S, Yamamoto F, Maemura K. Aortic Stiffness Is Associated with Coronary Microvascular Dysfunction in Patients with Non-obstructive Coronary Artery Disease. Intern Med 2020; 59:2981-2987. [PMID: 33268696 PMCID: PMC7759696 DOI: 10.2169/internalmedicine.5401-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective Associations between aortic stiffness and cardiovascular disease events are mediated in part by pathways that include coronary microvascular dysfunction (CMD) and remodeling. However, the relationship between aortic stiffness and CMD remains unclear. The present study aimed to determine whether aortic stiffness causes CMD as evaluated by the hyperemic microvascular resistance index (hMVRI) in patients with non-obstructive coronary artery disease (CAD). Methods The intracoronary physiological variables in 209 coronary arteries were evaluated in 121 patients with non-obstructive CAD (fractional flow reserve >0.80) or reference vessels. The cardio-ankle vascular index (CAVI) as a measure of aortic stiffness and atherosclerotic risk factors were also measured. Results Univariate analyses showed that hMVRI correlated with age (β=0.24, p=0.007), eicosapentaenoic acid (EPA; β=-0.18, p=0.048), EPA/arachidonic acid (AA) (EPA/AA) ratio (β=-0.22, p=0.014) and CAVI (β=0.30, p=0.001). A multivariate regression analysis identified CAVI (β=0.25, p=0.007) and EPA/AA ratio (β=-0.26, SE=0.211, p=0.003) as independent determinants of hMVRI. Conclusion Aortic stiffness may cause CMD in patients with non-obstructive CAD via increased coronary microvascular resistance. Aortic stiffness is associated with CMD which is evaluated as hyperemic microvascular resistance in patients with non-obstructive CAD.
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Affiliation(s)
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Fumi Yamamoto
- Department of Cardiology, Ureshino Medical Center, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
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10
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Muroya T, Kawano H, Koga S, Ikeda S, Yamamoto F, Miwa T, Kohno Y, Maemura K. Lower Circulating Omega-3 Polyunsaturated Fatty Acids Are Associated with Coronary Microvascular Dysfunction Evaluated by Hyperemic Microvascular Resistance in Patients with Stable Coronary Artery Disease. Int Heart J 2018; 59:1194-1201. [PMID: 30305577 DOI: 10.1536/ihj.17-459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The consumption of omega-3 polyunsaturated fatty acids (PUFAs) reduces the incidence of cardiovascular events and sudden cardiac death. Coronary microvascular dysfunction (CMD) is a predictor of cardiac mortality, but little information is known on the relationship between CMD and omega-3 PUFAs. This study aimed to identify the relationship between the serum levels of omega-3 PUFAs and the CMD evaluated by the hyperemic microvascular resistance index (hMVRI) to assess coronary microvascular function in patients with stable coronary artery disease (CAD).Intracoronary physiological variables (fractional flow reserve (FFR), hMVRI, mean distal coronary pressure (Pd), and average peak velocity (APV)) were measured in 108 patients. These parameters were evaluated in 150 coronary arteries with stenosis of intermediate severity and without significant ischemia (FFR > 0.80). The PUFA levels and atherosclerotic risk factors were also measured. Univariate analysis shows that hMVRI was negatively correlated with eicosapentaenoic acid (EPA)/arachidonic acid (AA) ratio (β = -0.31, P = 0.001) and EPA (β = -0.25, P = 0.009) and was positively correlated with dihomo-γ-linolenic acid (β = 0.26, P = 0.006). Multivariate regression analysis shows that the EPA/AA ratio was the only independent determinant of hMVRI (β = -0.234, SE = 0.231, P = 0.024). Furthermore, hMVRI decreased significantly from the lowest to highest tertiles of the EPA/AA ratio (P = 0.007). The EPA/AA ratio was positively correlated with APV at hyperemia (β = 0.26, P = 0.008) but not with Pd at hyperemia.A lower serum EPA/AA ratio may cause CMD in patients with stable CAD.
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Affiliation(s)
- Takahiro Muroya
- Department of Cardiology, Ureshino Medical Center.,Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Takashi Miwa
- Department of Cardiology, Ureshino Medical Center
| | - Yusuke Kohno
- Department of Cardiology, Ureshino Medical Center
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
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11
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Everaars H, de Waard GA, Driessen RS, Danad I, van de Ven PM, Raijmakers PG, Lammertsma AA, van Rossum AC, Knaapen P, van Royen N. Doppler Flow Velocity and Thermodilution to Assess Coronary Flow Reserve: A Head-to-Head Comparison With [ 15O]H 2O PET. JACC Cardiovasc Interv 2018; 11:2044-2054. [PMID: 30268877 DOI: 10.1016/j.jcin.2018.07.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study sought to compare Doppler flow velocity reserve (CFRDoppl) and thermodilution-derived coronary flow reserve (CFRthermo) head-to-head with the gold standard for quantification of myocardial perfusion, [15O]H2O positron emission tomography (PET). BACKGROUND Coronary flow reserve (CFR) is an important parameter for assessing coronary vascular function. To date, 2 techniques are available for invasive assessment of CFR: Doppler flow velocity and thermodilution. Although these techniques have been compared with each other, neither has been compared with [15O]H2O PET perfusion imaging. METHODS CFR was assessed in 98 vessels of 40 consecutive stable patients with suspected coronary artery disease. Patients underwent [15O]H2O PET, followed by invasive angiography in conjunction with simultaneous measurements of fractional flow reserve, CFRDoppl, and CFRthermo. Both normal and obstructed arteries were included. RESULTS The quality of Doppler flow velocity traces was significantly lower than that of thermodilution curves (p < 0.001). A moderate correlation was observed between CFRDoppl and CFRthermo (r = 0.59; p < 0.001). CFRDoppl correlated well with PET-derived CFR (CFRPET) (r = 0.82; p < 0.001). In contrast, the correlation between CFRthermo and CFRPET was only modest (r = 0.55; p < 0.001). This difference in correlation with CFRPET was significant (t = 4.9; df = 95; p < 0.001). Bland-Altman analysis revealed a tendency of CFRthermo to overestimate flow reserve at higher values. CONCLUSIONS Coronary flow reserve, determined using Doppler flow velocity, has superior agreement with [15O]H2O PET in comparison with CFRthermo.
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Affiliation(s)
- Henk Everaars
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Adriaan A Lammertsma
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
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12
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Gorla R, Verna E, Scotti S, Ghiringhelli S, Zoli L, Provasoli S, Garancini S, De Ponti R, Salerno-Uriarte JA. Clinical role of post-angioplasty hyperemic microvascular resistances in chronic ischemic left ventricular dysfunction. J Cardiovasc Med (Hagerstown) 2017; 18:332-340. [DOI: 10.2459/jcm.0000000000000490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Shome JS, Perera D, Plein S, Chiribiri A. Current perspectives in coronary microvascular dysfunction. Microcirculation 2017; 24. [DOI: 10.1111/micc.12340] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/06/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Joy S. Shome
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Divaka Perera
- Cardiovascular Division; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Sven Plein
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
- Division of Biomedical Imaging; Multidisciplinary Cardiovascular Research Centre; Leeds Institute of Cardiovascular and Metabolic Medicine; University of Leeds; Leeds UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
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14
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de Waard GA, Nijjer SS, van Lavieren MA, van der Hoeven NW, Petraco R, van de Hoef TP, Echavarría-Pinto M, Sen S, van de Ven PM, Knaapen P, Escaned J, Piek JJ, Davies JE, van Royen N. Invasive minimal Microvascular Resistance Is a New Index to Assess Microcirculatory Function Independent of Obstructive Coronary Artery Disease. J Am Heart Assoc 2016; 5:e004482. [PMID: 28007742 PMCID: PMC5210399 DOI: 10.1161/jaha.116.004482] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/18/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary microcirculatory dysfunction portends a poor cardiovascular outcome. Invasive assessment of microcirculatory dysfunction by coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) is affected by coronary artery disease (CAD). In this study we propose minimal microvascular resistance (mMR) as a new measure of microcirculatory dysfunction and aim to determine whether mMR is influenced by CAD. METHODS AND RESULTS We obtained 482 simultaneous measurements of intracoronary Doppler flow velocity and pressure. The mMR is defined as the ratio between distal coronary pressure and flow velocity during the hyperemic wave-free period. Measurements were divided into 2 cohorts. Cohort 1 was a paired analysis involving 81 pairs with a vessel with and without CAD to investigate whether HMR, CFR, and mMR are modulated by CAD. CFR was lower, and HMR was higher, in vessels with CAD than in vessels without CAD: 2.12±0.79 versus 2.56±0.63 mm Hg·cm-1·s, P<0.001, and 2.61±1.22 versus 2.31±0.89 mm Hg·cm-1·s, P=0.04, respectively. mMR was equal in vessels with and without CAD: 1.54±0.77 versus 1.53±0.57 mm Hg·cm-1·s, P=0.90. Differences for CFR occurred when FFR was 0.60 to 0.80 or ≤0.60 but not when FFR ≥0.80. For HMR, the difference occurred only when FFR ≤0.60. For mMR, no difference was observed in any FFR stratum. Cohort 2 was used for validation and showed significant relationships for CFR and HMR with FFR: Pearson r=0.488, P<0.001 and -0.159, P=0.03, respectively; mMR had no association with FFR: Pearson r=0.055; P=0.32. CONCLUSIONS mMR is a novel index to assess microcirculatory dysfunction and is not modified by the presence of obstructive CAD.
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Affiliation(s)
| | | | | | | | | | | | | | - Sayan Sen
- Imperial College London, London, United Kingdom
| | | | - Paul Knaapen
- VU University Medical Center, Amsterdam, The Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Jan J Piek
- Academic Medical Centre, Amsterdam, The Netherlands
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15
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Murai T, Lee T, Kanaji Y, Matsuda J, Usui E, Araki M, Niida T, Hishikari K, Ichijyo S, Hamaya R, Yonetsu T, Isobe M, Kakuta T. The influence of elective percutaneous coronary intervention on microvascular resistance: a serial assessment using the index of microcirculatory resistance. Am J Physiol Heart Circ Physiol 2016; 311:H520-31. [DOI: 10.1152/ajpheart.00837.2015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
This study investigates whether hyperemic microvascular resistance (MR) is influenced by elective percutaneous coronary intervention (PCI) by using the index of microcirculatory resistance (IMR). Seventy-one consecutive patients with stable angina pectoris undergoing elective PCI were prospectively studied. The IMR was measured before and after PCI and at the 10-mo follow-up. The IMR significantly decreased until follow-up; the pre-PCI, post-PCI, and follow-up IMRs had a median of 19.8 (interquartile range, 14.6–28.9), 16.2 (11.8–22.1), and 14.8 (11.8–18.7), respectively ( P < 0.001). The pre-PCI IMR was significantly correlated with the change in IMR between pre- and post-PCI ( r = 0.84, P < 0.001) and between pre-PCI and follow-up ( r = 0.93, P < 0.001). Pre-PCI IMR values were significantly higher in territories with decreases in IMR than in those with increases in IMR [pre-PCI IMR: 25.4 (18.4–35.5) vs. 12.5 (9.4–16.8), P < 0.001]. At follow-up, IMR values in territories showing decreases in IMR were significantly lower than those with increases in IMR [IMR at follow-up: 13.9 (10.9–17.6) vs. 16.6 (14.0–21.4), P = 0.013]. The IMR decrease was significantly associated with a greater shortening of mean transit time, indicating increases in coronary flow ( P < 0.001). The optimal cut-off values of pre-PCI IMR to predict a decrease in IMR after PCI and at follow-up were 16.8 and 17.0, respectively. In conclusion, elective PCI affected hyperemic MR and its change was associated with pre-PCI MR, resulting in showing a wide distribution. Overall hyperemic MR significantly decreased until follow-up. The modified hyperemic MR introduced by PCI may affect post-PCI coronary flow.
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Affiliation(s)
- Tadashi Murai
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsumin Lee
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Yoshihisa Kanaji
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Junji Matsuda
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Eisuke Usui
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Makoto Araki
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Takayuki Niida
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Keiichi Hishikari
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Sadamitsu Ichijyo
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Rikuta Hamaya
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Taishi Yonetsu
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan; and
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16
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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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17
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Geir Solberg O, Aaberge L, Ragnarsson A, Aas M, Endresen K, Šaltytė Benth J, Gullestad L, Stavem K. Comparison of simplified and comprehensive methods for assessing the index of microvascular resistance in heart transplant recipients. Catheter Cardiovasc Interv 2016; 87:283-90. [PMID: 26525162 DOI: 10.1002/ccd.26283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 08/06/2015] [Accepted: 10/03/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of the present study were to compare a simplified and a comprehensive method of estimating the index of microvascular resistance (IMR) and assess the changes from 7-11 weeks to 1 year after heart transplant (HTx). BACKGROUND he IMR is specific to the microvasculature and reflects the status of the microcirculation in cardiac patients and can be estimated via a simplified method (IMR(s)) or a comprehensive method (IMR(c)). The calculation for the latter includes coronary wedge pressure and central venous pressure. METHODS Consecutively transplanted patients (n = 48) underwent left and right heart catheterization including physiological evaluation at two time points post-HTx. The agreement between the values of IMR obtained using the IMR(s) and IMR(c) methods were assessed using Bland-Altman analysis. The agreements and differences were assessed using mixed model analysis. RESULTS The mean bias between IMRs and IMRc was 1.3 mm Hg·s (95% limits of agreement: -1.2, 3.8 mm Hg). Between 7-11 weeks and 1 year post-HTx there was a significant decline in IMR(s) values (P = 0.03) but a smaller and statistically nonsignificant decline in IMR(c) values (P = 0.13). The significant difference (P = 0.04) between IMR(c) and IMR(s) 7-11 weeks post-HTx was no longer present at 1 year (P = 0.24). CONCLUSIONS The IMR(s) method resulted in slightly higher IMR estimates and exhibited a somewhat larger change over the 10-month follow-up period than the IMR(c) method. However, the differences between the methods were small and unlikely to be of clinical importance.
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Affiliation(s)
- Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institue of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Asgrimur Ragnarsson
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Marit Aas
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Centre and Centre for Heart Failure Research, Faculty of Medicine, University of Oslo, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway.,Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
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18
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Ladwiniec A, Cunnington MS, Rossington J, Thackray S, Alamgir F, Hoye A. Microvascular dysfunction in the immediate aftermath of chronic total coronary occlusion recanalization. Catheter Cardiovasc Interv 2016; 87:1071-9. [PMID: 26756537 DOI: 10.1002/ccd.26392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/13/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to compare microvascular resistance under both baseline and hyperemic conditions immediately after percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) with an unobstructed reference vessel in the same patient BACKGROUND Microvascular dysfunction has been reported to be prevalent immediately after CTO PCI. However, previous studies have not made comparison with a reference vessel. Patients with a CTO may have global microvascular and/or endothelial dysfunction, making comparison with established normal values misleading. METHODS After successful CTO PCI in 21 consecutive patients, coronary pressure and flow velocity were measured at baseline and hyperemia in distal segments of the CTO/target vessel and an unobstructed reference vessel. Hemodynamics including hyperemic microvascular resistance (HMR), basal microvascular resistance (BMR), and instantaneous minimal microvascular resistance at baseline and hyperemia were calculated and compared between reference and target/CTO vessels. RESULTS After CTO PCI, BMR was reduced in the target/CTO vessel compared with the reference vessel: 3.58 mm Hg/cm/s vs 4.94 mm Hg/cm/s, difference -1.36 mm Hg/cm/s (-2.33 to -0.39, p = 0.008). We did not detect a difference in HMR: 1.82 mm Hg/cm/s vs 2.01 mm Hg/cm/s, difference -0.20 (-0.78 to 0.39, p = 0.49). Instantaneous minimal microvascular resistance correlated strongly with the length of stented segment at baseline (r = 0.63, p = 0.005) and hyperemia (r = 0.68, p = 0.002). CONCLUSIONS BMR is reduced in a recanalized CTO in the immediate aftermath of PCI compared to an unobstructed reference vessel; however, HMR appears to be preserved. A longer stented segment is associated with increased microvascular resistance. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Andrew Ladwiniec
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Michael S Cunnington
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Jennifer Rossington
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Simon Thackray
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Farquad Alamgir
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
| | - Angela Hoye
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull, HU16 5JQ, United Kingdom
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19
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Park SD, Lee MJ, Woo SI, Baek YS, Shin SH, Kim DH, Kwan J, Park KS. Epicardial Artery Stenosis with a High Index of Microcirculatory Resistance Is Frequently Functionally Insignificant as Estimated by Fractional Flow Reserve (FFR). Intern Med 2016; 55:97-103. [PMID: 26781006 DOI: 10.2169/internalmedicine.55.4080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Differences in microvascular integrity can diversely influence the functional assessment of epicardial coronary artery disease in each patient. We investigated the relevance of the index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) of intermediate coronary lesions. Methods The IMR and FFR were measured in 67 intermediate coronary lesions of the left anterior descending artery of 67 patients, by using a pressure sensor/thermistor-tipped guidewire. Results To assess the differences in FFR in relationship to the IMR value, patients were divided into tertile IMR groups as follows: Low-IMR (n=22, IMR 14±3), Mid-IMR (n=23, IMR 21±2), and High-IMR (n=22, IMR 36±10). An analysis of variance showed that the High-IMR group had significantly higher FFR values (0.87±0.07) than the Low-IMR group (0.81±0.08) (p=0.03). Functionally significant lesions with FFR ≤0.8 accounted for 9% of lesions in the High-IMR group, 36% in the Low-IMR group and 22% in the Mid-IMR group (p=0.02). In the multivariate logistic analysis, the IMR value was an independent determinant of FFR ≤0.8 (p=0.03). Conclusion In patients with a high IMR, intermediate lesions as identified with visual estimation were more frequently functionally insignificant. The IMR can provide additional information in understanding the mismatch between the anatomical and functional severity of intermediate coronary stenosis.
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Affiliation(s)
- Sang-Don Park
- Department of Internal Medicine, Inha University Hospital, South Korea
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20
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Nijjer SS, de Waard GA, Sen S, van de Hoef TP, Petraco R, Echavarría-Pinto M, van Lavieren MA, Meuwissen M, Danad I, Knaapen P, Escaned J, Piek JJ, Davies JE, van Royen N. Coronary pressure and flow relationships in humans: phasic analysis of normal and pathological vessels and the implications for stenosis assessment: a report from the Iberian-Dutch-English (IDEAL) collaborators. Eur Heart J 2015; 37:2069-80. [PMID: 26612582 PMCID: PMC4940452 DOI: 10.1093/eurheartj/ehv626] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/27/2015] [Indexed: 01/10/2023] Open
Abstract
Background Our understanding of human coronary physiological behaviour is derived from animal models. We sought to describe physiological behaviour across a large collection of invasive pressure and flow velocity measurements, to provide a better understanding of the relationships between these physiological parameters and to evaluate the rationale for resting stenosis assessment. Methods and results Five hundred and sixty-seven simultaneous intracoronary pressure and flow velocity assessments from 301 patients were analysed for coronary flow velocity, trans-stenotic pressure gradient (TG), and microvascular resistance (MVR). Measurements were made during baseline and hyperaemic conditions. The whole cardiac cycle and the diastolic wave-free period were assessed. Stenoses were assessed according to fractional flow reserve (FFR) and quantitative coronary angiography DS%. With progressive worsening of stenoses, from unobstructed angiographic normal vessels to those with FFR ≤ 0.50, hyperaemic flow falls significantly from 45 to 19 cm/s, Ptrend < 0.001 in a curvilinear pattern. Resting flow was unaffected by stenosis severity and was consistent across all strata of stenosis ( Ptrend > 0.05 for all). Trans-stenotic pressure gradient rose with stenosis severity for both rest and hyperaemic measures ( Ptrend < 0.001 for both). Microvascular resistance declines with stenosis severity under resting conditions ( Ptrend < 0.001), but was unchanged at hyperaemia (2.3 ± 1.1 mmHg/cm/s; Ptrend = 0.19). Conclusions With progressive stenosis severity, TG rises. However, while hyperaemic flow falls significantly, resting coronary flow is maintained by compensatory reduction of MVR, demonstrating coronary auto-regulation. These data support the translation of coronary physiological concepts derived from animals to patients with coronary artery disease and furthermore, suggest that resting pressure indices can be used to detect the haemodynamic significance of coronary artery stenoses.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ibrahim Danad
- VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul Knaapen
- VU University Medical Centre, Amsterdam, The Netherlands
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Jan J Piek
- Academic Medical Centre, Amsterdam, The Netherlands
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22
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Echavarría-Pinto M, Serruys PW, Garcia-Garcia HM, Broyd C, Cerrato E, Macaya C, Escaned J. Use of intracoronary physiology indices in acute coronary syndromes. Interv Cardiol 2015. [DOI: 10.2217/ica.15.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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23
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Ladwiniec A, Hoye A. The haemodynamic effects of collateral donation to a chronic total occlusion: Implications for patient management. Int J Cardiol 2015; 198:159-66. [PMID: 26163908 DOI: 10.1016/j.ijcard.2015.06.174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/23/2015] [Accepted: 06/29/2015] [Indexed: 01/09/2023]
Abstract
Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularization. Chronic total coronary occlusions are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary artery. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel's FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularized. As a consequence, in the setting of multi-vessel disease, optimal revascularization strategy might be altered. There is a paucity of work in the medical literature directly examining this phenomenon. We endeavoured to review the existing literature related to it, to summarise from current knowledge of coronary physiology what is known about the potential effects of CTO revascularization on both collateral flow and collateral donor vessel physiology, and to highlight where further studies might inform practice.
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Affiliation(s)
- Andrew Ladwiniec
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull HU16 5JQ, UK.
| | - Angela Hoye
- Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull HU16 5JQ, UK
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24
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Buch AN, Chen C, Ferguson TB. Revascularization for stable ischemic heart disease: are there new parallels between percutaneous coronary intervention and coronary artery bypass grafting? Interv Cardiol 2015. [DOI: 10.2217/ica.14.76] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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25
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Yamanaga K, Tsujita K, Komura N, Kaikita K, Sakamoto K, Miyazaki T, Saito M, Ishii M, Tabata N, Akasaka T, Sato K, Horio E, Arima Y, Kojima S, Tayama S, Nakamura S, Hokimoto S, Ogawa H. Single-wire pressure and flow velocity measurement for quantifying microvascular dysfunction in patients with coronary vasospastic angina. Am J Physiol Heart Circ Physiol 2015; 308:H478-84. [DOI: 10.1152/ajpheart.00593.2014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endothelial and vascular smooth muscle dysfunction of epicardial coronary arteries play a pivotal role in the pathogenesis of vasospastic angina (VSA). However, coronary microvascular (MV) function in patients with VSA is not fully understood. In the present study, subjects without coronary obstruction were divided into two groups according to the acetylcholine provocation test: VSA group ( n = 29) and non-VSA group ( n = 21). Hyperemic MV resistance (hMR) was measured using a dual-sensor (Doppler velocity and pressure)-equipped guidewire, and guidewire-derived hemodynamic parameters were compared. There were no between-group differences in clinical demographics, including potential factors affecting MV function (e.g., diabetes). Although coronary flow velocity reserve was similar between the two groups [2.4 ± 1.0 (VSA group) vs. 2.4 ± 0.9 (non-VSA group); P = 0.8], coronary vessel resistance and hMR were significantly elevated in the VSA group compared with the non-VSA group (2.6 ± 3.1 vs. 1.2 ± 0.8, P = 0.04; 1.9 ± 0.6 vs. 1.6 ± 0.5, P = 0.03, respectively). Coronary vasospasm, older age, E/e', and estimated glomerular filtration rate were significantly associated with MV dysfunction [defined as ≥ median value of hMR (1.6)] in univariate analysis. Coronary vasospasm most strongly predicted higher hMR in multivariate logistic regression analysis (odds ratio, 4.61; 95% confidence interval, 0.98–21.60; P = 0.053). In conclusion, coronary MV resistance is impaired in patients with VSA compared with non-VSA patients, whereas coronary flow velocity reserve is maintained at normal levels in both groups. In vivo assessment of hMR might be a promising index of coronary MV dysfunction in patients with VSA.
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Affiliation(s)
- Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Naohiro Komura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Takashi Miyazaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Michiyo Saito
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Tomonori Akasaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Koji Sato
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Eiji Horio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Shinji Tayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Sunao Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
- Division of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; and
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Camici PG, d'Amati G, Rimoldi O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol 2014; 12:48-62. [DOI: 10.1038/nrcardio.2014.160] [Citation(s) in RCA: 290] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Comparing the effect of clopidogrel versus ticagrelor on coronary microvascular dysfunction in acute coronary syndrome patients (TIME trial): study protocol for a randomized controlled trial. Trials 2014; 15:151. [PMID: 24885437 PMCID: PMC4031487 DOI: 10.1186/1745-6215-15-151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 04/16/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although prompt reperfusion treatment restores normal epicardial flow, microvascular dysfunction may persist in some patients with acute coronary syndrome (ACS). Impaired myocardial perfusion is caused by intraluminal platelets, fibrin thrombi and neutrophil plugging; antiplatelet agents play a significant role in terms of protecting against thrombus microembolization. A novel antiplatelet agent, ticagrelor, is a non-thienopyridine, direct P2Y12 blocker that has shown greater, more rapid and more consistent platelet inhibition than clopidogrel. However, the effects of ticagrelor on the prevention of microvascular dysfunction are uncertain. The present study is a comparison between clopidogrel and ticagrelor use for preventing microvascular dysfunction in patients with ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI, respectively). METHODS/DESIGN The TIME trial is a single-center, randomized, open-label, parallel-arm study designed to demonstrate the superiority of ticagrelor over clopidogrel. A total of 152 patients with a spectrum of STEMI or NSTEMI will undergo prospective random assignment to clopidogrel or ticagrelor (1:1 ratio). The primary endpoint is an index of microcirculatory resistance (IMR) measured after percutaneous coronary intervention (PCI); the secondary endpoint is wall motion score index assessed at 3 months by using echocardiography. DISCUSSION The TIME trial is the first study designed to compare the protective effect of clopidogrel and ticagrelor on coronary microvascular dysfunction in patients with STEMI and NSTEMI. TRIAL REGISTRATION ClinicalTrials.gov: NCT02026219. Registration date: 24 December 2013.
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Niccoli G, Falcioni E, Cosentino N, Fracassi F, Roberto M, Fabretti A, Panebianco M, Scalone G, Burzotta F, Trani C, Leone AM, Davies J, Crea F. Impact of accuracy of fractional flow reserve to reduction of microvascular resistance after intracoronary adenosine in patients with angina pectoris or non-ST-segment elevation myocardial infarction. Am J Cardiol 2014; 113:1461-7. [PMID: 24731651 DOI: 10.1016/j.amjcard.2014.01.422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 01/07/2023]
Abstract
Our study aimed to elucidate mechanisms underlying discordance between fractional flow reserve (FFR) and hyperemic stenosis resistance (hSR) in some patient subsets. To do this, we enrolled 30 consecutive patients with stable angina or non-ST elevation myocardial infarction (non-STEMI) and with a nonculprit intermediate coronary lesion (40% to 70%) by coronary angiography. We measured aortic pressure, flow velocity, and pressure distal to lesion simultaneously at basal level and during adenosine-induced (fixed intracoronary dose of 120 μg) hyperemia using a dual-sensor-equipped guidewire. Microvascular resistance (MR; pressure distal to lesion/flow velocity, mm Hg/cm/s) and variation (Δ) in MR levels were calculated both at baseline and after hyperemia, whereas FFR (cutoff <0.80) and hSR [(aortic pressure - pressure distal to lesion)/flow velocity, cutoff >0.80 mm Hg/cm/s] were assessed after intracoronary adenosine. Twenty-three patients (76.7%) showed concordance and 7 patients (23.3%) showed discordance between FFR and hSR (all cases with FFR >0.80 and hSR >0.80). Discordant patients presented more frequently with non-STEMI (85.7% vs 39.1%, p = 0.04), significantly higher C-reactive protein serum levels (median [interquartile range] 5.9 [5.1 to 6.8] vs 4.9 [3.7 to 6.2] mg/L, p = 0.007), and lower ΔMR (p = 0.03) values compared with concordant patients. In conclusion, patients with non-STEMI and those with increased C-reactive protein levels show a lower reduction in MR after intracoronary adenosine-induced hyperemia, leading to FFR underestimation.
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Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
| | - Elena Falcioni
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Nicola Cosentino
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Roberto
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandro Fabretti
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Mario Panebianco
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giancarla Scalone
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Justin Davies
- International Centre for Circulatory Health, NHLI, Imperial College London, London, United Kingdom
| | - Filippo Crea
- Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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van Lavieren MA, van de Hoef TP, Piek JJ. Coronary wedge pressure and collateral flow contribution: not a dichotomy! EUROINTERVENTION 2014; 9:1485-8. [PMID: 24755391 DOI: 10.4244/eijv9i12a250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Martijn A van Lavieren
- AMC Heart Center, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
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30
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Nolte F, van de Hoef TP, Meuwissen M, Voskuil M, Chamuleau SAJ, Henriques JPS, Verberne HJ, van Eck-Smit BLF, Koch KT, de Winter RJ, Spaan JAE, Tijssen JGP, Siebes M, Piek JJ. Increased hyperaemic coronary microvascular resistance adds to the presence of myocardial ischaemia. EUROINTERVENTION 2014; 9:1423-31. [PMID: 24755383 DOI: 10.4244/eijv9i12a240] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS It has been argued that hyperaemic microvascular resistance (HMR), defined as the ratio of mean distal coronary pressure to flow velocity, is overestimated in the presence of a coronary stenosis compared to actual microvascular resistance (MR), due to neglecting collateral flow. We aimed to test the hypothesis that HMR allows accurate identification of microvascular functional abnormalities by evaluating the association between high or low HMR and the presence of myocardial ischaemia on non-invasive stress testing. METHODS AND RESULTS Myocardial perfusion scintigraphy was performed in 228 patients, with 299 lesions to identify reversible myocardial ischaemia. Intracoronary distal pressure and flow velocity were assessed during adenosine-induced hyperaemia (20-40 µg, intracoronary) to determine hyperaemic stenosis resistance (HSR) and HMR. HMR >1.9 mmHg/cm/s was defined as high. The diagnostic odds ratio (OR) for myocardial ischaemia for lesions associated with high compared to low HMR was 2.6 (95% confidence interval [CI]: 1.5-4.4; p<0.001) overall, 3.3 (95% CI: 1.2-9.0; p=0.02) for lesions with HSR >0.8 mmHg/cm/s, and 1.3 (95% CI: 0.6-2.9; p=0.52) for lesions with HSR ≤0.8 mmHg/cm/s. CONCLUSIONS The increased risk of myocardial ischaemia in the presence of high HMR, uncorrected for collateral flow, demonstrates that HMR is reflective of an increase in actual MR, identifying pertinent pathophysiological alterations in the microvasculature.
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Affiliation(s)
- Froukje Nolte
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands
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van de Hoef TP, Nolte F, EchavarrÍa-Pinto M, van Lavieren MA, Damman P, Chamuleau SAJ, Voskuil M, Verberne HJ, Henriques JPS, van Eck-Smit BLF, Koch KT, de Winter RJ, Spaan JAE, Siebes M, Tijssen JGP, Meuwissen M, Piek JJ. Impact of hyperaemic microvascular resistance on fractional flow reserve measurements in patients with stable coronary artery disease: insights from combined stenosis and microvascular resistance assessment. Heart 2014; 100:951-9. [PMID: 24727867 DOI: 10.1136/heartjnl-2013-305124] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Fractional flow reserve (FFR) aims to identify the extent of epicardial disease, but may be obscured by involvement of the coronary microvasculature. We documented the impact of hyperaemic stenosis resistance (HSR) and hyperaemic microvascular resistance (HMR) on FFR, and its relationship with myocardial ischaemia in patients with stable coronary artery disease. METHODS AND RESULTS We evaluated 255 coronary arteries with stenoses of intermediate severity by means of intracoronary pressure and flow measurements to determine FFR, HSR and HMR. Myocardial perfusion scintigraphy (MPS) was performed to identify inducible myocardial ischaemia. In 178 patients, HMR was additionally determined in a reference coronary artery. Target vessel HMR was stratified according to reference vessel HMR tertiles. The diagnostic OR for inducible ischaemia on MPS of a positive compared with a negative FFR was significantly higher only in the presence of a high HMR (at the 0.75 and 0.80 FFR cut-off). Among stenoses with a positive FFR, the prevalence of ischaemia was significantly higher when HMR was high despite equivalent FFR across the HMR groups. This was paralleled by a concomitant significant increase in HSR with increasing HMR across groups. The relation between FFR and HSR (r(2)=0.54, p<0.001) was modulated by the magnitude of HMR, and improved substantially after adjustment for HMR (adjusted-r(2)=0.73, p<0.001), where, for epicardial disease of equivalent severity, FFR increased with increasing HMR. CONCLUSIONS Identification of epicardial disease severity by FFR is partly obscured by the microvascular resistance, which illustrates the necessity of combined pressure and flow measurements in daily practice.
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Affiliation(s)
- Tim P van de Hoef
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Froukje Nolte
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Mauro EchavarrÍa-Pinto
- Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Martijn A van Lavieren
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Damman
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Michiel Voskuil
- Department of Cardiology, University Medical Centre, Utrecht, The Netherlands
| | - Hein J Verberne
- Department of Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - José P S Henriques
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Berthe L F van Eck-Smit
- Department of Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T Koch
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jos A E Spaan
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Jan J Piek
- AMC Heartcentre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Echavarría-Pinto M, Gonzalo N, Ibañez B, Petraco R, Jimenez-Quevedo P, Sen S, Nijjer S, Tarkin J, Alfonso F, Núñez-Gil IJ, Bañuelos C, Quirós A, Fernández-Ortiz A, Macaya C, Koo BK, Davies J, Escaned J. Low Coronary Microcirculatory Resistance Associated With Profound Hypotension During Intravenous Adenosine Infusion. Circ Cardiovasc Interv 2014; 7:35-42. [DOI: 10.1161/circinterventions.113.000659] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Mauro Echavarría-Pinto
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Nieves Gonzalo
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Borja Ibañez
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Ricardo Petraco
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Pilar Jimenez-Quevedo
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Sayan Sen
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Sukkinder Nijjer
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Jason Tarkin
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Fernando Alfonso
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Ivan J. Núñez-Gil
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Camino Bañuelos
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Alicia Quirós
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Antonio Fernández-Ortiz
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Carlos Macaya
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Bon-Kwon Koo
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Justin Davies
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
| | - Javier Escaned
- From the Cardiovascular Institute, Hospital Clínico San Carlos and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (M.E.-P., B.I., A.Q., A.F.-O., J.E.); Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (N.G., P.J.-Q., F.A., I.J.N.-G., C.B., C.M.); International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom (R.P., S.S., S.N., J.T., J.D.); and
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Nolte F, Hyde ER, Rolandi C, Lee J, van Horssen P, Asrress K, van den Wijngaard JPHM, Cookson AN, van de Hoef T, Chabiniok R, Razavi R, Michler C, Hautvast GLTF, Piek JJ, Breeuwer M, Siebes M, Nagel E, Smith NP, Spaan JAE. Myocardial perfusion distribution and coronary arterial pressure and flow signals: clinical relevance in relation to multiscale modeling, a review. Med Biol Eng Comput 2013; 51:1271-86. [DOI: 10.1007/s11517-013-1088-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/11/2013] [Indexed: 01/25/2023]
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