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Lashgari M, Choudhury RP, Banerjee A. Patient-specific in silico 3D coronary model in cardiac catheterisation laboratories. Front Cardiovasc Med 2024; 11:1398290. [PMID: 39036504 PMCID: PMC11257904 DOI: 10.3389/fcvm.2024.1398290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/06/2024] [Indexed: 07/23/2024] Open
Abstract
Coronary artery disease is caused by the buildup of atherosclerotic plaque in the coronary arteries, affecting the blood supply to the heart, one of the leading causes of death around the world. X-ray coronary angiography is the most common procedure for diagnosing coronary artery disease, which uses contrast material and x-rays to observe vascular lesions. With this type of procedure, blood flow in coronary arteries is viewed in real-time, making it possible to detect stenoses precisely and control percutaneous coronary interventions and stent insertions. Angiograms of coronary arteries are used to plan the necessary revascularisation procedures based on the calculation of occlusions and the affected segments. However, their interpretation in cardiac catheterisation laboratories presently relies on sequentially evaluating multiple 2D image projections, which limits measuring lesion severity, identifying the true shape of vessels, and analysing quantitative data. In silico modelling, which involves computational simulations of patient-specific data, can revolutionise interventional cardiology by providing valuable insights and optimising treatment methods. This paper explores the challenges and future directions associated with applying patient-specific in silico models in catheterisation laboratories. We discuss the implications of the lack of patient-specific in silico models and how their absence hinders the ability to accurately predict and assess the behaviour of individual patients during interventional procedures. Then, we introduce the different components of a typical patient-specific in silico model and explore the potential future directions to bridge this gap and promote the development and utilisation of patient-specific in silico models in the catheterisation laboratories.
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Affiliation(s)
- Mojtaba Lashgari
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Robin P. Choudhury
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Abhirup Banerjee
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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2
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Heusch G, Andreadou I, Bell R, Bertero E, Botker HE, Davidson SM, Downey J, Eaton P, Ferdinandy P, Gersh BJ, Giacca M, Hausenloy DJ, Ibanez B, Krieg T, Maack C, Schulz R, Sellke F, Shah AM, Thiele H, Yellon DM, Di Lisa F. Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection. Redox Biol 2023; 67:102894. [PMID: 37839355 PMCID: PMC10590874 DOI: 10.1016/j.redox.2023.102894] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Robert Bell
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Edoardo Bertero
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Hans-Erik Botker
- Department of Cardiology, Institute for Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - James Downey
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Philip Eaton
- William Harvey Research Institute, Queen Mary University of London, Heart Centre, Charterhouse Square, London, United Kingdom
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mauro Giacca
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, United Kingdom
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom; Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, National Heart Research Institute Singapore, National Heart Centre, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), IIS-Fundación Jiménez Díaz University Hospital, and CIBERCV, Madrid, Spain
| | - Thomas Krieg
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Rainer Schulz
- Institute for Physiology, Justus-Liebig -Universität, Giessen, Germany
| | - Frank Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, London, United Kingdom
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Fabio Di Lisa
- Dipartimento di Scienze Biomediche, Università degli studi di Padova, Padova, Italy.
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Guo Y, Yang C, Wang X, Pei Z, Zhu H, Meng X, Zhou Z, Lang X, Ning S, Zhang R, Wang F. Regional Myocardial Work Measured by Echocardiography for the Detection of Myocardial Ischemic Segments: A Comparative Study With Invasive Fractional Flow Reserve. Front Cardiovasc Med 2022; 9:813710. [PMID: 35369304 PMCID: PMC8965858 DOI: 10.3389/fcvm.2022.813710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/21/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose This study is to assess the diagnostic value of noninvasive regional myocardial work (MW) by echocardiography for detecting the functional status of coronary stenosis using fractional flow reserve (FFR) as a standard criterion. Methods A total of 84 consecutive patients were included in this study, among which 92 vessels were identified with ≥50% stenosis confirmed by invasive coronary angiography. Patients were investigated by invasive FFR and transthoracic echocardiography. Regional MW indices including myocardial work index (MWI), myocardial constructive work (MCW), myocardial wasted work, and myocardial work efficiency were calculated. Results MWI and MCW were significantly impaired in the FFR ≤ 0.75 group compared with the FFR > 0.75 group (both p < 0.01). There were significant positive associations between MWI and MCW with FFR. In total group, MWI <1,623.7 mmHg% [sensitivity, 78.4%; specificity, 72.2%; area under the curve value, 0.768 (0.653-0.883)] and MCW <1,962.4 mmHg% [77.0%; 72.2%; 0.767 (0.661-0.872)], and in single-vessel subgroup, MWI <1,412.1 mmHg% [93.5%; 63.6%; 0.808 (0.652-0.965)] and MCW <1,943.3 mmHg% [(84.8%; 72.7%; 0.800 (0.657-0.943)] were optimal to detect left ventricular segments with an FFR ≤ 0.75. MWI and MCW significantly increased after percutaneous coronary intervention in 13 cases. Conclusion In patients with coronary artery disease, especially those with single-vessel stenosis, the regional MW measured by echocardiography exhibited a good diagnostic value in detecting significant myocardial ischemia compared to the standard FFR approach.
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Affiliation(s)
- Ying Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Chenguang Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Zuowei Pei
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Huolan Zhu
- Department of Gerontology, Shanxi Provincial People's Hospital, Shanxi Provincial Clinical Research Center for Geriatric Medicine, Xi'an, China
| | - Xuyang Meng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ziyu Zhou
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaotong Lang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Sun Ning
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ruisheng Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Demir OM, Rahman H, van de Hoef TP, Escaned J, Piek JJ, Plein S, Perera D. Invasive and non-invasive assessment of ischaemia in chronic coronary syndromes: translating pathophysiology to clinical practice. Eur Heart J 2021; 43:105-117. [PMID: 34516621 PMCID: PMC8757583 DOI: 10.1093/eurheartj/ehab548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/22/2021] [Accepted: 08/05/2021] [Indexed: 01/10/2023] Open
Abstract
Intracoronary physiology testing has emerged as a valuable diagnostic approach in the management of patients with chronic coronary syndrome, circumventing limitations like inferring coronary function from anatomical assessment and low spatial resolution associated with angiography or non-invasive tests. The value of hyperaemic translesional pressure ratios to estimate the functional relevance of coronary stenoses is supported by a wealth of prognostic data. The continuing drive to further simplify this approach led to the development of non-hyperaemic pressure-based indices. Recent attention has focussed on estimating physiology without even measuring coronary pressure. However, the reduction in procedural time and ease of accessibility afforded by these simplifications needs to be counterbalanced against the increasing burden of physiological assumptions, which may impact on the ability to reliably identify an ischaemic substrate, the ultimate goal during catheter laboratory assessment. In that regard, measurement of both coronary pressure and flow enables comprehensive physiological evaluation of both epicardial and microcirculatory components of the vasculature, although widespread adoption has been hampered by perceived technical complexity and, in general, an underappreciation of the role of the microvasculature. In parallel, entirely non-invasive tools have matured, with the utilization of various techniques including computational fluid dynamic and quantitative perfusion analysis. This review article appraises the strengths and limitations for each test in investigating myocardial ischaemia and discusses a comprehensive algorithm that could be used to obtain a diagnosis in all patients with angina scheduled for coronary angiography, including those who are not found to have obstructive epicardial coronary disease.
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Affiliation(s)
- Ozan M Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Tim P van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, SpainCalle del Prof Martín Lagos, Madrid 28040, Spain
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK
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5
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Levy BI, Heusch G, Camici PG. The many faces of myocardial ischaemia and angina. Cardiovasc Res 2020; 115:1460-1470. [PMID: 31228187 DOI: 10.1093/cvr/cvz160] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/25/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
Obstructive disease of the epicardial coronary arteries is the main cause of angina. However, a number of patients with anginal symptoms have normal coronaries or non-obstructive coronary artery disease (CAD) despite electrocardiographic evidence of ischaemia during stress testing. In addition to limited microvascular vasodilator capacity, the coronary microcirculation of these patients is particularly sensitive to vasoconstrictor stimuli, in a condition known as microvascular angina. This review briefly summarizes the determinants and control of coronary blood flow (CBF) and myocardial perfusion. It subsequently analyses the mechanisms responsible for transient myocardial ischaemia: obstructive CAD, coronary spasm and coronary microvascular dysfunction in the absence of epicardial coronary lesions, and variable combinations of structural anomalies, impaired endothelium-dependent and/or -independent vasodilation, and enhanced perception of pain. Lastly, we exemplify mechanism of angina during tachycardia. Distal to a coronary stenosis, coronary dilator reserve is already recruited and can be nearly exhausted at rest distal to a severe stenosis. Increased heart rate reduces the duration of diastole and thus CBF when metabolic vasodilation is no longer able to increase CBF. The increase in myocardial oxygen consumption and resulting metabolic vasodilation in adjacent myocardium without stenotic coronary arteries further acts to divert blood flow away from the post-stenotic coronary vascular bed through collaterals.
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Affiliation(s)
- Bernard I Levy
- Inserm U970 and Vessels and Blood Institute, 8 Rue Guy Patin, Paris, France
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, Universitätsklinikum Essen, Essen, Germany
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
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Kawaguchi N, Okayama H, Kawamura G, Shigematsu T, Takahashi T, Kawada Y, Hiasa G, Yamada T, Matsuoka H, Kazatani Y, Miyagawa M, Mochizuki T. Clinical Usefulness of Coronary Flow Reserve Ratio for the Detection of Significant Coronary Artery Disease on 13N-Ammonia Positron Emission Tomography. Circ J 2018; 82:486-493. [DOI: 10.1253/circj.cj-17-0745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoto Kawaguchi
- Department of Radiology, Ehime University Graduate School of Medicine
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital
| | - Go Kawamura
- Department of Cardiology, Ehime Prefectural Central Hospital
| | | | | | | | - Go Hiasa
- Department of Cardiology, Ehime Prefectural Central Hospital
| | | | | | - Yukio Kazatani
- Department of Cardiology, Ehime Prefectural Central Hospital
| | - Masao Miyagawa
- Department of Radiology, Ehime University Graduate School of Medicine
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Verna E, Provasoli S, Ghiringhelli S, Morandi F, Salerno-Uriarte J. Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndrome. Int J Cardiol 2018; 250:4-10. [DOI: 10.1016/j.ijcard.2017.07.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/31/2017] [Accepted: 07/11/2017] [Indexed: 01/26/2023]
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8
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Vijayan S, Barmby DS, Pearson IR, Davies AG, Wheatcroft SB, Sivananthan M. Assessing Coronary Blood Flow Physiology in the Cardiac Catheterisation Laboratory. Curr Cardiol Rev 2017; 13:232-243. [PMID: 28545351 PMCID: PMC5633718 DOI: 10.2174/1573403x13666170525102618] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/09/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Abstract
Background: Contemporary management of coronary disease focuses on the treatment of stenoses in the major epicardial vessels. However, myocardial blood flow is known to be contingent on a range of factors in addition to the patency of the epicardial vessels. These include anatomical and physiological factors such as the extent of myocardium supplied by the vessel, systemic blood pres-sure, the natural variation in vascular tone in response to physiological needs which allows for coro-nary autoregulation and pathological factors such as the presence of downstream obstruction to flow due to disease of the small coronary vessels or myocardium. The assessment of clinical effectiveness and adequacy of coronary revascularisation requires the ability to comprehensively and accurately as-sess and measure myocardial perfusion. Conclusion: In this article, we review the current methods of evaluating coronary blood flow and my-ocardial perfusion in the cardiac catheterisation laboratory.
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Affiliation(s)
- Sethumadhavan Vijayan
- Interventional Fellow, Department of Cardiology, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - David S Barmby
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Ian R Pearson
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Andrew G Davies
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Mohan Sivananthan
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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9
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Ivabradine in chronic stable angina: Effects by and beyond heart rate reduction. Int J Cardiol 2016; 215:1-6. [DOI: 10.1016/j.ijcard.2016.04.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 04/02/2016] [Indexed: 11/23/2022]
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10
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Sinclair MD, Lee J, Cookson AN, Rivolo S, Hyde ER, Smith NP. Measurement and modeling of coronary blood flow. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2015; 7:335-56. [PMID: 26123867 DOI: 10.1002/wsbm.1309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023]
Abstract
Ischemic heart disease that comprises both coronary artery disease and microvascular disease is the single greatest cause of death globally. In this context, enhancing our understanding of the interaction of coronary structure and function is not only fundamental for advancing basic physiology but also crucial for identifying new targets for treating these diseases. A central challenge for understanding coronary blood flow is that coronary structure and function exhibit different behaviors across a range of spatial and temporal scales. While experimental studies have sought to understand this feature by isolating specific mechanisms, in tandem, computational modeling is increasingly also providing a unique framework to integrate mechanistic behaviors across different scales. In addition, clinical methods for assessing coronary disease severity are continuously being informed and updated by findings in basic physiology. Coupling these technologies, computational modeling of the coronary circulation is emerging as a bridge between the experimental and clinical domains, providing a framework to integrate imaging and measurements from multiple sources with mathematical descriptions of governing physical laws. State-of-the-art computational modeling is being used to combine mechanistic models with data to provide new insight into coronary physiology, optimization of medical technologies, and new applications to guide clinical practice.
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Affiliation(s)
- Matthew D Sinclair
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Jack Lee
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Andrew N Cookson
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Simone Rivolo
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Eoin R Hyde
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK
| | - Nicolas P Smith
- Division of Imaging Sciences and Biomedical Engineering, British Heart Foundation (BHF) Centre of Excellence, King's College London, London, UK.,Department of Engineering, University of Auckland, Auckland, New Zealand
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11
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One-Dimensional Modelling of the Coronary Circulation. Application to Noninvasive Quantification of Fractional Flow Reserve (FFR). ACTA ACUST UNITED AC 2015. [DOI: 10.1007/978-3-319-15799-3_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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12
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13
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Hong YJ, Choi YH, Park SY, Nam CW, Cho JH, Kang WY, Lee SR, Lee SY, Kim SW, Lim SY, Yun KH, Kim JS, Kim JW, Kang WC, Kim KS, Choi JH, Chung JW, Kim SJ, Ahn Y, Jeong MH. Clinical Outcomes in Patients with Intermediate Coronary Stenoses: MINIATURE Investigators (Korea MultIceNter TrIal on Long-Term Clinical Outcome According to the Plaque Burden and Treatment Strategy in Lesions with MinimUm Lumen ARea lEss Than 4 mm(2) Using Intravascular Ultrasound). Korean Circ J 2014; 44:148-55. [PMID: 24876855 PMCID: PMC4037636 DOI: 10.4070/kcj.2014.44.3.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 02/04/2014] [Accepted: 02/21/2014] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives We evaluated the two-year clinical outcomes in patients with angiographically intermediate lesions according to the plaque burden and treatment strategy. Subjects and Methods We prospectively enrolled patients with angiographically intermediate lesions (diameter stenosis 30-70%) with an intravascular ultrasound (IVUS) minimum lumen area (MLA) <4 mm2 with 50-70% plaque burden of 16 Korean percutaneous coronary intervention centers. Patients were divided into medical therapy group (n=85) and zotarolimus-eluting stent group (ZES; Resolute) group (n=74). We evaluated the incidences of two-year major adverse cardiovascular events (MACE). Results A two-year clinical follow-up was completed in 143 patients and MACE occurred in 12 patients. There were no significant differences in the incidences of death (1.3% vs. 3.0%, p=0.471), target vessel-related non-fatal myocardial infarction (0.0% vs. 0.0%, p=1.000) and target vessel revascularizations (7.8% vs. 4.5%, p=0.425) between medical and ZES groups. Independent predictors of two-year MACE included acute myocardial infarction {odds ratio (OR)=2.87; 95% confidence interval (CI) 1.43-6.12, p=0.014}, diabetes mellitus (OR=2.46; 95% CI 1.24-5.56, p=0.028) and non-statin therapy (OR=2.32; 95% CI 1.18-5.24, p=0.034). Conclusion Medical therapy shows comparable results with ZES, and myocardial infarction, diabetes mellitus and non-statin therapy were associated with the occurrence of two-year MACE in patients with intermediate lesion with IVUS MLA <4 mm2 with 50-70% of plaque burden.
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Affiliation(s)
- Young Joon Hong
- Division of Cardiology, Chonnam National University School of Medicine, Gwangju, Korea
| | - Yun Ha Choi
- Division of Cardiology, Chonnam National University School of Medicine, Gwangju, Korea
| | - Soo Young Park
- Division of Cardiology, Chonnam National University School of Medicine, Gwangju, Korea
| | - Chang Wook Nam
- Division of Cardiology, Keimyung University College of Medicine, Dongsan Medical Center, Daegu, Korea
| | - Jang Hyun Cho
- Division of Cardiology, Saint Carollo Hospital, Suncheon, Korea
| | - Won Yu Kang
- Division of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Sang Rok Lee
- Division of Cardiology, Chonbuk National University College of Medicine, Jeonju, Korea
| | - Sung Yun Lee
- Division of Cardiology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sang Wook Kim
- Division of Cardiology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sang Yeob Lim
- Division of Cardiology, Korea University College of Medicine, Ansan Hospital, Ansan, Korea
| | - Kyung Ho Yun
- Division of Cardiology, Wonkwang University College of Medicine, Iksan, Korea
| | - Jung Sun Kim
- Division of Cardiology, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Jin Won Kim
- Division of Cardiology, Korea University Guro Hospital, Seoul, Korea
| | - Woong Chol Kang
- Division of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Ki Seok Kim
- Division of Cardiology, Jeju National University College of Medicine, Jeju, Korea
| | - Jin Ho Choi
- Division of Cardiology, Samsung Medical Center, Seoul, Korea
| | - Joong Wha Chung
- Division of Cardiology, Chosun University College of Medicine, Gwangju, Korea
| | - Soo Joong Kim
- Division of Cardiology, KyungHee University Medical Center, Seoul, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Chonnam National University School of Medicine, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Chonnam National University School of Medicine, Gwangju, Korea
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14
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Abstract
Coronary blood flow is tightly autoregulated but is subject to epicardial and microvascular obstruction, primarily owing to coronary atherosclerosis. Because coronary flow limitation underlies ischemic heart disease, an understanding of coronary physiology is paramount. Measurement of coronary blood flow, once relegated to the research laboratory is now easily performed in the cardiac catheterization laboratory. In particular, the measurement of fractional flow reserve has been extensively studied and is an important adjunct to clinical decision making. Measurement of coronary flow informs clinicians of prognosis, guides revascularization therapy, and forms the basis of ongoing research in treatment of complex myocardial disease processes. Newer methods of assessing coronary flow measurements are undergoing validation for clinical use and should further enhance our ability to assess the importance of coronary flow in clinical disease.
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Kapoor N, Yalamanchili V, Siddiqui T, Raza S, Leesar MA. Cardioprotective effect of high-dose intragraft adenosine infusion on microvascular function and prevention of no-reflow during saphenous vein grafts intervention. Catheter Cardiovasc Interv 2014; 83:1045-54. [PMID: 24307656 DOI: 10.1002/ccd.25248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/07/2013] [Accepted: 10/10/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND Despite the use of embolic protection devices, no-reflow can still occur during saphenous vein grafts (SVGs) intervention. High-dose intracoronary adenosine infusion preconditions the myocardium, improves coronary flow, and prevents no-reflow. The role of high-dose intragraft adenosine infusion on protection of microvascular function and prevention of no-reflow has not been investigated OBJECTIVES We investigated the cardioprotective effect of high-dose intragraft adenosine infusion, compared with placebo, on microvascular function and prevention of no-reflow during SVGs intervention. METHODS We randomized 22 patients with SVGs stenoses to receive either a 10-min intragraft adenosine infusion (200 μg/min; total dose = 2,000 μg) or normal saline prior to stenting. Average peak velocity (APV), coronary flow velocity reserve (CVR), thrombolysis in myocardial infarction (TIMI) frame count (TFC), TIMI myocardial perfusion grade (TMPG), and the rate of no-reflow were compared between the two groups before adenosine or saline infusions and after stenting RESULTS After stenting, hyperemic APV, CVR, and TMPG were significantly higher in the adenosine-treated group than in the control group (60 ± 18 vs. 35 ± 10 cm/sec; 2.6 ± 0.54 vs. 1.8 ± 0.47; and 2.8 ± 0.90 vs. 2.1 ± 0.80, respectively; P < 0.05. TFC was significantly lower in the adenosine-treated group than in the control group (14 ± 3.0 vs. 26 ± 13; P < 0.05). In the control group, four patients (36%) developed no-reflow compared to none in the adenosine-treated patient; P < 0.05 CONCLUSIONS: This study provides the first evidence that high-dose intragraft adenosine infusion compared with placebo protects microvascular function and prevents no-reflow during SVGs intervention.
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Affiliation(s)
- Nikhil Kapoor
- Division of Cardiology, University of Louisville, Louisville, Kentucky
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Meuwissen M, Siebes M, Chamuleau SAJ, Tijssen JGP, Spaan JAE, Piek JJ. Intracoronary pressure and flow velocity for hemodynamic evaluation of coronary stenoses. Expert Rev Cardiovasc Ther 2014; 1:471-9. [PMID: 15030274 DOI: 10.1586/14779072.1.3.471] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adequate patient selection for percutaneous coronary intervention is of utmost importance to minimize early and late complications. Consequently, objective evidence for myocardial ischemia is mandatory for the management of patients with coronary artery disease, in particular in multivessel disease and intermediate lesions (40-70% diameter stenosis on angiography). The use of sensor-equipped guide wires for the assessment of functional coronary lesion severity has become widespread in the catheterization laboratory. The indices derived from pressure or flow measurements, fractional flow reserve, coronary flow velocity reserve and relative coronary flow velocity reserve show a high agreement with noninvasive stress testing. However, while these indices are based on either intracoronary pressure or flow, they do not investigate the hemodynamics of the coronary circulation entirely, leading to ambiguous outcomes. Only the use of simultaneously measured pressure and flow will avoid any possible misinterpretation of the data.
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Affiliation(s)
- Martijn Meuwissen
- Department of Cardiology, Room B2-250, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Koudstaal S, Jansen Of Lorkeers SJ, van Slochteren FJ, van der Spoel TIG, van de Hoef TP, Sluijter JP, Siebes M, Doevendans PA, Piek JJ, Chamuleau SAJ. Assessment of coronary microvascular resistance in the chronic infarcted pig heart. J Cell Mol Med 2013; 17:1128-35. [PMID: 23910946 PMCID: PMC4118172 DOI: 10.1111/jcmm.12089] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 05/20/2013] [Indexed: 12/24/2022] Open
Abstract
Pre-clinical studies aimed at treating ischemic heart disease (i.e. stem cell- and growth factor therapy) often consider restoration of the impaired microvascular circulation as an important treatment goal. However, serial in vivo measurement hereof is often lacking. The purpose of this study was to evaluate the applicability of intracoronary pressure and flow velocity as a measure of microvascular resistance in a large animal model of chronic myocardial infarction (MI). Myocardial infarction was induced in Dalland Landrace pigs (n = 13; 68.9 ± 4.1 kg) by a 75-min. balloon occlusion of the left circumflex artery (LCX). Intracoronary pressure and flow velocity parameters were measured simultaneously at rest and during adenosine-induced hyperemia, using the Combowire (Volcano) before and 4 weeks after MI. Various pressure- and/or flow-derived indices were evaluated. Hyperemic microvascular resistance (HMR) was significantly increased by 28% in the infarct-related artery, based on a significantly decreased peak average peak flow velocity (pAPV) by 20% at 4 weeks post-MI (P = 0.03). Capillary density in the infarct zone was decreased compared to the remote area (658 ± 207/mm2versus 1650 ± 304/mm2, P = 0.017). In addition, arterioles in the infarct zone showed excessive thickening of the alpha smooth muscle actin (αSMA) positive cell layer compared to the remote area (33.55 ± 4.25 μm versus 14.64 ± 1.39 μm, P = 0.002). Intracoronary measurement of HMR successfully detected increased microvascular resistance that might be caused by the loss of capillaries and arteriolar remodelling in the chronic infarcted pig heart. Thus, HMR may serve as a novel outcome measure in pre-clinical studies for serial assessment of microvascular circulation.
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Affiliation(s)
- Stefan Koudstaal
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands; Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, The Netherlands
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Takarada S, Zhang Z, Molloi S. An angiographic technique for coronary fractional flow reserve measurement: in vivo validation. Int J Cardiovasc Imaging 2012; 29:535-44. [PMID: 22936416 DOI: 10.1007/s10554-012-0119-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 08/16/2012] [Indexed: 11/25/2022]
Abstract
Fractional flow reserve (FFR) is an important prognostic determinant in a clinical setting. However, its measurement currently requires the use of invasive pressure wire, while an angiographic technique based on first-pass distribution analysis and scaling laws can be used to measure FFR using only image data. Eight anesthetized swine were instrumented with flow probe on the proximal segment of the left anterior descending (LAD) coronary arteries. Volumetric blood flow from the flow probe (Qp), coronary pressure (Pa) and right atrium pressure (Pv) were continuously recorded. Flow probe-based FFR (FFRq) was measured from the ratio of flow with and without stenosis. To determine the angiography-based FFR (FFRa), the ratio of blood flow in the presence of a stenosis (QS) to theoretically normal blood flow (QN) was calculated. A region of interest in the LAD arterial bed was drawn to generate time-density curves using angiographic images. QS was measured using a time-density curve and the assumption that blood was momentarily replaced with contrast agent during the injection. QN was estimated from the total coronary arterial volume using scaling laws. Pressure-wire measurements of FFR (FFRp), which was calculated from the ratio of distal coronary pressure (Pd) divided by proximal pressure (Pa), were continuously obtained during the study. A total of 54 measurements of FFRa, FFRp, and FFRq were taken. FFRa showed a good correlation with FFRq (FFRa = 0.97 FFRq +0.06, r(2) = 0.80, p < 0.001), although FFRp overestimated the FFRq (FFRp = 0.657 FFRq + 0.313, r(2) = 0.710, p < 0.0001). Additionally, the Bland-Altman analysis showed a close agreement between FFRa and FFRq. This angiographic technique to measure FFR can potentially be used to evaluate both anatomical and physiological assessments of a coronary stenosis during routine diagnostic cardiac catheterization that requires no pressure wires.
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Affiliation(s)
- Shigeho Takarada
- Department of Radiological Sciences, Medical Sciences, B-140, University of California, Irvine, CA 92697, USA
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Ruscazio M, Montisci R, Bezante G, Caiati C, Balbi M, Tona F, Lai G, Cadeddu M, Pirisi R, Brunelli C, Iliceto S, Meloni L. Early Noninvasive Evaluation of Coronary Flow Reserve after Angioplasty in the Left Anterior Descending Coronary Artery Identifies Patients at High Risk of Restenosis at Follow-Up. J Am Soc Echocardiogr 2012; 25:902-10. [DOI: 10.1016/j.echo.2012.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Indexed: 11/25/2022]
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Zhang Z, Takarada S, Molloi S. Quantification of absolute coronary flow reserve and relative fractional flow reserve in a swine animal model using angiographic image data. Am J Physiol Heart Circ Physiol 2012; 303:H401-10. [PMID: 22661513 DOI: 10.1152/ajpheart.00153.2012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Coronary flow reserve (CFR) and fractional flow reserve (FFR) are important physiological indexes for coronary disease. The purpose of this study was to validate the CFR and FFR measurement techniques using only angiographic image data. Fifteen swine were instrumented with an ultrasound flow probe on the left anterior descending artery (LAD). Microspheres were gradually injected into the LAD to create microvascular disruption. An occluder was used to produce stenosis. Contrast material injections were made into the left coronary artery during image acquisition. Volumetric blood flow from the flow probe (Q(q)) was continuously recorded. Angiography-based blood flow (Q(a)) was calculated by using a time-density curve based on the first-pass analysis technique. Flow probe-based CFR (CFR(q)) and angiography-based CFR (CFR(a)) were calculated as the ratio of hyperemic to baseline flow using Q(q) and Q(a), respectively. Relative angiographic FFR (relative FFR(a)) was calculated as the ratio of the normalized Q(a) in LAD to the left circumflex artery (LC(X)) during hyperemia. Flow probe-based FFR (FFR(q)) was measured from the ratio of hyperemic flow with and without disease. CFR(a) showed a strong correlation with the gold standard CFR(q) (CFR(a) = 0.91 CFR(q) + 0.30; r = 0.90; P < 0.0001). Relative FFR(a) correlated linearly with FFR(q) (relative FFR(a) = 0.86 FFR(q) + 0.05; r = 0.90; P < 0.0001). The quantification of CFR and relative FFR(a) using angiographic image data was validated in a swine model. This angiographic technique can potentially be used for coronary physiological assessment during routine cardiac catheterization.
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Affiliation(s)
- Zhang Zhang
- Department of Radiological Sciences, University of California, Irvine, USA
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Is discordance of coronary flow reserve and fractional flow reserve due to methodology or clinically relevant coronary pathophysiology? JACC Cardiovasc Imaging 2012; 5:193-202. [PMID: 22340827 DOI: 10.1016/j.jcmg.2011.09.020] [Citation(s) in RCA: 236] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether observed discordance between coronary flow reserve (CFR) and fractional flow reserve (FFR) is due to methodology or reflects basic coronary pathophysiology. BACKGROUND Despite the clinical importance of coronary physiological assessment, relationships between its 2 most common tools, CFR and FFR, remain poorly defined. METHODS The worst CFR and stress relative uptake were recorded from 1,500 sequential cardiac positron emission tomography cases from our center. From the literature, we assembled all combined, invasive CFR-FFR measurements, including a subset before and after angioplasty. Both datasets were compared with a fluid dynamic model of the coronary circulation predicting relationships between CFR and FFR for variable diffuse and focal narrowing. RESULTS A modest but significant linear relationship exists between CFR and FFR both invasively (r = 0.34, p < 0.001) and using positron emission tomography (r = 0.36, p < 0.001). Most clinical patients undergoing CFR or FFR measurements have diffusely reduced CFR consistent with diffuse atherosclerosis or small-vessel disease. The theoretical model predicts linear relationships between CFR and FFR for progressive stenosis with slopes dependent on diffuse narrowing, matching observed data. Reported changes in CFR and FFR with angioplasty agree with model predictions of removing focal stenosis but leaving diffuse disease. Although CFR-FFR concordance is common, discordance is due to dominant or absent diffuse versus focal disease, reflecting basic pathophysiology. CONCLUSIONS CFR is linearly related to FFR for progressive stenosis superimposed on diffuse narrowing. The relative contributions of focal and diffuse disease define the slope and values along the linear CFR and FFR relationship. Discordant CFR and FFR values reflect divergent extremes of focal and diffuse disease, not failure of either tool. With such discordance observed by invasive and noninvasive techniques and also fitting fluid dynamic predictions, it reflects clinically relevant basic coronary pathophysiology, not methodology.
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van de Hoef TP, Nolte F, Rolandi MC, Piek JJ, van den Wijngaard JPHM, Spaan JAE, Siebes M. Coronary pressure-flow relations as basis for the understanding of coronary physiology. J Mol Cell Cardiol 2011; 52:786-93. [PMID: 21840314 DOI: 10.1016/j.yjmcc.2011.07.025] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 07/27/2011] [Accepted: 07/28/2011] [Indexed: 12/21/2022]
Abstract
Recent technological advancements in the area of intracoronary physiology, as well as non-invasive contrast perfusion imaging, allow to make clinical decisions with respect to percutaneous coronary interventions and to identify microcirculatory coronary pathophysiology. The basic characteristics of coronary hemodynamics, as described by pressure-flow relations in the normal and diseased heart, need to be understood for a proper interpretation of these physiological measurements. Especially the hyperemic coronary pressure-flow relation, as well as the influence of cardiac function on it, bears great clinical significance. The interaction of a coronary stenosis with the coronary pressure-flow relation can be understood from the stenosis pressure drop-flow velocity relationship. Based on these relationships the clinically applied concepts of coronary flow velocity reserve, fractional flow reserve, stenosis resistance and microvascular resistance are discussed. Attention is further paid to the heterogeneous nature of myocardial perfusion, the vulnerability of the subendocardium and the role of collateral flow on hyperemic coronary pressure-flow relations. This article is part of a Special Issue entitled "Coronary Blood Flow".
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Affiliation(s)
- Tim P van de Hoef
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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23
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Wall shear over high degree stenoses pertinent to atherothrombosis. J Biomech 2010; 43:2970-7. [DOI: 10.1016/j.jbiomech.2010.07.011] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Revised: 06/17/2010] [Accepted: 07/14/2010] [Indexed: 11/17/2022]
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Heusch G. Adenosine and maximum coronary vasodilation in humans: myth and misconceptions in the assessment of coronary reserve. Basic Res Cardiol 2010; 105:1-5. [PMID: 19941145 DOI: 10.1007/s00395-009-0074-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Saad M, Toelg R, Khattab A, Kassner G, Abdel-Wahab M, Richardt G. Determination of haemodynamic significance of intermediate coronary lesions using three-dimensional coronary reconstruction. EUROINTERVENTION 2009; 5:573-9. [DOI: 10.4244/eijv5i5a93] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Shedden L, Oldroyd K, Connolly P. Current issues in coronary stent technology. Proc Inst Mech Eng H 2009; 223:515-24. [PMID: 19623905 DOI: 10.1243/09544119jeim541] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Coronary artery stents have become the medical device of choice for the treatment of coronary artery disease. Since their introduction in 1987, significant advances in stent technology have taken place. A major objective of these developments was the reduction of in-stent restenosis, the formation of neointimal tissue inside the stent triggered by vessel injury and the inflammatory response, which results in renarrowing of the coronary artery. Improvements in strut configuration, thickness, and materials have enhanced deliverability and reduced vessel damage. Currently available drug-eluting stents release drugs that reduce neointimal formation through the arrest of cell proliferation. Drug-eluting stents have significantly reduced rates of in-stent restenosis. However, concerns have been raised with respect to their long-term safety, particularly in relation to the occurrence of late thrombosis. The post-procedural monitoring of stent-related complications is also of interest, including the relative suitability of invasive techniques such as angiography and intravascular ultrasound, and non-invasive techniques such as computed tomography and magnetic resonance imaging scanning. This paper reviews the current issues in stent technology.
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Affiliation(s)
- L Shedden
- Department of Bioengineering, University of Strathclyde, Glasgow, UK
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Magni V, Chieffo A, Colombo A. Evaluation of intermediate coronary stenosis with intravascular ultrasound and fractional flow reserve: Its use and abuse. Catheter Cardiovasc Interv 2009; 73:441-8. [PMID: 19133668 DOI: 10.1002/ccd.21812] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Clinical decision making in patients with intermediate coronary stenosis is still debated. Intravascular ultrasound (IVUS) examination and/or functional assessment of coronary stenosis by fractional flow reserve (FFR) are currently used to define the severity of such lesions. There are very few studies with a small sample size that have a head-to-head comparison between IVUS and FFR in the evaluation of angiographically de novo intermediate lesions. There are no randomized, controlled trials to demonstrate the superiority of IVUS versus FFR in providing improved clinical outcomes in comparison with angiography alone. However, the issue of superiority might be irrelevant, because IVUS and FFR could be complementary techniques to be used in the catheterization laboratory to provide critical anatomic and functional data that permit more accurate decisions in the management of the patient.
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Barmeyer AA, Stork A, Muellerleile K, Schofer AK, Tiburtius C, Koester R, Heitzer T, Adam G, Meinertz T, Lund GK. Comparison of quantitative coronary angiography and first-pass perfusion magnetic resonance imaging for the detection of an impaired coronary perfusion in nonsevere coronary stenosis. J Magn Reson Imaging 2008; 27:1005-11. [PMID: 18425839 DOI: 10.1002/jmri.21341] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To compare quantitative coronary angiography (QCA) and first-pass perfusion magnetic resonance imaging (FPP-MRI) in symptomatic patients with nonsevere coronary stenosis to detect a reduced coronary flow velocity reserve (CFVR). MATERIALS AND METHODS In 35 patients, FPP-MRI and CFVR measurements were performed in 40 coronary arteries with a diameter stenosis (DS) <70% by QCA. From FPP-MRI a myocardial perfusion reserve index (MPRI) was calculated. CFVR was calculated as the ratio of the average peak flow velocity during infusion of adenosine and at rest and was considered reduced if <2. Diagnostic performance of MPRI and DS to detect a reduced CFVR was compared by receiver operating characteristic (ROC) curve analysis. RESULTS CFVR was reduced in 16 coronary arteries (40%). Mean DS did not differ in coronary arteries with a reduced CFVR (41.0% +/- 13.3) and a normal CFVR (36.5% +/- 12.3; P = 0.281). Mean MPRI was lower in coronary arteries with a reduced CFVR (1.12 +/- 0.12) compared to a normal CFVR (1.33 +/- 0.2; P < 0.001). Sensitivity, specificity, and area under the ROC curve (AUC) were higher for MPRI (81%, 79%, 0.84) than for DS (56%, 58%, 0.60). CONCLUSION FPP-MRI detects impaired CFVR in symptomatic patients with nonsevere coronary stenosis more accurately than QCA and can identify patients with symptomatic ischemia.
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Affiliation(s)
- Achim A Barmeyer
- Department of Cardiology/Angiology, Center for Cardiology and Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Sun N, Wood NB, Hughes AD, Thom SAM, Yun Xu X. Effects of transmural pressure and wall shear stress on LDL accumulation in the arterial wall: a numerical study using a multilayered model. Am J Physiol Heart Circ Physiol 2007; 292:H3148-57. [PMID: 17277019 DOI: 10.1152/ajpheart.01281.2006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The accumulation of low-density lipoprotein (LDL) is recognized as one of the main contributors in atherogenesis. Mathematical models have been constructed to simulate mass transport in large arteries and the consequent lipid accumulation in the arterial wall. The objective of this study was to investigate the influences of wall shear stress and transmural pressure on LDL accumulation in the arterial wall by a multilayered, coupled lumen-wall model. The model employs the Navier-Stokes equations and Darcy's Law for fluid dynamics, convection-diffusion-reaction equations for mass balance, and Kedem-Katchalsky equations for interfacial coupling. To determine physiologically realistic model parameters, an optimization approach that searches optimal parameters based on experimental data was developed. Two sets of model parameters corresponding to different transmural pressures were found by the optimization approach using experimental data in the literature. Furthermore, a shear-dependent hydraulic conductivity relation reported previously was adopted. The integrated multilayered model was applied to an axisymmetric stenosis simulating an idealized, mildly stenosed coronary artery. The results show that low wall shear stress leads to focal LDL accumulation by weakening the convective clearance effect of transmural flow, whereas high transmural pressure, associated with hypertension, leads to global elevation of LDL concentration in the arterial wall by facilitating the passage of LDL through wall layers.
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Affiliation(s)
- Nanfeng Sun
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK.
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Christou MAC, Siontis GCM, Katritsis DG, Ioannidis JPA. Meta-analysis of fractional flow reserve versus quantitative coronary angiography and noninvasive imaging for evaluation of myocardial ischemia. Am J Cardiol 2007; 99:450-6. [PMID: 17293182 DOI: 10.1016/j.amjcard.2006.09.092] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Revised: 09/07/2006] [Accepted: 09/07/2006] [Indexed: 12/13/2022]
Abstract
We performed a meta-analysis of 31 studies comparing the results of fractional flow reserve (FFR) against quantitative coronary angiography (QCA) and/or noninvasive imaging of the same lesions. Studies were retrieved from PubMed (last search February 2006). Across 18 studies (1,522 lesions), QCA had a random effects sensitivity of 78% (95% confidence interval [CI] 67 to 86) and specificity of 51% (95% CI 40 to 61) against FFR (0.75 cutoff). Overall concordances were 61% for lesions with diameter stenosis 30% to 70%, 67% for stenoses >70%, and 95% for stenoses <30%. Compared with noninvasive imaging (21 studies, 1,249 lesions), FFR had a sensitivity of 76% (95% CI 69 to 82) and specificity of 76% (95% CI 71 to 81) by random effects. Summary receiver-operator characteristic estimates were similar. Most data addressed comparisons with perfusion scintigraphy (976 lesions, sensitivity 75%, specificity 77%), and some data were also available for dobutamine stress echocardiography (273 lesions, sensitivity 82%, specificity 74%). In conclusion, QCA does not predict the functional significance of coronary lesions. FFR shows modest concordance with noninvasive imaging tests. The prognostic implications of discordant FFR and imaging results need further study.
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Affiliation(s)
- Maria A C Christou
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Banerjee RK, Sinha Roy A, Back LH, Back MR, Khoury SF, Millard RW. Characterizing momentum change and viscous loss of a hemodynamic endpoint in assessment of coronary lesions. J Biomech 2006; 40:652-62. [PMID: 16530204 DOI: 10.1016/j.jbiomech.2006.01.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 01/21/2006] [Indexed: 12/19/2022]
Abstract
Myocardial fractional flow reserve (FFR(myo)) and coronary flow reserve (CFR), measured with guidewire, and quantitative angiography (QA) are widely used in combination to distinguish ischemic from non-ischemic coronary stenoses. Recent studies have shown that simultaneous measurements of FFR(myo) and CFR are recommended to dissociate conduit epicardial coronary stenoses from distal resistance microvascular disease. In this study, a more comprehensive diagnostic parameter, named as lesion flow coefficient, c, is proposed. The coefficient, c, which accounts for mean pressure drop, Delta p, mean coronary flow, Q, and percentage area stenosis, can be used to assess the hemodynamic severity of a coronary artery stenoses. Importantly, the contribution of viscous loss and loss due to momentum change for several lesion sizes can be distinguished using c. FFR(myo), CFR and c were calculated for pre-angioplasty, intermediate and post-angioplasty epicardial lesions, without microvascular disease. While hyperemic c decreased from 0.65 for pre-angioplasty to 0.48 for post-angioplasty lesion with guidewire of size 0.35 mm, FFR(myo) increased from 0.52 to 0.87, and CFR increased from 1.72 to 3.45, respectively. Thus, reduced loss produced by momentum change due to lower percentage area stenosis decreased c. For post-angioplasty lesion, c decreased from 0.55 to 0.48 with the insertion of guidewire. Hence, increased viscous loss due to the presence of guidewire decreased c compared with a lesion without guidewire. Further, c showed a linear relationship with FFR(myo), CFR and percentage area stenosis for pre-angioplasty, intermediate and post-angioplasty lesion. These baseline values of c were developed from fluid dynamics fundamentals for focal lesions, and provided a single hemodynamic endpoint to evaluate coronary stenosis severity.
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Affiliation(s)
- Rupak K Banerjee
- Department of Mechanical Engineering, University of Cincinnati, Cincinnati, OH, USA.
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Jensen LO, Thayssen P, Pedersen KE, Haghfelt T. Effect of simvastatin on coronary flow reserve in patients with atherosclerosis and hypercholesterolemia: an intracoronary Doppler study. Coron Artery Dis 2006; 17:51-6. [PMID: 16374142 DOI: 10.1097/00019501-200602000-00009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early stages of coronary atherosclerosis are accompanied by a functional impairment of coronary vasodilator capacity and endothelial dysfunction. Reduced coronary flow reserve has been reported in patients with hypercholesterolemia, despite angiographically normal coronary arteries. The aim of the study was to evaluate the effect of simvastatin on coronary flow reserve. METHODS The study was an open non-placebo-controlled serial investigation in which every patient acted as his own control: 36 male patients with hypercholesterolemia and a non-significant coronary artery lesion in a not previously revascularized coronary artery. Intracoronary Doppler measurements were performed. Coronary flow reserve, relative coronary flow reserve and average peak velocity were performed at baseline, after 3 months on a lipid-lowering diet (control period), and after another 12 months of simvastatin 40 mg/day. In the same patient cohort, significant reduction in lesion plaque plus media has been demonstrated by intravascular ultrasound. RESULTS Changes in coronary flow reserve were not influenced by either diet or simvastatin (2.5+/-0.6 vs. 2.6+/-0.5 vs. 2.6+/-0.6, P=ns). Maximum hyperemic flow (34.8+/-12.2 vs. 36.7+/-12.5 vs. 42.5+/-13.1, P<0.001) as well as resting flow (14.3+/-5.3 vs. 14.5+/-4.4 vs. 16.6+/-4.6, P<0.001) increased significantly after 12 months simvastatin therapy. CONCLUSION Despite plaque plus media, regression simvastatin therapy for 12 months does not affect coronary flow reserve obtained using serial intracoronary Doppler studies. Simvastatin, however, increases the hyperemic flow velocity.
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Affiliation(s)
- Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Van Herck PL, Vrints CJ, Carlier SG. Coronary Circulation and Interventional Cardiology. Ann Biomed Eng 2005; 33:1735-42. [PMID: 16389522 DOI: 10.1007/s10439-005-8778-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2005] [Accepted: 06/03/2005] [Indexed: 10/25/2022]
Abstract
Cardiovascular disease has long been the leading cause of death in developed countries and it is rapidly becoming the number one killer in developing countries. Sudden heart attacks remain the primary cause of death in the United States: over 1.4 million attacks are suffered every year, more than half of which prove fatal. Interventional Cardiology is aimed to alleviate symptoms of cardiac pains and poor coronary circulation, and reduce the risk of death and nonfatal myocardial infarction. Our understanding of the coronary circulation has improved several folds due to the introduction of advance technologies. Yet, the microcirculatory flow needs future investigation.
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Affiliation(s)
- P L Van Herck
- Department of Cardiology, Antwerp University, Belgium
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Sinha Roy A, Banerjee RK, Back LH, Back MR, Khoury S, Millard RW. Delineating the guide-wire flow obstruction effect in assessment of fractional flow reserve and coronary flow reserve measurements. Am J Physiol Heart Circ Physiol 2005; 289:H392-7. [PMID: 15734887 DOI: 10.1152/ajpheart.00798.2004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemodynamic analysis was conducted to determine uncertainty in clinical measurements of coronary flow reserve (CFR) and fractional flow reserve (FFR) over pathophysiological conditions in a patient group with coronary artery disease during angioplasty. The vasodilation-distal perfusion pressure (CFR-p(rh)) curve was obtained for 0.35- and 0.46-mm guide wires. Our hypothesis is that a guide wire spanning the lesions elevates the pressure gradient and reduces the flow during hyperemic measurements. Maximal CFR-p(rh) was uniquely determined by the intersection of measured CFR and calculated p(rh) of native and residual epicardial lesions in patients without microvascular disease, during angioplasty. Extrapolation of the linear curve gave a zero-coronary flow mean pressure (p(zf)) of approximately 20 mmHg and a corresponding p(rh) of 55 mmHg in the native lesions, which coincided with the level that causes ischemia in human hearts. On this linear curve, values of CFR and FFRmyo (pathophysiological condition) and CFRg and FFRmyog (in the presence of the guide wire) were obtained in native and residual lesions. A strong linear correlation was found between CFR and CFRg [CFR = CFRg x 0.689 + 1.271 (R2= 0.99) for 0.46 mm and CFR = CFRg x 0.757 + 1.004 (R2= 0.99) for 0.35 mm] and between FFRmyo and FFRmyog [FFRmyo = FFRmyog x 0.737 + 0.263 (R2= 0.99) for 0.46 mm and FFRmyo = FFRmyog x 0.790 + 0.210 (R2= 0.99) for 0.35 mm]. This study establishes a strong correlation between CFR and CFRg and between FFRmyo and FFRmyog, which could be used to obtain the true state of occlusion in the coronary artery during angioplasty.
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Affiliation(s)
- Abhijit Sinha Roy
- Dept. of Mechanical Engineering, 688 Rhodes Hall, PO Box 210072, Cincinnati, OH 45221-0072, USA
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36
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Dagres N, Saller B, Haude M, Hüsing J, von Birgelen C, Schmermund A, Sack S, Baumgart D, Mann K, Erbel R. Insulin sensitivity and coronary vasoreactivity: insulin sensitivity relates to adenosine-stimulated coronary flow response in human subjects. Clin Endocrinol (Oxf) 2004; 61:724-31. [PMID: 15579187 DOI: 10.1111/j.1365-2265.2004.02156.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Diabetes is associated with coronary microvasculature abnormalities and impaired coronary flow reserve (CFR). CFR is the ratio of coronary flow under maximal vasodilation to basal flow and is a measure for coronary vasoreactivity. Insulin resistance is the central defect in the development of type 2 diabetes, preceding its onset by 10-20 years. Thus, the relationship between insulin sensitivity and CFR in nondiabetic subjects is particularly interesting. The aim of the study was to investigate this relationship. DESIGN Cross-sectional study. PATIENTS The study population consisted of 18 nondiabetic subjects without coronary artery stenosis on coronary angiography. We excluded patients with structural heart disease or with conditions affecting CFR or insulin sensitivity such as low density lipoprotein (LDL)-cholesterol > or = 4.14 mmol/l, smoking, hypertension or obesity with a body mass index (BMI) > 28 kg/m(2). MEASUREMENTS AND RESULTS CFR was 3.1 +/- 0.8 (range 1.7-4.8), as assessed by intracoronary Doppler measurements in the left anterior descending coronary arteries after adenosine stimulation. Intravascular ultrasound revealed zero to moderate coronary atherosclerotic changes. Whole-body insulin sensitivity (M-value) was 7.5 +/- 2.9 mg/kg/min (range 2.2-12.6), as assessed by the hyperinsulinaemic-euglycaemic clamp test. Subjects with low CFR (< 3.0) had a significantly lower M-value than subjects with normal CFR (> 3.0) (6.0 +/- 2.5 vs. 9.0 +/- 2.5 mg/kg/min, P = 0.021). Univariate linear regression demonstrated a strong correlation between CFR and M-value (r = 0.76, P < 0.001). In multiple regression analysis, the significant association of CFR with M-value was independent of potential confounders (sex, age, BMI, LDL-cholesterol and plaque burden on intravascular ultrasound). Bootstrap analysis corroborated this finding. CONCLUSIONS Whole-body insulin sensitivity relates to coronary vasoreactivity. Across a wide range of both insulin sensitivity and coronary flow reserve from markedly abnormal to normal values, an increase in insulin sensitivity appears to be associated with an increase in coronary flow reserve. Insulin resistance is therefore associated with coronary microvasculature abnormalities in nondiabetics.
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Affiliation(s)
- N Dagres
- Cardiology Clinic, University of Essen, Essen, Germany.
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Wieneke H, von Birgelen C, Haude M, Eggebrecht H, Möhlenkamp S, Schmermund A, Böse D, Altmann C, Bartel T, Erbel R. Determinants of coronary blood flow in humans: quantification by intracoronary Doppler and ultrasound. J Appl Physiol (1985) 2004; 98:1076-82. [PMID: 15516363 DOI: 10.1152/japplphysiol.00724.2004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The direct determinants of coronary flow are lumen area and blood flow velocity; however, the precise mechanisms that control these factors are not fully understood. The aim of the present study was to assess by which mechanisms lumen area and coronary flow velocity interact with hemodynamic and morphometric factors, thereby influencing coronary flow. Intracoronary Doppler and ultrasound measurements were performed in 28 patients without coronary lumen irregularities. Flow velocity and lumen cross-sectional area were measured in the proximal segments of all three coronary arteries. Global lumen cross-sectional area and global flow were obtained by adding up the values of all three coronary arteries. Left ventricular mass was assessed by echocardiography. Stress-mass-heart rate and pressure-rate products reflecting myocardial oxygen demand were calculated. Global coronary flow increased during adenosine-induced hyperemia from 197 +/- 72 to 637 +/- 204 ml/min (P < 0.001). Global coronary flow closely correlated with the stress-mass-heart rate product (r = 0.62; P < 0.001). Looking at the two constituents of flow separately, global coronary cross-sectional area was closely related to left ventricular muscle mass (r = 0.61; P < 0.001), whereas mean coronary flow velocity at rest showed a strong linear relation with the pressure-rate product (r = 0.64; P < 0.001). There was no interaction between cross-sectional area and blood flow velocity in any of the coronary vessels. Coronary lumen size and flow velocity, the two determinants of coronary flow, are principally determined by different physiological factors. Long-term flow adaptation is achieved by an increase in coronary lumen size, whereas short-term myocardial oxygen requirements are met by changes in resting flow velocity.
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Affiliation(s)
- Heinrich Wieneke
- Department of Cardiology, University Essen, Hufelandstr. 55, D-45122 Essen, Germany.
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Hirata K, Amudha K, Elina R, Hozumi T, Yoshikawa J, Homma S, Lang CC. Measurement of coronary vasomotor function: getting to the heart of the matter in cardiovascular research. Clin Sci (Lond) 2004; 107:449-60. [PMID: 15362973 DOI: 10.1042/cs20040226] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Measurement of endothelial function in patients has emerged as a useful tool for cardiovascular research. Although no gold standard for the measurement of endothelial function exists, the measurement of flow-mediated dilation in the brachial artery, assessed with Doppler ultrasonography, is the most studied method. However, the assumption that endothelial dysfunction detected in brachial arteries is a manifestation of systemic endothelial dysfunction including the coronary circulation may not be entirely valid. Brachial and myocardial circulations differ in terms of the microvascular architecture, the pattern of blood flow and vascular resistance (e.g. shunt vessels occur in the hand but not in the myocardium), their metabolic regulation, type of receptors that contribute to humoral regulation and the pathways that are activated to induce hyperaemia. In this context, measuring coronary vasomotor function may be more useful than brachial artery measures to predict and assess potential myocardial damage related to limited vascular responsiveness. This review aims to provide an overview of the basic concept of coronary flow reserve and its different modalities of measurement, as well as its utility in cardiovascular research.
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Affiliation(s)
- Kumiko Hirata
- Division of Cardiology, Columbia University, New York, USA
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Eicken A, Genz T, Kühn A, Hauser M, Hess J. Impaired left ventricular function after arterial switch operation: exclusion of significant coronary artery stenosis with an intravascular Doppler guidewire. Pediatr Cardiol 2004; 25:62-4. [PMID: 14583831 DOI: 10.1007/s00246-003-0485-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Patients after arterial switch operation for transposition of the great arteries are at risk for coronary artery stenosis or obstruction due to intraoperative manipulation. This case describes an infant with impaired left ventricular function 8 months after arterial switch operation. A hemodynamically significant left coronary artery stenosis was excluded by determination of coronary flow reserve using an intravascular Doppler guidewire.
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Affiliation(s)
- A Eicken
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technical University, Munich, Germany.
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40
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Herrmann SC, El-Shafei A, Kern MJ. Current concepts in coronary physiology for the interventionalist. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2003; 5:109-31. [PMID: 12959728 DOI: 10.1080/14628840310017357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Coronary angiography remains the 'gold standard' for the diagnosis of epicardial coronary disease. However, precise quantification of stenosis severity is limited because of the complex three-dimensional geometry of epicardial plaques. To assist the angiographer in lesion assessment, several physiologic measurements have been developed to evaluate stenosis severity, including coronary flow reserve, relative coronary flow reserve and fractional flow reserve. Physiologic lesion assessment can also be an invaluable tool in coronary intervention, evaluating efficacy of angioplasty and stent deployment.
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Voudris V, Avramides D, Koutelou M, Malakos J, Manginas A, Papadakis M, Cokkinos DV. Relative Coronary Flow Velocity Reserve Improves Correlation With Stress Myocardial Perfusion Imaging in Assessment of Coronary Artery Stenoses. Chest 2003; 124:1266-74. [PMID: 14555555 DOI: 10.1378/chest.124.4.1266] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To evaluate the angiographic and coronary flow velocity parameters that best correlate with the results of stress myocardial perfusion imaging. DESIGN Criterion standard. SETTING Tertiary care center. PATIENTS Forty-eight patients undergoing diagnostic coronary angiography for angina or silent ischemia. INTERVENTIONS We performed angiographic and coronary flow velocity measurements at rest and during hyperemia at the post-stenotic segment and in the adjacent angiographically normal branch of the left coronary artery. Relative coronary flow velocity reserve (RCFVR) was calculated as the ratio of post-stenotic to reference vessel coronary flow velocity reserve (CFVR). The best cutoff points for reversible perfusion defects were calculated using receiver operating characteristic curves. MEASUREMENTS AND RESULTS Post-stenotic CFVR showed fairly good correlations with minimal lumen diameter and percentage of diameter stenosis (r = 0.57 and r = 0.55, respectively; p < 0.001). RCFVR showed stronger correlations with these angiographic indexes of stenosis severity (r = 0.66 and r = 0.68, respectively; p < 0.0001). Based on receiver operating characteristic cutoff values (1.67 for post-stenotic CFVR and 0.64 for RCFVR), RCFVR had better agreement with myocardial perfusion imaging results, compared to post-stenotic CFVR (92% vs 75%, respectively). This agreement was more meaningful in patients with moderate coronary artery stenoses (50 to 75%). The area under the curve was 0.65 (not significant) for post-stenotic CFVR and 0.88 (p < 0.01) for RCFVR. CONCLUSIONS RCFVR describes better than post-stenotic CFVR the functional significance of coronary artery stenoses.
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Affiliation(s)
- Vassilis Voudris
- First Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece.
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Leesar MA, Abdul-Baki T, Yalamanchili V, Hakim J, Kern M. Conflicting functional assessment of stenoses in patients with previous myocardial infarction. Catheter Cardiovasc Interv 2003; 59:489-95. [PMID: 12891614 DOI: 10.1002/ccd.10550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The utility of fractional flow reserve, absolute and relative flow reserve, and intravascular ultrasound may have an impact on decision-making for percutaneous coronary intervention in patients with previous myocardial infarction and microvascular dysfunction. The role for fractional flow reserve, absolute and relative flow reserve, and intravascular ultrasound is discussed.
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Affiliation(s)
- Massoud A Leesar
- Division of Cardiology, University of Louisville, Louisville, Kentucky 40292, USA.
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43
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Botas J. Evaluación y guía terapéutica de las lesiones coronarias intermedias en el laboratorio de hemodinámica. Rev Esp Cardiol 2003; 56:1218-30. [PMID: 14670275 DOI: 10.1016/s0300-8932(03)77041-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Contrast angiography has been used for nearly five decades to evaluate the severity of coronary lesions. However, when attempting to distinguish between intermediate coronary lesions able or unable to produce ischemia, the technique has several limitations. A large number of patients undergo cardiac catheterization without prior evaluation of coronary perfusion by non-invasive tests. This number is likely to increase in the coming years, because current recommendations favor the invasive treatment of acute coronary syndromes. This has triggered marked interest in new diagnostic techniques capable of assessing the physiological significance of intermediate lesions in the catheterization room. This paper reviews the different techniques currently available for scientifically assessing the significance of such lesions. The advantages and limitations of each are discussed.
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Affiliation(s)
- Javier Botas
- Servicio de Cardiología. Hospital General Gregorio Marañón. Madrid. España.
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Shalman E, Rosenfeld M, Dgany E, Einav S. Numerical modeling of the flow in stenosed coronary artery. The relationship between main hemodynamic parameters. Comput Biol Med 2002; 32:329-44. [PMID: 12102752 DOI: 10.1016/s0010-4825(01)00033-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The severity of coronary arterial stenosis is usually measured by either simple geometrical parameters, such as percent diameter stenosis, or hemodynamically based parameters, such as the fractional flow reserve (FFR) or coronary flow reserve (CFR). The present study aimed to establish a relationship between actual hemodynamic conditions and the parameters that define stenosis severity in the clinical setting. We used a computational model of the blood flow in a vessel with a blunt stenosis and an autoregulated vascular bed to simulate a stenosed blood vessel. A key point in creating realistic simulations is to properly model arterial autoregulation. A constant flow regulation mechanism resulted in CFR and FFR values that were within the physiological range, while a constant wall-shear stress model yielded unrealistic values. The simulation tools developed in the present study may be useful in the clinical assessment of single and multiple stenoses by means of minimally invasive methods.
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Affiliation(s)
- E Shalman
- Faculty of Engineering, Tel-Aviv University, 69978 Tel Aviv, Israel
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45
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Reddy HK, Koshy SKG, Sturek M, Jayam VK, Bedi A, McCullough PA. Rationale and methods for assessment of coronary flow prior to coronary intervention: where are we headed? J Interv Cardiol 2002; 15:335-41. [PMID: 12238433 DOI: 10.1111/j.1540-8183.2002.tb01114.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hanumanth K Reddy
- University of Missouri-Columbia School of Medicine, Department of Internal Medicine, Division of Cardiology, Dalton Cardiovascular Research Center, Columbia, USA
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46
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Candell-Riera J, Martín-Comín J, Escaned J, Peteiro J. [Physiologic evaluation of coronary circulation. Role of invasive and non invasive techniques]. Rev Esp Cardiol 2002; 55:271-91. [PMID: 11893319 DOI: 10.1016/s0300-8932(02)76596-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.
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Seo JK, Kwan J, Suh JH, Kim DH, Lee KH, Hyun IY, Choe WS, Park KS, Lee WH. Early dipyridamole stress myocardial SPECT to detect residual stenosis of infarct related artery: comparison with coronary angiography and fractional flow reserve. Korean J Intern Med 2002; 17:7-13. [PMID: 12014218 PMCID: PMC4531649 DOI: 10.3904/kjim.2002.17.1.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The detection of residual stenosis of infarct related artery (IRA) at early stage after acute myocardial infarction (AMI) is crucial in clinical decision making for interventional revascularization. The aim of this study was to evaluate the relevancy of early dipyridamole stress myocardial SPECT to detect functionally and luminologically significant residual stenosis of IRA after AMI. METHODS Twenty five consecutive patients (M:F = 19:6, age: 56 +/- 13 yrs) with AMI underwent SPECT and coronary angiography within 5 days of the attack. Infarct related arteries with FFR < 0.75 and diameter stenosis (DST) > 70% were regarded to have functionally and morphologically significant residual stenosis. Reversible perfusion defect was defined if there was improvement of the perfusion score more than one grade in infarct segments on rest images of SPECT compared with stress images. RESULTS Mean FFR and DST were 0.76 +/- 0.14 and 74 +/- 15%. SPECT showed no significant correlation with both FFR and DST with Kendall's coefficiency of 0.28 (p = 0.05) and 0.13 (p = 0.35). The sensitivity and specificity of SPECT to detect functionally and morphologically significant residual stenosis were 92%, 31% and 83%, 29%. CONCLUSION The early dipyridamole stress myocardial SPECT after AMI does not seem to be a useful non-invasive test for the detection of functionally and luminologically significant residual stenosis of IRA.
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Affiliation(s)
- Jeong Kee Seo
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, 7-206, Shinheung-Dong 3-Ga, Jung-Ku, Inchon, Korea, 400-103
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48
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Yang Y, Bartel T, Eggebrecht H, Latina L, von Birgelen C, Caspari G, Wang X, Erbel R. Non-invasive assessment of coronary flow velocity reserve: a new method using transthoracic Doppler echocardiography. Curr Med Sci 2002; 22:158-63. [PMID: 12658763 DOI: 10.1007/bf02857683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2001] [Indexed: 10/19/2022]
Abstract
Transthoracic Doppler echocardiography (TTDE) allows noninvasive flow measurement in the distal left anterior descending artery (LAD). The feasibility of detecting coronary flow by contrast-enhanced TTDE with second harmonic technique was assessed, the coronary flow velocity reserve (CFVR) was evaluated in comparison to intracoronary Doppler flow (ICD) analysis and the CFVR after PTCA in LAD was investigated. In 77 (96%) of 80 patients, CFVR was successfully determined with intravenous adenosine infusion. Doppler signal quality was evaluated in the first 46 patients by use of intravenous Levovist infusion and second harmonic technique. The Doppler flow was not visible in 1. patient only. CFVR determined from TTDE (2.77 +/- 0.65) was correlated closely with those from ICD (2.88 +/- 0.78) measurements (y = 0.73x + 0.67, r = 0.87, P < 0.001). In conclusion, TTDE is a feasible method and provides reliable data on CFVR which can be used for follow-up after PTCA.
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Affiliation(s)
- Ya Yang
- Institute of Cardiovascular Disease, Xiehe Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030
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49
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Claeys MJ, Bosmans JM, Hendrix J, Vrints CJ. Reliability of fractional flow reserve measurements in patients with associated microvascular dysfunction: importance of flow on translesional pressure gradient. Catheter Cardiovasc Interv 2001; 54:427-34. [PMID: 11747174 DOI: 10.1002/ccd.2005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fractional flow reserve (FFR) has been applied with success as a lesion-specific functional indicator of stenosis severity, at least in patients with normal microcirculation. This study sought to assess the reliability of FFR calculations in patients with associated microvascular dysfunction (e.g., post myocardial infarction, or post-MI). First, the effect of coronary flow changes on translesional pressure gradient was assessed. Therefore, intracoronary pressure and flow was recorded simultaneously across 19 non-infarct-related lesions (both pre- and postinterventional lesions with a mean diameter stenosis of 47% +/- 12%). Measurements were performed by means of a pressure and Doppler wire during maximal hyperemia and also during submaximal hyperemia induced by low-dose adenosine. The drop of coronary flow from 48 +/- 23 ml/min during maximal hyperemia to 36 +/- 18 ml/min during submaximal hyperemia was associated with a small decrease in translesional pressure gradient (from 22 +/- 12 mm Hg to 19 +/- 12 mm Hg; P = 0.02) and a small increase in the mean distal/arterial pressure ratio (Pd/Pa) going from 77% +/- 11% to 81% +/- 11% (P = 0.003). Then, intracoronary pressure and flow measurements were compared across 21 non-infarct-related lesions vs. 22 matched infarct-related lesions. For a similar angiographic stenosis severity (% DS = +/- 44%), maximal flow was 48 +/- 22 ml/min in the non-infarct arteries and 37 +/- 26 ml/min in the infarct arteries (P = 0.03), confirming the presence of severe microvascular dysfunction in infarct regions. Similar to the earlier findings, this hyperemic flow reduction in MI patients was associated with a small increase of FFR (= Pd/Pa): 79% +/- 12% in no MI vs. 83% +/- 12% in MI patients (P = 0.3). A reduction of hyperemic flow by +25%, [correction] such as can be found in patients with severely impaired microvascular function, has a limited effect on FFR calculations (+ 5%). This finding allows the application of standard FFR calculations in a more general population of ischemic heart disease, including patients with recent MI.
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Affiliation(s)
- M J Claeys
- Department of Cardiology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium.
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50
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Kern MJ. Curriculum in interventional cardiology: coronary pressure and flow measurements in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2001; 54:378-400. [PMID: 11747168 DOI: 10.1002/ccd.1303] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- M J Kern
- J. Gerard Mudd Cardiac Catheterization Laboratory, St. Louis University Health Sciences Center, St. Louis, Missouri 63110, USA.
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