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Shahandeh N, Song J, Saito K, Honda Y, Zimmermann FM, Ahn JM, Fearon WF, Parikh RV. Invasive Coronary Physiology in Heart Transplant Recipients: State-of-the-Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100627. [PMID: 39130712 PMCID: PMC11307478 DOI: 10.1016/j.jscai.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 08/13/2024]
Abstract
Cardiac allograft vasculopathy is a leading cause of allograft failure and death among heart transplant recipients. Routine coronary angiography and intravascular ultrasound in the early posttransplant period are widely accepted as the current standard-of-care diagnostic modalities. However, many studies have now demonstrated that invasive coronary physiological assessment provides complementary long-term prognostic data and helps identify patients who are at risk of accelerated cardiac allograft vasculopathy and acute rejection.
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Affiliation(s)
- Negeen Shahandeh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Justin Song
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Kan Saito
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | | | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University and VA Palo Alto Health Care Systems, Stanford, California
| | - Rushi V. Parikh
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California
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Badano LP, Miglioranza MH, Edvardsen T, Colafranceschi AS, Muraru D, Bacal F, Nieman K, Zoppellaro G, Marcondes Braga FG, Binder T, Habib G, Lancellotti P, Sicari R, Cosyns B, Donal E, Lombardi M, Sarvari S. European Association of Cardiovascular Imaging/Cardiovascular Imaging Department of the Brazilian Society of Cardiology recommendations for the use of cardiac imaging to assess and follow patients after heart transplantation. ACTA ACUST UNITED AC 2015; 16:919-48. [DOI: 10.1093/ehjci/jev139] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/02/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Luigi P. Badano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | - Fernando Bacal
- Heart Transplant Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Koen Nieman
- Intensive Cardiac Care Unit and Cardiac CT Research, Erasmus MC, Rotterdam, The Netherlands
| | - Giacomo Zoppellaro
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy
| | | | - Thomas Binder
- Department of Cardiology, University of Vienna, Wien, Austria
| | - Gilbert Habib
- Service de Cardiologie, Hôpital La Timone, Marseille, France
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
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Mirelis JG, García-Pavía P, Cavero MA, González-López E, Echavarria-Pinto M, Pastrana M, Segovia J, Oteo JF, Alonso-Pulpón L, Escaned J. Resonancia magnética para la detección no invasiva de la enfermedad microcirculatoria asociada a la vasculopatía de alotrasplante: validación de la determinación intracoronaria. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Mirelis JG, García-Pavía P, Cavero MA, González-López E, Echavarria-Pinto M, Pastrana M, Segovia J, Oteo JF, Alonso-Pulpón L, Escaned J. Magnetic Resonance for Noninvasive Detection of Microcirculatory Disease Associated With Allograft Vasculopathy: Intracoronary Measurement Validation. ACTA ACUST UNITED AC 2015; 68:571-8. [DOI: 10.1016/j.rec.2014.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 07/18/2014] [Indexed: 01/13/2023]
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Skorić B, Čikeš M, Ljubas Maček J, Baričević Ž, Škorak I, Gašparović H, Biočina B, Miličić D. Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis. Croat Med J 2015; 55:562-76. [PMID: 25559827 PMCID: PMC4295072 DOI: 10.3325/cmj.2014.55.562] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.
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Affiliation(s)
- Boško Skorić
- Bosko Skoric, University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital Center Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia,
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Gewirtz H. PET measurement of adenosine stimulated absolute myocardial blood flow for physiological assessment of the coronary circulation. J Nucl Cardiol 2012; 19:347-54. [PMID: 22231036 DOI: 10.1007/s12350-011-9510-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Considerable awareness has been raised of late of the need to reduce radiation exposure and control costs of x-ray and radionuclide imaging procedures. PET/CT cameras are now widely available and in conjunction with appropriate radionuclides and commercially available software make quantitative measurement of absolute MBF feasible for routine clinical practice. Quantitative measurement of absolute MBF under condition of coronary vasodilation permits independent assessment of the functional status of each of the three major coronary perfusion zones and so obviates the need for rest MBF determination in the great majority of cases. Coronary microvascular function also may be assessed in this same way. Thus, the stress-only protocol with quantitative PET measurement of MBF provides essential information required for clinical decision making related to need for catheterization and intervention for patients with known or suspected ischemic heart disease. Moreover, the single PET determination of maximal MBF in contrast to the usual rest/stress procedure addresses both safety and cost concerns. The present review focuses on: (1) quantitative PET measurements of myocardial blood flow for physiological assessment of the coronary circulation and (2) the value and potential limitations of performing stress only imaging in the clinical context.
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Affiliation(s)
- Henry Gewirtz
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Cardiac Unit/Yawkey 5E, Boston, MA 02114, USA.
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Thompson D, Koster MJ, Wagner RH, Heroux A, Barron JT. Single photon emission computed tomography myocardial perfusion imaging to detect cardiac allograft vasculopathy. Eur Heart J Cardiovasc Imaging 2011; 13:271-5. [DOI: 10.1093/ejechocard/jer270] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac transplant recipients. Many transplant centers perform routine annual surveillance coronary angiography. However, angiography can underdiagnose or miss CAV due to its diffuse nature. Intravascular ultrasound (IVUS) is more sensitive than angiography. IVUS provides not only accurate information on lumen size, but also quantification of intimal thickening, vessel wall morphology, and composition. IVUS has evolved as a valuable adjunct to angiography and the optimal diagnostic tool for early detection. Noninvasive testing such as dobutamine stress echocardiography and nuclear stress test have shown considerable accuracy in diagnosing significant CAV. Computed tomographic imaging and cardiac magnetic resonance imaging are promising new modalities but require further study. This article reviews the diagnostic methods that are currently available.
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Osto E, Tona F, Angelini A, Montisci R, Ruscazio M, Vinci A, Tarantini G, Ramondo A, Gambino A, Thiene G, Caforio ALP, Gerosa G, Iliceto S. Determinants of coronary flow reserve in heart transplantation: a study performed with contrast-enhanced echocardiography. J Heart Lung Transplant 2009; 28:453-60. [PMID: 19416773 DOI: 10.1016/j.healun.2009.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 02/19/2009] [Accepted: 02/19/2009] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Determination of coronary flow reserve (CFR) is increasingly being used in cardiac allograft vasculopathy (CAV). We aimed to identify determinants of CFR in heart transplantation (HT). METHODS CFR was measured by transthoracic echocardiography in 119 HT recipients (97 men, 22 women; 50 +/- 12 years of age at HT and 8 +/- 5 years post-HT). CFR was expressed as the ratio of hyperemic (adenosine infusion at a rate of 0.14 mg/kg) to basal diastolic flow velocity. Rejection scores (RS) on endomyocardial biopsy were calculated. Angiographic CAV was analyzed using a qualitative grading system. The coronary tree was divided into 17 traits and a CAV severity/diffusion index (SDI) was calculated for each patient, summing the scores assigned to all lesions. RESULTS Upon multivariate analysis, CFR was related to CAV (p = 0.001), interventricular septum thickness (p = 0.01), ischemic heart disease pre-HT (p = 0.02) and SDI and SDI/segment number (p < 0.0001 and p = 0.003, respectively). In patients without CAV, CFR was related only to RS for severe grades (p = 0.01). CONCLUSIONS Left ventricular hypertrophy, CAV and its severity/diffusion independently contribute to reduced CFR. In patients without angiographic CAV, CFR was only independently related to RS. Because a high rejection burden is associated with increased risk of CAV, CFR reduction may be an early marker of CAV. Microvascular dysfunction may contribute to the late morbidity and mortality seen in HT.
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Affiliation(s)
- Elena Osto
- Department of Cardiology, University of Padova, Padova, Italy
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Features of cardiac allograft coronary endothelial dysfunction. Am J Cardiol 2009; 103:1154-8. [PMID: 19361606 DOI: 10.1016/j.amjcard.2008.12.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 12/21/2008] [Accepted: 12/21/2008] [Indexed: 11/22/2022]
Abstract
The aim of the study was to evaluate the features and mechanism of cardiac allograft coronary endothelial dysfunction. Coronary blood flow and epicardial coronary artery diameter response to intracoronary acetylcholine and N(G)-monomethyl-l-arginine were assessed in 19 cyclosporine-treated heart transplant recipients with normal coronary angiograms (3.8 +/- 2.3 years after transplantation) and compared with 19 age-, gender-, and cardiovascular risk factor-matched nontransplantation control patients with normal coronary angiograms. Heart transplant recipients had more epicardial vasoconstriction in response to intracoronary acetylcholine (mean -16 +/- 19% [SD] vs 4 +/- 10%; p = 0.036). Microvascular endothelial function was similar between groups. Coronary flow reserve in response to adenosine was higher in the transplant group (3.6 +/- 0.8 vs 3.1 +/- 0.7; p = 0.04). The effect of N(G)-monomethyl-l-arginine (64 micromol/min) on coronary blood flow (-16 +/- 21% vs -37 +/- 19%; p = 0.018), coronary artery diameter (-10 +/- 13% vs -21 +/- 11%; p = 0.04), and coronary vascular resistance (34 +/- 40% vs 73 +/- 63%; p = 0.047) was significantly attenuated in the transplant group compared with controls. In conclusion, cardiac allograft epicardial coronary endothelial function was abnormal and may be related to an impaired endogenous NO synthetase pathway and reduced endothelial nitric oxide production in transplant recipients.
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Okamura A, Ito H, Iwakura K, Kawano S, Kurotobi T, Date M, Inoue K, Ogihara T, Fujii K. Detection and quantification of embolic particles during percutaneous coronary intervention to stable plaque: It correlates to coronary flow dynamics and myocardial damage. Catheter Cardiovasc Interv 2007; 69:425-31. [PMID: 17191241 DOI: 10.1002/ccd.20971] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We detected embolic particles liberated from plaque during percutaneous coronary intervention (PCI) as high-intensity transient signals (HITS) with a Doppler guidewire and studied their impact on coronary flow dynamics and the myocardium in patients with stable angina pectoris. BACKGROUND These embolic particles during PCI may cause myocardial injury. However, this was difficult to confirm because it was impossible to detect embolic particles. METHODS We performed balloon angioplasty followed by stenting in 31 patients while monitoring coronary flow velocity. After PCI, we measured average peak velocity at baseline and after infusion of adenosine 5'-triphosphate to calculate coronary flow velocity reserve (CFVR) and coronary resistance index (CRI). In patients with PCI to the left coronary artery (n = 21), we calculated relative CFVR as the ratio of CFVR in the target vessel to that in the reference vessel. We measured cardiac troponin T (cTnT) the day after PCI. RESULTS HITS were detected in 27 (87%) of 31 patients and the majority were observed after stenting. The total number of HITS was correlated with CRI (r = 0.36, P = 0.049) or relative CFVR (r = 0.65, P = 0.0036) but not with CFVR (r = 0.048, P = 0.82). Thirteen patients showed elevated cTnT (range, 0.05-0.31 ng/ml) and the total number of HITS was greater in those with elevated cTnT than in those without elevated cTnT (24 +/- 9 vs. 10 +/- 7, P = 0.0007). CONCLUSIONS Embolic particles are frequently observed during PCI to stable plaque and the majority are liberated after stenting. There appears to be a quantitative relationship between amounts of HITS and coronary microvessel dysfunction and minor myocardial injury.
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Affiliation(s)
- Atsunori Okamura
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
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Fearon WF, Hirohata A, Nakamura M, Luikart H, Lee DP, Vagelos RH, Hunt SA, Valantine HA, Fitzgerald PJ, Yock PG, Yeung AC. Discordant changes in epicardial and microvascular coronary physiology after cardiac transplantation: Physiologic Investigation for Transplant Arteriopathy II (PITA II) study. J Heart Lung Transplant 2006; 25:765-71. [PMID: 16818118 DOI: 10.1016/j.healun.2006.03.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 09/29/2005] [Accepted: 03/02/2006] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Investigating changes in coronary physiology that occur after cardiac transplantation has been challenging. Simultaneous and independent assessment of the epicardial artery by measuring fractional flow reserve (FFR) and of the microvasculature by calculating the index of microvascular resistance (IMR) with a single coronary pressure wire may be useful. METHODS Twenty-five asymptomatic patients with normal coronary angiograms underwent FFR, thermodilution-derived IMR and coronary flow reserve (CFR) and intravascular ultrasound (IVUS) evaluation soon after cardiac transplantation and 1 year later. RESULTS FFR significantly worsened (0.90 +/- 0.05 at baseline to 0.85 +/- 0.06 at 1 year, p = 0.004). FFR correlated strongly with percent plaque volume as measured by IVUS (r = -0.58, p < 0.0001). IMR improved significantly (29.2 +/- 15.9 at baseline to 19.3 +/- 7.6 units at 1 year, p = 0.007). CFR increased, but not significantly (2.6 +/- 1.4 at baseline to 3.2 +/- 1.2 at 1 year, p = not significant). Diabetes and donor heart ischemic time independently predicted baseline IMR. Treatment with rapamycin independently predicted FFR at 1 year. CONCLUSIONS New coronary physiologic measures, FFR and IMR, show that epicardial artery physiology worsens and correlates with anatomic changes, whereas microvascular physiology improves during the first year after cardiac transplantation. CFR, the traditional method for evaluating coronary circulatory physiology, did not identify these changes.
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Affiliation(s)
- William F Fearon
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California 94305-5637, USA.
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Bacal F, Moreira L, Souza G, Rodrigues AC, Fiorelli A, Stolf N, Bocchi E, Bellotti G, Ramires JAF. Dobutamine stress echocardiography predicts cardiac events or death in asymptomatic patients long-term after heart transplantation: 4-year prospective evaluation. J Heart Lung Transplant 2005; 23:1238-44. [PMID: 15539121 DOI: 10.1016/j.healun.2003.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2003] [Revised: 08/25/2003] [Accepted: 09/05/2003] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) remains the major cause of death after cardiac transplantation during long-term follow-up. Nevertheless, annual angiographic evaluation is difficult to perform routinely. We evaluated the value of clinical risk factors and non-invasive testing for cardiac allograft vasculopathy in predicting cardiac events or death in asymptomatic patients with normal ventricular function during long-term follow-up after heart transplantation. METHODS We studied 39 patients, mean aged 48 +/- 13 years, at 86 +/- 31 months after heart transplantation. Patients underwent thallium scintigraphy, treadmill stress testing, dobutamine stress echocardiography, and angiography to detect CAV. We prospectively observed all patients an additional 4 years for acute myocardial infarction, congestive heart failure, or death. RESULTS Angiography detected CAV in 15 patients (38%). Three patients had acute myocardial infarction and another 7 had congestive heart failure, representing 25% of cardiac events during the study period. Nine deaths (23%) occurred during the same observation time. Univariate analysis showed that increased body mass index, positive dobutamine stress echocardiography results, and positive angiography results were associated significantly with cardiac events or death during follow-up. In the absence of coronary angiography, stepwise logistic regression identified positive dobutamine echocardiography results as the unique independent predictor of cardiac events (p = 0.001) or death (p = 0.002). CONCLUSION Cardiac events and death after heart transplantation increased during long-term follow-up of this population. However, dobutamine stress echocardiography is well tolerated and, in the absence of routine angiographic evaluation, may be a strong predictor of these events.
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Affiliation(s)
- Fernando Bacal
- Heart Institute, University of São Paulo Medical School, Sao Paulo, Brazil.
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Abstract
Cardiac allograft vasculopathy (CAV) is the major obstacle to long-term survival after heart transplantation. It is a rapidly progressive, obliterative form of coronary vasculopathy distinct from classic atheromatous disease. The pathogenesis is most likely multifactorial and involves both alloantigen dependent and independent mechanisms. Since there is no definitive treatment for CAV and new immunosuppressive agents can only slow the progression of this disease, the prophylaxis and modification of numerous risk factors remains the foundation of posttransplant management in the heart transplant recipient. In this review, we discuss current understanding of the pathogenesis of CAV, novel diagnostic and therapeutic avenues and explore optimal approaches to risk factors modification.
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Affiliation(s)
- Katherine Lietz
- Cardiovascular Division, University of Minnesota, Minneapolis, MN 55455, USA
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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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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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Wieneke H, Schmermund A, Ge J, Altmann C, Haude M, Von Birgelen C, Baumgart D, Dirsch O, Erbel R. Increased heterogeneity of coronary perfusion in patients with early coronary atherosclerosis. Am Heart J 2001; 142:691-7. [PMID: 11579361 DOI: 10.1067/mhj.2001.116764] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND In patients with typical angina but angiographically normal coronary arteries, abnormal vasomotor function is assumed to be a major underlying cause. However, data on this issue are conflicting, and recent studies suggest that fluid dynamic abnormalities exist in these patients. The aim of the study was to evaluate whether early stages of atherosclerosis are characterized by alterations of baseline coronary hemodynamics and endothelium-independent vasomotion. Besides established intracoronary Doppler parameters, heterogeneity of perfusion was assessed and related to early signs of atherosclerosis as determined by electron-beam computed tomography (EBCT). METHODS In 59 patients with typical angina and angiographically normal or near-normal coronary arteries, intracoronary Doppler measurements were performed in all 3 major coronary arteries. Baseline average peak velocity (bAPV) and hyperemic average peak velocity (hAPV) in response to intracoronary injection of adenosine were measured, and coronary flow velocity reserve (CFVR) was calculated. Heterogeneity was assessed as variability of bAPV, hAPV, and CFVR and was calculated as (STD/MEAN). 100. Doppler data were analyzed according to tertiles of the EBCT-derived Agatston calcium score (ie, score 0-1 [lowest tertile], 2-28 [medium tertile], and >28 [highest tertile]). RESULTS The mean EBCT-derived Agatston calcium score was 49 +/- 107. No coronary calcium was observed in 17 (29%) patients. The mean values of bAPV, hAPV, and CFVR were not different between the calcium score tertiles. However, patients in the highest tertile had a significantly increased variability index of bAPV (29.6% +/- 11.6%) compared with patients in the lowest tertile (13.4% +/- 7.3%, P <.0001). Variability of CFVR was also increased in these patients (15.5% +/- 11.7% vs 10.5% +/- 4.0%, P =.03). CONCLUSION These results indicate that early stages of atherosclerosis are characterized by microvascular abnormalities that do not uniformly affect the myocardium but are heterogeneous. The high variability of baseline coronary flow velocity with increasing coronary calcium suggests that in patients with early stages of atherosclerosis fluid dynamic effects may play a crucial role even in the absence of angiographically appreciable epicardial stenoses.
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Affiliation(s)
- H Wieneke
- Department of Cardiology, University Clinic Essen, Germany.
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Kurita A, Matsui T, Ishizuka T, Takase B, Satomura K, Hara S. New thermo-couple copper constantan catheter for measuring regional coronary blood flow and evaluating metabolism. JAPANESE HEART JOURNAL 2001; 42:495-506. [PMID: 11693285 DOI: 10.1536/jhj.42.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A new thermodilution catheter with a thermo-couple copper constantan and latex balloon in the tip has recently been developed. This device has two orifices. The left anterior descending (LAD) and/or left circumflex (LCX) flows were measured using a Doppler flow wire. The correlation between the LAD and GCV flow as well as between the LCX and CS-GCV flow were studied in closed chest animals. The flow distributions were evaluated by colored microspheres that were infused into the LAD and LCX. The regional lactate extraction ratio was measured by GCV and/or CS blood sampling performed either with or without balloon inflation before and during pacing in either LAD or LCX occluded animals. The correlations between the LAD and GCV flow, as well as between the LCX and CS-GCV flow were significant (r=0.96, r=0.93, n=30, p<0.001). The flow distribution by color microspheres in the GCV was 75+/-10% for the LAD, whereas in CS it was 70+/-12% for the LCX. By pacing, the lactate extraction ratio of the drained blood from the ischemic myocardium was +10+/-3% in the GCV blood, whereas it was -10+/-4% (p<0.01) in the CS blood. Thus, this new thermodilution catheter with a balloon was found to be useful for measuring regional coronary hemodynamics and also for evaluating the regional myocardial metabolism.
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Affiliation(s)
- A Kurita
- Department of Biomedical Engineering, National Defense College, Tokorozawa, Saitama, Japan
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Chamuleau SA, Meuwissen M, van Eck-Smit BL, Koch KT, de Jong A, de Winter RJ, Schotborgh CE, Bax M, Verberne HJ, Tijssen JG, Piek JJ. Fractional flow reserve, absolute and relative coronary blood flow velocity reserve in relation to the results of technetium-99m sestamibi single-photon emission computed tomography in patients with two-vessel coronary artery disease. J Am Coll Cardiol 2001; 37:1316-22. [PMID: 11300441 DOI: 10.1016/s0735-1097(01)01173-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We sought to perform a direct comparison between perfusion scintigraphic results and intracoronary-derived hemodynamic variables (fractional flow reserve [FFR]; absolute and relative coronary flow velocity reserve [CFVR and rCFVR, respectively]) in patients with two-vessel disease. BACKGROUND There is limited information on the diagnostic accuracy of intracoronary-derived variables (CFVR, FFR and rCFVR) in patients with multivessel disease. METHODS Dipyridamole technetium-99m sestamibi (MIBI) single-photon emission computed tomography (SPECT) was performed in 127 patients. The presence of reversible perfusion defects in the region of interest was determined. Within one week, angiography was performed; CFVR, rCFVR and FFR were determined in 161 coronary lesions after intracoronary administration of adenosine. The predictive value for the presence of reversible perfusion defects on MIBI SPECT of CFVR, rCFVR and FFR was evaluated by the area under the curve (AUC) of the receiver operating characteristics curves. RESULTS The mean percentage diameter stenosis was 57% (range 35% to 85%), as measured by quantitative coronary angiography. Using per-patient analysis, the AUCs for CFVR (0.70 +/- 0.052), rCFVR (0.72 +/- 0.051) and FFR (0.76 +/- 0.050) were not significantly different (p = NS). The percentages of agreement with the results of MIBI SPECT were 76%, 78% and 77% for CFVR, rCFVR and FFR, respectively. Per-lesion analysis, using all 161 measured lesions, yielded similar results. CONCLUSIONS The diagnostic accuracy of three intracoronary-derived hemodynamic variables, as compared with the results of perfusion scintigraphy, is similar in patients with two-vessel coronary artery disease. Cut-offvalues of 2.0 for CFVR, 0.65 for rCFVR and 0.75 for FFR can be used for clinical decision-making in this patient cohort. Discordant results were obtained in 23% of the cases that require prospective evaluation for appropriate patient management.
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Affiliation(s)
- S A Chamuleau
- Department of Cardiology, Academic Medical Center of Amsterdam, The Netherlands.
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Fang JC, Kinlay S, Wexberg P, Amirzadeh A, Gibson CM, Selwyn AP, Ganz P. Use of the thrombolysis in myocardial infarction frame count for the quantitative assessment of transplant-associated arteriosclerosis. Am J Cardiol 2000; 86:890-2. [PMID: 11024410 DOI: 10.1016/s0002-9149(00)01115-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J C Fang
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Abstract
Coronary artery disease in the transplanted heart limits the long-term success of cardiac transplantation. Intravascular ultrasound studies reveal a dual morphology with donor-transmitted and de novo plaques. Coronary vasomotor dysfunction may occur independently of morphological alterations. The disease is characterized by the interaction of activated T lymphocytes with cytokines and donor epicardial and microvascular endothelium. Various noxious stimuli contribute to the continuing inflammatory response. Consequently, adhesion molecule expression is upregulated, leukocytes migrate into the allograft, thrombocytes accumulate, and growth factors are expressed, finally resulting in functional and morphological chronic allograft lesions. Blocking the activation of T cells, CD4+ cytokines, and adhesion molecules may prevent endothelial injury and subsequent intimal thickening. Strategies to decrease the formation of anti-endothelial and anti-HLA-DR antibodies may also be protective, as may antiproliferative drugs, augmentation of endogenous nitric oxide bioactivity, and new immunosuppressive regimens. Revascularization procedures have a limited role in treating significant focal lesions. Retransplantation, the only definitive treatment, remains ethically controversial.
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Affiliation(s)
- M Weis
- Medizinische Klinik und Poliklinik I, University Hospital Grosshadern, Munich, Germany.
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