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Ryan M, De Silva K, Morgan H, O’Gallagher K, Demir OM, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah AM, Chiribiri A, Perera D. Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability. Circ Cardiovasc Interv 2022; 15:e012394. [PMID: 36538582 PMCID: PMC9760472 DOI: 10.1161/circinterventions.122.012394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/28/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary angiography and viability testing are the cornerstones of diagnosing and managing ischemic cardiomyopathy. At present, no single test serves both needs. Coronary wave intensity analysis interrogates both contractility and microvascular physiology of the subtended myocardium and therefore has the potential to fulfil the goal of completely assessing coronary physiology and myocardial viability in a single procedure. We hypothesized that coronary wave intensity analysis measured during coronary angiography would predict viability with a similar accuracy to late-gadolinium-enhanced cardiac magnetic resonance imaging. METHODS Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. Coronary wave intensity analysis was assessed during cardiac catheterization at rest, during adenosine-induced hyperemia, and during low-dose dobutamine stress using a dual pressure-Doppler sensing coronary guidewire. Scar burden was assessed with cardiac magnetic resonance imaging. Regional left ventricular function was assessed at baseline and 6-month follow-up after optimization of medical-therapy±revascularization, using transthoracic echocardiography. The primary outcome was myocardial viability, determined by the retrospective observation of functional recovery. RESULTS Forty participants underwent baseline physiology, cardiac magnetic resonance imaging, and echocardiography, and 30 had echocardiography at 6 months; 21/42 territories were viable on follow-up echocardiography. Resting backward compression wave energy was significantly greater in viable than in nonviable territories (-5240±3772 versus -1873±1605 W m-2 s-1, P<0.001), and had comparable accuracy to cardiac magnetic resonance imaging for predicting viability (area under the curve 0.812 versus 0.757, P=0.649); a threshold of -2500 W m-2 s-1 had 86% sensitivity and 76% specificity. CONCLUSIONS Backward compression wave energy has accuracy similar to that of late-gadolinium-enhanced cardiac magnetic resonance imaging in the prediction of viability. Coronary wave intensity analysis has the potential to streamline the management of ischemic cardiomyopathy, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.
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Affiliation(s)
- Matthew Ryan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kalpa De Silva
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Holly Morgan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kevin O’Gallagher
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ozan M. Demir
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Haseeb Rahman
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Howard Ellis
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Luke Dancy
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | - Daniel Sado
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | | | | | - Michael Marber
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ajay M. Shah
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
- Imaging Sciences Division, King’s College London, UK (A.C.)
| | - Divaka Perera
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
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Tamaru H, Fujii K, Fukunaga M, Imanaka T, Kawai K, Miki K, Horimatsu T, Nishimura M, Saita T, Sumiyoshi A, Shibuya M, Masuyama T, Ishihara M. Mechanisms of gradual pressure drop in angiographically normal left anterior descending and right coronary artery: Insights from wave intensity analysis. J Cardiol 2021; 78:72-78. [PMID: 33509679 DOI: 10.1016/j.jjcc.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/17/2020] [Accepted: 01/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study evaluated the mechanism of decline in coronary pressure from the proximal to the distal part of the coronary arteries in the left anterior descending (LAD) versus the right coronary artery (RCA) from the insight of coronary hemodynamics using wave intensity analysis (WIA). METHODS Twelve patients with angiographically normal LAD and RCA were prospectively enrolled. Distal coronary pressure, mean aortic pressure, and average peak velocity were measured at 4 different positions: 9, 6, 3, and 0 cm distal from each coronary ostium. RESULTS The distal-to-proximal coronary pressure ratio during maximum hyperemia gradually decreased in proportion to the distance from the ostium (0.92±0.03 and 0.98±0.03 at 9 cm distal to the LAD and RCA ostium). WIA showed the dominant forward-traveling compression wave gradually decreased and the backward-traveling suction wave gradually decreased in proportion to the decrease in coronary pressure through the length of the non-diseased LAD but not the RCA. CONCLUSIONS The pushing wave and suction wave intensities on WIA were diminished in proportion to the distance from the ostium of the LAD despite the wave intensity not changing across the length of the RCA, which may lead to gradual intracoronary pressure drop in the angiographically normal LAD.
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Affiliation(s)
- Hiroto Tamaru
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan; Department of Cardiology, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Kenichi Fujii
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Hirakata, Osaka 5731010, Japan.
| | - Masashi Fukunaga
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takahiro Imanaka
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kenji Kawai
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kojiro Miki
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tetsuo Horimatsu
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Machiko Nishimura
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ten Saita
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akinori Sumiyoshi
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masahiko Shibuya
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tohru Masuyama
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masaharu Ishihara
- Division of Cardiovascular Medicine and Coronary Heart Disease, Hyogo College of Medicine, Nishinomiya, Japan
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Affiliation(s)
- Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, King's College London, London, United Kingdom.
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Abstract
PURPOSE OF REVIEW Hibernation is an important and reversible cause of myocardial dysfunction in ischaemic heart failure. RECENT FINDINGS Hibernation is an adaptive process that promotes myocyte survival over maintaining contractile function. It is innate to mammalian physiology, sharing features with physiological hibernation in other species. Advanced imaging methods have reasonable accuracy in identifying hibernating myocardium. Novel superior hybrid methods may provide diagnostic potential. New evidence supports the role of surgical revascularisation in ischaemic heart failure, but the role of viability tests in planning such procedures remains unclear. Research to date has exclusively involved patients with ambulatory heart failure: Investigating the role of hibernation in ADHF is a key avenue for the future. Whilst our understanding of hibernation pathophysiology has improved dramatically, the clinical utility of identifying and targeting hibernation remains unclear.
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Affiliation(s)
- Matthew J Ryan
- The Rayne Institute, St Thomas' Hospital, 4th Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Divaka Perera
- The Rayne Institute, St Thomas' Hospital, 4th Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK.
- Cardiovascular Division, King's College London, London, UK.
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Claridge S, Briceno N, Chen Z, De Silva K, Modi B, Jackson T, Behar JM, Niederer S, Rinaldi CA, Perera D. Changes in contractility determine coronary haemodynamics in dyssynchronous left ventricular heart failure, not vice versa. IJC HEART & VASCULATURE 2018; 19:8-13. [PMID: 29946557 PMCID: PMC6016072 DOI: 10.1016/j.ijcha.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Biventricular pacing has been shown to increase both cardiac contractility and coronary flow acutely but the causal relationship is unclear. We hypothesised that changes in coronary flow are secondary to changes in cardiac contractility. We sought to examine this relationship by modulating coronary flow and cardiac contractility. METHODS Contractility and lusitropy were altered by varying the location of pacing in 8 patients. Coronary autoregulation was transiently disabled with intracoronary adenosine. Simultaneous coronary flow velocity, coronary pressure and left ventricular pressure data were measured in the different pacing settings with and without hyperaemia and wave intensity analysis performed. RESULTS Multisite pacing was effective at altering left ventricular contractility and lusitropy (pos. dp/dtmax -13% to +10% and neg. dp/dtmax -15% to +17% compared to baseline). Intracoronary adenosine decreased microvascular resistance (362.5 mm Hg/s/m to 156.7 mm Hg/s/m, p < 0.001) and increased LAD flow velocity (22 cm/s vs 45 cm/s, p < 0.001) but did not acutely change contractility or lusitropy. The magnitude of the dominant accelerating wave, the Backward Expansion Wave, was proportional to the degree of contractility as well as lusitropy (r = 0.47, p < 0.01 and r = -0.50, p < 0.01). Perfusion efficiency (the proportion of accelerating waves) increased at hyperaemia (76% rest vs 81% hyperaemia, p = 0.04). Perfusion efficiency correlated with contractility and lusitropy at rest (r = 0.43 & -0.50 respectively, p = 0.01) and hyperaemia (r = 0.59 & -0.6, p < 0.01). CONCLUSIONS Acutely increasing coronary flow with adenosine in patients with systolic heart failure does not increase contractility. Changes in coronary flow with biventricular pacing are likely to be a consequence of enhanced cardiac contractility from resynchronization and not vice versa.
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Affiliation(s)
- Simon Claridge
- Department of Imaging Sciences, King's College, London, United Kingdom
| | - Natalia Briceno
- NIHR Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom
| | - Zhong Chen
- Department of Imaging Sciences, King's College, London, United Kingdom
| | - Kalpa De Silva
- NIHR Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom
| | - Bhavik Modi
- NIHR Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom
| | - Tom Jackson
- Department of Imaging Sciences, King's College, London, United Kingdom
| | - Jonathan M. Behar
- Department of Imaging Sciences, King's College, London, United Kingdom
| | - Steven Niederer
- Department of Imaging Sciences, King's College, London, United Kingdom
| | | | - Divaka Perera
- NIHR Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, United Kingdom
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Mynard JP, Penny DJ, Smolich JJ. Major influence of a 'smoke and mirrors' effect caused by wave reflection on early diastolic coronary arterial wave intensity. J Physiol 2018; 596:993-1017. [PMID: 29318640 DOI: 10.1113/jp274710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/02/2018] [Indexed: 01/25/2023] Open
Abstract
KEY POINTS Coronary wave intensity analysis (WIA) is an emerging technique for assessing upstream and downstream influences on myocardial perfusion. It is thought that a dominant backward decompression wave (BDWdia ) is generated by a distal suction effect, while early-diastolic forward decompression (FDWdia ) and compression (FCWdia ) waves originate in the aorta. We show that wave reflection also makes a substantial contribution to FDWdia , FCWdia and BDWdia , as quantified by a novel method. In 18 sheep, wave reflection accounted for ∼70% of BDWdia , whereas distal suction dominated in a computer model representing a hypertensive human. Non-linear addition/subtraction of mechanistically distinct waves (e.g. wave reflection and distal suction) obfuscates the true contribution of upstream and downstream forces on measured waves (the 'smoke and mirrors' effect). The mechanisms underlying coronary WIA are more complex than previously thought and the impact of wave reflection should be considered when interpreting clinical and experimental data. ABSTRACT Coronary arterial wave intensity analysis (WIA) is thought to provide clear insight into upstream and downstream forces on coronary flow, with a large early-diastolic surge in coronary flow accompanied by a prominent backward decompression wave (BDWdia ), as well as a forward decompression wave (FDWdia ) and forward compression wave (FCWdia ). The BDWdia is believed to arise from distal suction due to release of extravascular compression by relaxing myocardium, while FDWdia and FCWdia are thought to be transmitted from the aorta into the coronary arteries. Based on an established multi-scale computational model and high-fidelity measurements from the proximal circumflex artery (Cx) of 18 anaesthetized sheep, we present evidence that wave reflection has a major impact on each of these three waves, with a non-linear addition/subtraction of reflected waves obscuring the true influence of upstream and downstream forces through concealment and exaggeration, i.e. a 'smoke and mirrors' effect. We also describe methods, requiring additional measurement of aortic WIA, for unravelling the separate influences of wave reflection versus active upstream/downstream forces on coronary waves. Distal wave reflection accounted for ∼70% of the BDWdia in sheep, but had a lesser influence (∼25%) in the computer model representing a hypertensive human. Negative reflection of the BDWdia at the coronary-aortic junction attenuated the Cx FDWdia (by ∼40% in sheep) and augmented Cx FCWdia (∼5-fold), relative to the corresponding aortic waves. We conclude that wave reflection has a major influence on early-diastolic WIA, and thus needs to be considered when interpreting coronary WIA profiles.
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Affiliation(s)
- Jonathan P Mynard
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Daniel J Penny
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, VIC 3052, Australia.,Institute of Reproduction and Development, Monash University, Clayton, VIC, Australia
| | - Joseph J Smolich
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Institute of Reproduction and Development, Monash University, Clayton, VIC, Australia
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7
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Asrress KN, Williams R, Lockie T, Khawaja MZ, De Silva K, Lumley M, Patterson T, Arri S, Ihsan S, Ellis H, Guilcher A, Clapp B, Chowienczyk PJ, Plein S, Perera D, Marber MS, Redwood SR. Physiology of Angina and Its Alleviation With Nitroglycerin: Insights From Invasive Catheter Laboratory Measurements During Exercise. Circulation 2017; 136:24-34. [PMID: 28468975 PMCID: PMC5491223 DOI: 10.1161/circulationaha.116.025856] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 04/26/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND The mechanisms governing exercise-induced angina and its alleviation by the most commonly used antianginal drug, nitroglycerin, are incompletely understood. The purpose of this study was to develop a method by which the effects of antianginal drugs could be evaluated invasively during physiological exercise to gain further understanding of the clinical impact of angina and nitroglycerin. METHODS Forty patients (mean age, 65.2±7.6 years) with exertional angina and coronary artery disease underwent cardiac catheterization via radial access and performed incremental exercise using a supine cycle ergometer. As they developed limiting angina, sublingual nitroglycerin was administered to half the patients, and all patients continued to exercise for 2 minutes at the same workload. Throughout exercise, distal coronary pressure and flow velocity and central aortic pressure were recorded with sensor wires. RESULTS Patients continued to exercise after nitroglycerin administration with less ST-segment depression (P=0.003) and therefore myocardial ischemia. Significant reductions in afterload (aortic pressure, P=0.030) and myocardial oxygen demand were seen (tension-time index, P=0.024; rate-pressure product, P=0.046), as well as an increase in myocardial oxygen supply (Buckberg index, P=0.017). Exercise reduced peripheral arterial wave reflection (P<0.05), which was not further augmented by the administration of nitroglycerin (P=0.648). The observed increases in coronary pressure gradient, stenosis resistance, and flow velocity did not reach statistical significance; however, the diastolic velocity-pressure gradient relation was consistent with a significant increase in relative stenosis severity (k coefficient, P<0.0001), in keeping with exercise-induced vasoconstriction of stenosed epicardial segments and dilatation of normal segments, with trends toward reversal with nitroglycerin. CONCLUSIONS The catheterization laboratory protocol provides a model to study myocardial ischemia and the actions of novel and established antianginal drugs. Administration of nitroglycerin causes changes in the systemic and coronary circulation that combine to reduce myocardial oxygen demand and to increase supply, thereby attenuating exercise-induced ischemia. Designing antianginal therapies that exploit these mechanisms may provide new therapeutic strategies.
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Affiliation(s)
- Kaleab N Asrress
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.).
| | - Rupert Williams
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Timothy Lockie
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Muhammed Z Khawaja
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Kalpa De Silva
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Matthew Lumley
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Tiffany Patterson
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Satpal Arri
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Sana Ihsan
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Howard Ellis
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Antoine Guilcher
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Brian Clapp
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Philip J Chowienczyk
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Sven Plein
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Divaka Perera
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Michael S Marber
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Simon R Redwood
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
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8
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Asrress KN, Allahwala U, Bhindi R. Contemporary assessment of coronary hemodynamics in the catheter laboratory. Future Cardiol 2016; 12:601-604. [PMID: 27791386 DOI: 10.2217/fca-2016-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Kaleab N Asrress
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
| | - Usaid Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Kolling Institute, University of Sydney, Sydney, 2065, Australia
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9
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Ladwiniec A, White PA, Nijjer SS, O’Sullivan M, West NE, Davies JE, Hoole SP. Diastolic Backward-Traveling Decompression (Suction) Wave Correlates With Simultaneously Acquired Indices of Diastolic Function and Is Reduced in Left Ventricular Stunning. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.003779. [DOI: 10.1161/circinterventions.116.003779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/25/2016] [Indexed: 01/10/2023]
Abstract
Background—
Wave intensity analysis can distinguish proximal (propulsion) and distal (suction) influences on coronary blood flow and is purported to reflect myocardial performance and microvascular function. Quantifying the amplitude of the peak, backwards expansion wave (BEW) may have clinical utility. However, simultaneously acquired wave intensity analysis and left ventricular (LV) pressure–volume loop data, confirming the origin and effect of myocardial function on the BEW in humans, have not been previously reported.
Methods and Results—
Patients with single-vessel left anterior descending coronary disease and normal ventricular function (n=13) were recruited prospectively. We simultaneously measured LV function with a conductance catheter and derived wave intensity analysis using a pressure–low velocity guidewire at baseline and again 30 minutes after a 1-minute coronary balloon occlusion. The peak BEW correlated with the indices of diastolic LV function: LV dP/dt
min
(
r
s
=−0.59;
P
=0.002) and τ (
r
s
=−0.59;
P
=0.002), but not with systolic function. In 12 patients with paired measurements 30 minutes post balloon occlusion, LV dP/dt
max
decreased from 1437.1±163.9 to 1299.4±152.9 mm Hg/s (median difference, −110.4 [−183.3 to −70.4];
P
=0.015) and τ increased from 48.3±7.4 to 52.4±7.9 ms (difference, 4.1 [1.3–6.9];
P
=0.01), but basal average peak coronary flow velocity was unchanged, indicating LV stunning post balloon occlusion. However, the peak BEW amplitude decreased from −9.95±5.45 W·m
–2
/s
2
×10
5
to −7.52±5.00 W·m
–2
/s
2
×10
5
(difference 2.43×10
5
[0.20×10
5
to 4.67×10
5
;
P
=0.04]).
Conclusions—
Peak BEW assessed by coronary wave intensity analysis correlates with invasive indices of LV diastolic function and mirrors changes in LV diastolic function confirming the origin of the suction wave. This may have implications for physiological lesion assessment after percutaneous coronary intervention.
Clinical Trial Registration—
URL:
http://www.isrctn.org
. Unique identifier: ISRCTN42864201.
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Affiliation(s)
- Andrew Ladwiniec
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Paul A. White
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Sukhjinder S. Nijjer
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Michael O’Sullivan
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Nick E.J. West
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Justin E. Davies
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
| | - Stephen P. Hoole
- From the Department of Cardiology, Papworth Hospital, Cambridge, United Kingdom (A.L., M.O., N.E.J.W., S.P.H.); Department of Medical Physics and Clinical Engineering, Addenbrooke’s Hospital, Cambridge, United Kingdom (P.A.W.); and International Centre for Circulatory Health, Imperial College, London, United Kingdom (S.S.N., J.E.D.)
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10
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Rivolo S, Patterson T, Asrress KN, Marber M, Redwood S, Smith NP, Lee J. Accurate and Standardized Coronary Wave Intensity Analysis. IEEE Trans Biomed Eng 2016; 64:1187-1196. [PMID: 28113201 DOI: 10.1109/tbme.2016.2593518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Coronary wave intensity analysis (cWIA) has increasingly been applied in the clinical research setting to distinguish between the proximal and distal mechanical influences on coronary blood flow. Recently, a cWIA-derived clinical index demonstrated prognostic value in predicting functional recovery postmyocardial infarction. Nevertheless, the known operator dependence of the cWIA metrics currently hampers its routine application in clinical practice. Specifically, it was recently demonstrated that the cWIA metrics are highly dependent on the chosen Savitzky-Golay filter parameters used to smooth the acquired traces. Therefore, a novel method to make cWIA standardized and automatic was proposed and evaluated in vivo. METHODS The novel approach combines an adaptive Savitzky-Golay filter with high-order central finite differencing after ensemble-averaging the acquired waveforms. Its accuracy was assessed using in vivo human data. The proposed approach was then modified to automatically perform beat wise cWIA. Finally, the feasibility (accuracy and robustness) of the method was evaluated. RESULTS The automatic cWIA algorithm provided satisfactory accuracy under a wide range of noise scenarios (≤10% and ≤20% error in the estimation of wave areas and peaks, respectively). These results were confirmed when beat-by-beat cWIA was performed. CONCLUSION An accurate, standardized, and automated cWIA was developed. Moreover, the feasibility of beat wise cWIA was demonstrated for the first time. SIGNIFICANCE The proposed algorithm provides practitioners with a standardized technique that could broaden the application of cWIA in the clinical practice as enabling multicenter trials. Furthermore, the demonstrated potential of beatwise cWIA opens the possibility investigating the coronary physiology in real time.
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Affiliation(s)
- Simone Rivolo
- Division of Imaging Science and Biomedical EngineeringKing's College London
| | | | | | | | | | | | - Jack Lee
- Division of Imaging Science and Biomedical EngineeringKing's College London
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11
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Lumley M, Williams R, Asrress KN, Arri S, Briceno N, Ellis H, Rajani R, Siebes M, Piek JJ, Clapp B, Redwood SR, Marber MS, Chambers JB, Perera D. Coronary Physiology During Exercise and Vasodilation in the Healthy Heart and in Severe Aortic Stenosis. J Am Coll Cardiol 2016; 68:688-97. [DOI: 10.1016/j.jacc.2016.05.071] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 01/10/2023]
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12
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Rivolo S, Hadjilucas L, Sinclair M, van Horssen P, van den Wijngaard J, Wesolowski R, Chiribiri A, Siebes M, Smith NP, Lee J. Impact of coronary bifurcation morphology on wave propagation. Am J Physiol Heart Circ Physiol 2016; 311:H855-H870. [PMID: 27402665 PMCID: PMC5114464 DOI: 10.1152/ajpheart.00130.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/05/2016] [Indexed: 01/09/2023]
Abstract
The branching pattern of the coronary vasculature is a key determinant of its function and plays a crucial role in shaping the pressure and velocity wave forms measured for clinical diagnosis. However, although multiple scaling laws have been proposed to characterize the branching pattern, the implications they have on wave propagation remain unassessed to date. To bridge this gap, we have developed a new theoretical framework by combining the mathematical formulation of scaling laws with the wave propagation theory in the pulsatile flow regime. This framework was then validated in multiple species using high-resolution cryomicrotome images of porcine, canine, and human coronary networks. Results demonstrate that the forward well-matchedness (no reflection for pressure/flow waves traveling from the coronary stem toward the microcirculation) is a salient feature in the coronary vasculature, and this result remains robust under many scenarios of the underlying pulse wave speed distribution assumed in the network. This result also implies a significant damping of the backward traveling waves, especially for smaller vessels (radius, <0.3 mm). Furthermore, the theoretical prediction of increasing area ratios (ratio between the area of the mother and daughter vessels) in more symmetric bifurcations found in the distal circulation was confirmed by experimental measurements. No differences were observed by clustering the vessel segments in terms of transmurality (from epicardium to endocardium) or perfusion territories (left anterior descending, left circumflex, and right coronary artery).
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Affiliation(s)
- Simone Rivolo
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union
| | - Lucas Hadjilucas
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union
| | - Matthew Sinclair
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union
| | - Pepijn van Horssen
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen van den Wijngaard
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Roman Wesolowski
- Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union; and
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union; and
| | - Maria Siebes
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolas P Smith
- Faculty of Engineering, The University of Auckland, Auckland, New Zealand
| | - Jack Lee
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom, European Union;
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13
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van Lavieren MA, van de Hoef TP, Sjauw KD, Piek JJ, Ferrara A, De Bruyne B, Gould KL. How should I treat a patient with refractory angina and a single stenosis with normal FFR but abnormal CFR? EUROINTERVENTION 2016; 11:125-8. [PMID: 25982657 DOI: 10.4244/eijv11i1a23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Martijn A van Lavieren
- AMC Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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14
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Lee J, Nordsletten D, Cookson A, Rivolo S, Smith N. In silico coronary wave intensity analysis: application of an integrated one-dimensional and poromechanical model of cardiac perfusion. Biomech Model Mechanobiol 2016; 15:1535-1555. [PMID: 27008197 PMCID: PMC5106513 DOI: 10.1007/s10237-016-0782-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 03/08/2016] [Indexed: 01/09/2023]
Abstract
Coronary wave intensity analysis (cWIA) is a diagnostic technique based on invasive measurement of coronary pressure and velocity waveforms. The theory of WIA allows the forward- and backward-propagating coronary waves to be separated and attributed to their origin and timing, thus serving as a sensitive and specific cardiac functional indicator. In recent years, an increasing number of clinical studies have begun to establish associations between changes in specific waves and various diseases of myocardium and perfusion. These studies are, however, currently confined to a trial-and-error approach and are subject to technological limitations which may confound accurate interpretations. In this work, we have developed a biophysically based cardiac perfusion model which incorporates full ventricular–aortic–coronary coupling. This was achieved by integrating our previous work on one-dimensional modelling of vascular flow and poroelastic perfusion within an active myocardial mechanics framework. Extensive parameterisation was performed, yielding a close agreement with physiological levels of global coronary and myocardial function as well as experimentally observed cumulative wave intensity magnitudes. Results indicate a strong dependence of the backward suction wave on QRS duration and vascular resistance, the forward pushing wave on the rate of myocyte tension development, and the late forward pushing wave on the aortic valve dynamics. These findings are not only consistent with experimental observations, but offer a greater specificity to the wave-originating mechanisms, thus demonstrating the value of the integrated model as a tool for clinical investigation.
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Affiliation(s)
- Jack Lee
- Department of Biomedical Engineering, King's College London, 3rd Floor, Lambeth Wing, St Thomas' Hospital, London, UK.
| | - David Nordsletten
- Department of Biomedical Engineering, King's College London, 3rd Floor, Lambeth Wing, St Thomas' Hospital, London, UK
| | - Andrew Cookson
- Department of Biomedical Engineering, King's College London, 3rd Floor, Lambeth Wing, St Thomas' Hospital, London, UK
| | - Simone Rivolo
- Department of Biomedical Engineering, King's College London, 3rd Floor, Lambeth Wing, St Thomas' Hospital, London, UK
| | - Nicolas Smith
- Department of Biomedical Engineering, King's College London, 3rd Floor, Lambeth Wing, St Thomas' Hospital, London, UK
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15
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Smolich JJ, Mynard JP. A step toward clinically applicable noninvasive coronary wave intensity analysis. Am J Physiol Heart Circ Physiol 2016; 310:H525-7. [PMID: 26825516 DOI: 10.1152/ajpheart.00014.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Joseph J Smolich
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Jonathan P Mynard
- Heart Research, Clinical Sciences, Murdoch Childrens Research Institute and Department of Paediatrics, University of Melbourne, Melbourne, Australia
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16
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Broyd CJ, Nijjer S, Sen S, Petraco R, Jones S, Al-Lamee R, Foin N, Al-Bustami M, Sethi A, Kaprielian R, Ramrakha P, Khan M, Malik IS, Francis DP, Parker K, Hughes AD, Mikhail GW, Mayet J, Davies JE. Estimation of coronary wave intensity analysis using noninvasive techniques and its application to exercise physiology. Am J Physiol Heart Circ Physiol 2015; 310:H619-27. [PMID: 26683900 DOI: 10.1152/ajpheart.00575.2015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/17/2015] [Indexed: 01/10/2023]
Abstract
Wave intensity analysis (WIA) has found particular applicability in the coronary circulation where it can quantify traveling waves that accelerate and decelerate blood flow. The most important wave for the regulation of flow is the backward-traveling decompression wave (BDW). Coronary WIA has hitherto always been calculated from invasive measures of pressure and flow. However, recently it has become feasible to obtain estimates of these waveforms noninvasively. In this study we set out to assess the agreement between invasive and noninvasive coronary WIA at rest and measure the effect of exercise. Twenty-two patients (mean age 60) with unobstructed coronaries underwent invasive WIA in the left anterior descending artery (LAD). Immediately afterwards, noninvasive LAD flow and pressure were recorded and WIA calculated from pulsed-wave Doppler coronary flow velocity and central blood pressure waveforms measured using a cuff-based technique. Nine of these patients underwent noninvasive coronary WIA assessment during exercise. A pattern of six waves were observed in both modalities. The BDW was similar between invasive and noninvasive measures [peak: 14.9 ± 7.8 vs. -13.8 ± 7.1 × 10(4) W·m(-2)·s(-2), concordance correlation coefficient (CCC): 0.73, P < 0.01; cumulative: -64.4 ± 32.8 vs. -59.4 ± 34.2 × 10(2) W·m(-2)·s(-1), CCC: 0.66, P < 0.01], but smaller waves were underestimated noninvasively. Increased left ventricular mass correlated with a decreased noninvasive BDW fraction (r = -0.48, P = 0.02). Exercise increased the BDW: at maximum exercise peak BDW was -47.0 ± 29.5 × 10(4) W·m(-2)·s(-2) (P < 0.01 vs. rest) and cumulative BDW -19.2 ± 12.6 × 10(3) W·m(-2)·s(-1) (P < 0.01 vs. rest). The BDW can be measured noninvasively with acceptable reliably potentially simplifying assessments and increasing the applicability of coronary WIA.
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Affiliation(s)
| | | | - Sayan Sen
- Imperial College London, London, United Kingdom
| | | | - Siana Jones
- University College London, London, United Kingdom
| | | | | | - Mahmud Al-Bustami
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Amarjit Sethi
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Raffi Kaprielian
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Punit Ramrakha
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Masood Khan
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Iqbal S Malik
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | | | - Kim Parker
- Imperial College London, London, United Kingdom
| | | | - Ghada W Mikhail
- Imperial College London National Health Service Trust, London, United Kingdom; and
| | - Jamil Mayet
- Imperial College London, London, United Kingdom
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17
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Claridge S, Chen Z, Jackson T, De Silva K, Behar J, Sohal M, Webb J, Hyde E, Lumley M, Asrress K, Williams R, Bostock J, Ali M, Gill J, O'Neill M, Razavi R, Niederer S, Perera D, Rinaldi CA. Effects of Epicardial and Endocardial Cardiac Resynchronization Therapy on Coronary Flow: Insights From Wave Intensity Analysis. J Am Heart Assoc 2015; 4:JAHA.115.002626. [PMID: 26679935 PMCID: PMC4845290 DOI: 10.1161/jaha.115.002626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background The increase in global coronary flow seen with conventional biventricular pacing is mediated by an increase in the dominant backward expansion wave (BEW). Little is known about the determinants of flow in the left‐sided epicardial coronary arteries beyond this or the effect of endocardial pacing stimulation on coronary physiology. Methods and Results Eleven patients with a chronically implanted biventricular pacemaker underwent an acute hemodynamic and electrophysiological study. Five of 11 patients also took part in a left ventricular endocardial pacing protocol at the same time. Conventional biventricular pacing, delivered epicardially from the coronary sinus, resulted in a 9% increase in flow (average peak velocity) in the left anterior descending artery (LAD), mediated by a 13% increase in the area under the BEW (P=0.004). Endocardial pacing resulted in a 27% increase in LAD flow, mediated by a 112% increase in the area under the forward compression wave (FCW) and a 43% increase in the area under the BEW (P=0.048 and P=0.036, respectively). There were no significant changes in circumflex parameters. Conventional biventricular pacing resulted in homogenization of timing of coronary flow compared with baseline (mean difference in time to peak in the LAD versus circumflex artery: FCW 39 ms [baseline] versus 3 ms [conventional biventricular pacing], P=0.008; BEW 47 ms [baseline] versus 8 ms [conventional biventricular pacing], P=0.004). Conclusions Epicardial and endocardial pacing result in increased coronary flow in the left anterior descending artery and homogenization of the timing of waves that determine flow in the LAD and the circumflex artery. The increase in both the FCW and the BEW with endocardial pacing may be the result of a more physiological activation pattern than that of epicardial pacing, which resulted in an increase of only the BEW.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Motin Ali
- Guy's and St Thomas’ Hospital TrustLondonUK
| | - Jaswinder Gill
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | - Mark O'Neill
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | - Reza Razavi
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
| | | | - Divaka Perera
- Guy's and St Thomas’ Hospital Trust and King's CollegeLondonUK
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18
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19
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Echavarría-Pinto M, Serruys PW, Garcia-Garcia HM, Broyd C, Cerrato E, Macaya C, Escaned J. Use of intracoronary physiology indices in acute coronary syndromes. Interv Cardiol 2015. [DOI: 10.2217/ica.15.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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20
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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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21
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Myat A, Patel N, Tehrani S, Banning AP, Redwood SR, Bhatt DL. Percutaneous Circulatory Assist Devices for High-Risk Coronary Intervention. JACC Cardiovasc Interv 2015; 8:229-244. [DOI: 10.1016/j.jcin.2014.07.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/17/2014] [Indexed: 10/24/2022]
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22
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Coronary and Microvascular Physiology During Intra-Aortic Balloon Counterpulsation. JACC Cardiovasc Interv 2014; 7:631-40. [DOI: 10.1016/j.jcin.2013.11.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 11/11/2013] [Accepted: 11/21/2013] [Indexed: 01/09/2023]
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Wave speed in human coronary arteries is not influenced by microvascular vasodilation: implications for wave intensity analysis. Basic Res Cardiol 2014; 109:405. [PMID: 24515727 DOI: 10.1007/s00395-014-0405-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/07/2014] [Accepted: 01/29/2014] [Indexed: 01/10/2023]
Abstract
Wave intensity analysis and wave separation are powerful tools for interrogating coronary, myocardial and microvascular physiology. Wave speed is integral to these calculations and is usually estimated by the single-point technique (SPc), a feasible but as yet unvalidated approach in coronary vessels. We aimed to directly measure wave speed in human coronary arteries and assess the impact of adenosine and nitrate administration. In 14 patients, the transit time Δt between two pressure signals was measured in angiographically normal coronary arteries using a microcatheter equipped with two high-fidelity pressure sensors located Δs = 5 cm apart. Simultaneously, intracoronary pressure and flow velocity were measured with a dual-sensor wire to derive SPc. Actual wave speed was calculated as DNc = Δs/Δt. Hemodynamic signals were recorded at baseline and during adenosine-induced hyperemia, before and after nitroglycerin administration. The energy of separated wave intensity components was assessed using SPc and DNc. At baseline, DNc equaled SPc (15.9 ± 1.8 vs. 16.6 ± 1.5 m/s). Adenosine-induced hyperemia lowered SPc by 40 % (p < 0.005), while DNc remained unchanged, leading to marked differences in respective separated wave energies. Nitroglycerin did not affect DNc, whereas SPc transiently fell to 12.0 ± 1.2 m/s (p < 0.02). Human coronary wave speed is reliably estimated by SPc under resting conditions but not during adenosine-induced vasodilation. Since coronary wave speed is unaffected by microvascular dilation, the SPc estimate at rest can serve as surrogate for separating wave intensity signals obtained during hyperemia, thus greatly extending the scope of WIA to study coronary physiology in humans.
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Rivolo S, Asrress KN, Chiribiri A, Sammut E, Wesolowski R, Bloch LØ, Grøndal AK, Hønge JL, Kim WY, Marber M, Redwood S, Nagel E, Smith NP, Lee J. Enhancing coronary Wave Intensity Analysis robustness by high order central finite differences. Artery Res 2014; 8:98-109. [PMID: 25187852 PMCID: PMC4148204 DOI: 10.1016/j.artres.2014.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/13/2014] [Accepted: 03/14/2014] [Indexed: 01/09/2023] Open
Abstract
Background Coronary Wave Intensity Analysis (cWIA) is a technique capable of separating the effects of proximal arterial haemodynamics from cardiac mechanics. Studies have identified WIA-derived indices that are closely correlated with several disease processes and predictive of functional recovery following myocardial infarction. The cWIA clinical application has, however, been limited by technical challenges including a lack of standardization across different studies and the derived indices' sensitivity to the processing parameters. Specifically, a critical step in WIA is the noise removal for evaluation of derivatives of the acquired signals, typically performed by applying a Savitzky–Golay filter, to reduce the high frequency acquisition noise. Methods The impact of the filter parameter selection on cWIA output, and on the derived clinical metrics (integral areas and peaks of the major waves), is first analysed. The sensitivity analysis is performed either by using the filter as a differentiator to calculate the signals' time derivative or by applying the filter to smooth the ensemble-averaged waveforms. Furthermore, the power-spectrum of the ensemble-averaged waveforms contains little high-frequency components, which motivated us to propose an alternative approach to compute the time derivatives of the acquired waveforms using a central finite difference scheme. Results and Conclusion The cWIA output and consequently the derived clinical metrics are significantly affected by the filter parameters, irrespective of its use as a smoothing filter or a differentiator. The proposed approach is parameter-free and, when applied to the 10 in-vivo human datasets and the 50 in-vivo animal datasets, enhances the cWIA robustness by significantly reducing the outcome variability (by 60%).
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Affiliation(s)
- Simone Rivolo
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London SE1 7EH, UK
| | - Kaleab N Asrress
- Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas Hospital, London SE1 7EH, UK
| | - Amedeo Chiribiri
- Division of Imaging Science and Biomedical Engineering, King's College London, King's Health Partner, St. Thomas Hospital, London SE1 7EH, UK
| | - Eva Sammut
- Division of Imaging Science and Biomedical Engineering, King's College London, King's Health Partner, St. Thomas Hospital, London SE1 7EH, UK
| | - Roman Wesolowski
- Division of Imaging Science and Biomedical Engineering, King's College London, King's Health Partner, St. Thomas Hospital, London SE1 7EH, UK
| | - Lars Ø Bloch
- Department of Cardiology, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Denmark
| | - Anne K Grøndal
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Denmark
| | - Jesper L Hønge
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Denmark
| | - Won Y Kim
- Department of Cardiology, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, Denmark
| | - Michael Marber
- Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas Hospital, London SE1 7EH, UK
| | - Simon Redwood
- Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas Hospital, London SE1 7EH, UK
| | - Eike Nagel
- Division of Imaging Science and Biomedical Engineering, King's College London, King's Health Partner, St. Thomas Hospital, London SE1 7EH, UK
| | - Nicolas P Smith
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London SE1 7EH, UK
| | - Jack Lee
- Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London SE1 7EH, UK
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