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Minten L, Bennett J, Otsuki H, Takahashi K, Fearon WF, Dubois C. Differential Effect of Aortic Valve Replacement for Severe Aortic Stenosis on Hyperemic and Resting Epicardial Coronary Pressure Indices. J Am Heart Assoc 2024; 13:e034401. [PMID: 38761080 PMCID: PMC11179829 DOI: 10.1161/jaha.124.034401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Coronary pressure indices to assess coronary artery disease are currently underused in patients with aortic stenosis due to many potential physiological effects that might hinder their interpretation. Studies with varying sample sizes have provided us with conflicting results on the effect of transcatheter aortic valve replacement (TAVR) on these indices. The aim of this meta-analysis was to study immediate and long-term effects of TAVR on fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs). METHODS AND RESULTS Lesion-specific coronary pressure data were extracted from 6 studies, resulting in 147 lesions for immediate change in FFR analysis and 105 for NHPR analysis. To investigate the long-term changes, 93 lesions for FFR analysis and 68 for NHPR analysis were found. Lesion data were pooled and compared with paired t tests. Immediately after TAVR, FFR decreased significantly (-0.0130±0.0406 SD, P: 0.0002) while NHPR remained stable (0.0003±0.0675, P: 0.9675). Long-term after TAVR, FFR decreased significantly (-0.0230±0.0747, P: 0.0038) while NHPR increased nonsignificantly (0.0166±0.0699, P: 0.0543). When only borderline NHPR lesions were considered, this increase became significant (0.0249±0.0441, P: 0.0015). Sensitivity analysis confirmed our results in borderline lesions. CONCLUSIONS TAVR resulted in small significant, but opposite, changes in FFR and NHPR. Using the standard cut-offs in patients with severe aortic stenosis, FFR might underestimate the physiological significance of a coronary lesion while NHPRs might overestimate its significance. The described changes only play a clinically relevant role in borderline lesions. Therefore, even in patients with aortic stenosis, an overtly positive or negative physiological assessment can be trusted.
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Affiliation(s)
- Lennert Minten
- Department of Cardiovascular Sciences Katholieke Universiteit Leuven Leuven Belgium
- Division of Cardiovascular Medicine Stanford University Palo Alto CA
| | - Johan Bennett
- Department of Cardiovascular Sciences Katholieke Universiteit Leuven Leuven Belgium
- Department of Cardiovascular Medicine University Hospitals Leuven (UZ Leuven) Leuven Belgium
| | - Hisao Otsuki
- Division of Cardiovascular Medicine Stanford University Palo Alto CA
| | - Kuniaki Takahashi
- Division of Cardiovascular Medicine Stanford University Palo Alto CA
| | - William F Fearon
- Division of Cardiovascular Medicine Stanford University Palo Alto CA
| | - Christophe Dubois
- Department of Cardiovascular Sciences Katholieke Universiteit Leuven Leuven Belgium
- Department of Cardiovascular Medicine University Hospitals Leuven (UZ Leuven) Leuven Belgium
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Li X, Simakov S, Liu Y, Liu T, Wang Y, Liang F. The Influence of Aortic Valve Disease on Coronary Hemodynamics: A Computational Model-Based Study. Bioengineering (Basel) 2023; 10:709. [PMID: 37370640 DOI: 10.3390/bioengineering10060709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/31/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Aortic valve disease (AVD) often coexists with coronary artery disease (CAD), but whether and how the two diseases are correlated remains poorly understood. In this study, a zero-three dimensional (0-3D) multi-scale modeling method was developed to integrate coronary artery hemodynamics, aortic valve dynamics, coronary flow autoregulation mechanism, and systemic hemodynamics into a unique model system, thereby yielding a mathematical tool for quantifying the influences of aortic valve stenosis (AS) and aortic valve regurgitation (AR) on hemodynamics in large coronary arteries. The model was applied to simulate blood flows in six patient-specific left anterior descending coronary arteries (LADs) under various aortic valve conditions (i.e., control (free of AVD), AS, and AR). Obtained results showed that the space-averaged oscillatory shear index (SA-OSI) was significantly higher under the AS condition but lower under the AR condition in comparison with the control condition. Relatively, the overall magnitude of wall shear stress was less affected by AVD. Further data analysis revealed that AS induced the increase in OSI in LADs mainly through its role in augmenting the low-frequency components of coronary flow waveform. These findings imply that AS might increase the risk or progression of CAD by deteriorating the hemodynamic environment in coronary arteries.
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Affiliation(s)
- Xuanyu Li
- Department of Engineering Mechanics, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Sergey Simakov
- Marchuk Institute of Numerical Mathematics of the Russian Academy of Sciences, Moscow 119991, Russia
| | - Youjun Liu
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing 100124, China
| | - Taiwei Liu
- Department of Engineering Mechanics, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Yue Wang
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Fuyou Liang
- Department of Engineering Mechanics, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
- State Key Laboratory of Ocean Engineering, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
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Dobrolinska MM, Gąsior P, Błach A, Gocoł R, Hudziak D, Wojakowski W. Myocardial Perfusion and Coronary Physiology Assessment of Microvascular Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation-Rationale and Design. Biomimetics (Basel) 2022; 7:biomimetics7040230. [PMID: 36546930 PMCID: PMC9775333 DOI: 10.3390/biomimetics7040230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is 30-68%. Nevertheless, there is still not enough evidence to use invasive assessment of lesion severity, because the hemodynamic milieu of AS may impact the fractional flow reserve (FFR) and non-hyperemic indices. Therefore, the aim of the study is two-fold. First, to measure acute and long-term changes of FFR, index of microvascular resistance (IMR), and coronary flow reserve (CFR) in patients undergoing TAVI procedure. Second, to compare the diagnostic accuracy of intracoronary indices with myocardial perfusion measured by cadmium-zinc-telluride single-photon emission tomography (CZT-SPECT) and find cut-off values defining significant stenosis. We plan to enroll 40 patients eligible for TAVI with intermediate stenosis (30-70%) in the left anterior descending (LAD) coronary artery. In each patient FFR, CFR, and IMR will be measured in addition to myocardial blood flow calculated by CZT-SPECT before and either immediately after TAVI (acute cohort) or in 6 months (late cohort) after the procedure. FFR, CFR, and IMR will be matched with the results of myocardial perfusion measured by CZT-SPECT in the area of LAD. As a result, cut-off values of FFR, CFR, and IMR defining the decreased blood flow will be found.
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Affiliation(s)
- M. M. Dobrolinska
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
- Correspondence:
| | - P. Gąsior
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
| | - A. Błach
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
- Nuclear Medicine Department, Voxel Medical Diagnostic Centre, 40-635 Katowice, Poland
| | - R. Gocoł
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - D. Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, 40-635 Katowice, Poland
| | - W. Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, 40-635 Katowice, Poland
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Serial changes of coronary flow reserve over one year after transcatheter aortic valve implantation in patients with severe aortic stenosis. IJC HEART & VASCULATURE 2022; 42:101090. [PMID: 35873862 PMCID: PMC9304717 DOI: 10.1016/j.ijcha.2022.101090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 01/09/2023]
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Minten L, McCutcheon K, Bennett J, Dubois C. Coronary physiology to guide treatment of coronary artery disease in a patient with severe aortic valve stenosis: friend or foe? A case report. Eur Heart J Case Rep 2022; 6:ytac333. [PMID: 36004043 PMCID: PMC9395135 DOI: 10.1093/ehjcr/ytac333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/16/2022] [Accepted: 07/26/2022] [Indexed: 01/09/2023]
Abstract
Abstract
Background
Severe aortic valve stenosis (AS) is the most frequent valve pathology in the developed world requiring intervention. Due to common factors in pathogenesis, patients with AS frequently have concomitant coronary artery disease (CAD). Determining the relative contribution of each component to the disease state is not easy as there is much overlap in complaints. Moreover, severe AS interferes with the haemodynamic assessment of intermediate coronary lesions.
Case summary
In this case report we describe the presentation and management of an 84-year-old patient, with a severely degenerated aortic valve bioprosthesis and an intermediate coronary artery lesion, presenting with acute decompensated heart failure and chest pain. Initial invasive haemodynamic assessment of the coronary lesion provided challenging findings and a second catheterization and intervention was needed to free the patient from his chest pain.
Discussion
Optimal assessment and treatment of CAD before valve replacement are controversial. Aortic valve stenosis on itself can lead to subendocardial ischaemia with subsequent angina pectoris. Simultaneously, AS can significantly affect coronary haemodynamics, hereby interfering with intra-coronary haemodynamic assessment of co-existing coronary lesions. Currently used coronary physiological indices are not validated in the AS population and valve replacement has variable effects on the fractional flow reserve and commonly used resting indices, such as the resting full-cycle ratio. Further research on this topic is needed and an overview of currently running studies that will advance this field significantly is provided.
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Affiliation(s)
- Lennert Minten
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven , Herestraat 49, 3000 Leuven , Belgium
- Department of Cardiovascular Medicine, University Hospitals Leuven (UZ Leuven) , 3000 Leuven , Belgium
| | - Keir McCutcheon
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven , Herestraat 49, 3000 Leuven , Belgium
| | - Johan Bennett
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven , Herestraat 49, 3000 Leuven , Belgium
- Department of Cardiovascular Medicine, University Hospitals Leuven (UZ Leuven) , 3000 Leuven , Belgium
| | - Christophe Dubois
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven , Herestraat 49, 3000 Leuven , Belgium
- Department of Cardiovascular Medicine, University Hospitals Leuven (UZ Leuven) , 3000 Leuven , Belgium
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Sabbah M, Olsen NT, Minkkinen M, Holmvang L, Tilsted H, Pedersen F, Joshi FR, Ahtarovski K, Sørensen R, Linde JJ, Søndergaard L, Pijls N, Lønborg J, Engstrøm T. Microcirculatory Function in Nonhypertrophic and Hypertrophic Myocardium in Patients With Aortic Valve Stenosis. J Am Heart Assoc 2022; 11:e025381. [PMID: 35470693 PMCID: PMC9238586 DOI: 10.1161/jaha.122.025381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Left ventricular hypertrophy (LVH) has often been supposed to be associated with abnormal myocardial blood flow and resistance. The aim of this study was to evaluate and quantify the physiological and pathological changes in myocardial blood flow and microcirculatory resistance in patients with and without LVH attributable to severe aortic stenosis. Methods and Results Absolute coronary blood flow and microvascular resistance were measured using a novel technique with continuous thermodilution and infusion of saline. In addition, myocardial mass was assessed with cardiac magnetic resonance imaging. Fifty-three patients with aortic valve stenosis were enrolled in the study. In 32 patients with LVH, hyperemic blood flow per gram of tissue was significantly decreased compared with 21 patients without LVH (1.26±0.48 versus 1.66±0.65 mL·min-1·g-1; P=0.018), whereas minimal resistance indexed for left ventricular mass was significantly increased in patients with LVH (63 [47-82] versus 43 [35-63] Wood Units·kg; P=0.014). Conclusions Patients with LVH attributable to severe aortic stenosis had lower hyperemic blood flow per gram of myocardium and higher minimal myocardial resistance compared with patients without LVH.
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Affiliation(s)
- Muhammad Sabbah
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Niels Thue Olsen
- Department of CardiologyCopenhagen University Hospital–Herlev and GentofteGentofteDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Mikko Minkkinen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Hans‐Henrik Tilsted
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Frants Pedersen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Francis R. Joshi
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Kiril Ahtarovski
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Rikke Sørensen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Jesper James Linde
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lars Søndergaard
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nico Pijls
- Department of CardiologyCatharina HospitalEindhoventhe Netherlands
| | - Jacob Lønborg
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Thomas Engstrøm
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
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7
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Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.
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Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Srdjan Aleksandric
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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8
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Agreement between iFR and other non-hyperaemic pressure ratios in severe aortic stenosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:47-52. [DOI: 10.1016/j.carrev.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 01/10/2023]
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Bilak JM, Alam U, Miller CA, McCann GP, Arnold JR, Kanagala P. Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction: Pathophysiology, Assessment, Prevalence and Prognosis. Card Fail Rev 2022; 8:e24. [PMID: 35846985 PMCID: PMC9274364 DOI: 10.15420/cfr.2022.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) currently accounts for approximately half of all new heart failure cases in the community. HFpEF is closely associated with chronic lifestyle-related diseases, such as obesity and type 2 diabetes, and clinical outcomes are worse in those with than without comorbidities. HFpEF is pathophysiologically distinct from heart failure with reduced ejection fraction, which may explain, in part, the disparity of treatment options available between the two heart failure phenotypes. The mechanisms underlying HFpEF are complex, with coronary microvascular dysfunction (MVD) being proposed as a potential key driver in its pathophysiology. In this review, the authors highlight the evidence implicating MVD in HFpEF pathophysiology, the diagnostic approaches for identifying MVD (both invasive and non-invasive) and the prevalence and prognostic significance of MVD.
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Affiliation(s)
- Joanna M Bilak
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Uazman Alam
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of ManchesterManchester, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of LiverpoolLiverpool, UK
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science CentreManchester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Prathap Kanagala
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Liverpool Centre for Cardiovascular Sciences, Faculty of Health and Life SciencesLiverpool, UK
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Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M, Kennon S, Forrest JK, Mathur A, Mullen MJ, Lansky A, Baumbach A. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:2083-2096. [PMID: 34620388 DOI: 10.1016/j.jcin.2021.07.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Michail
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Krishnaraj Rathod
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Daniel A Jones
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mick Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Mathur
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andreas Baumbach
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA.
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11
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Kleczynski P, Dziewierz A, Rzeszutko L, Dudek D, Legutko J. Hyperemic versus non-hyperemic indexes for coronary physiology assessment in patients with severe aortic stenosis. Adv Med Sci 2021; 66:366-371. [PMID: 34315011 DOI: 10.1016/j.advms.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/22/2021] [Accepted: 07/18/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Recent data suggests that fractional flow reserve (FFR) may underestimate intermediate coronary stenosis in the presence of severe aortic stenosis (AS), whereas instantaneous wave-free ratio (iFR) values may remain similar after treatment of AS, yet the evidence still lacks to use iFR as the reference. We aimed to compare FFR/iFR values in the AS setting. MATERIALS AND METHODS The functional significance of 416 coronary lesions in 221 patients with severe AS was investigated with iFR and FFR. RESULTS The diagnostic agreement between iFR and FFR has been tested, using the cut-off value of 0.89 for iFR and 0.80 for FFR. The mean diameter stenosis was 58.6 ± 13.4% with FFR of 0.85 ± 0.07 and iFR of 0.90 ± 0.04. FFR ≤0.80 was identified in 26.0% and iFR≤0.89 in 33.2% of interrogated vessels. Good agreement between iFR and FFR was confirmed (Intraclass Correlation Coefficient 0.83 [95%CI 0.79-0.85]). The overall diagnostic accuracy (AUC in ROC analysis) of FFR in detecting iFR≤0.89 was 0.997 (95%CI 0.986 to 1.000; p<0.001) and of iFR in detecting FFR≤0.80 was 0.995 (95%CI 0.983 to 0.999; p<0.001). The optimal cut-off value for FFR to detect iFR≤0.89 was 0.82 with sensitivity, specificity, and accuracy of 97.1%, 98.9%, and 97.7%, respectively, and for IFR to detect FFR≤0.80 was 0.88 with sensitivity, specificity, and accuracy of 99.1%, 95.8%, and 97.4%, respectively. CONCLUSION In the presence of AS, FFR has good agreement with iFR. However, the optimal FFR/iFR threshold to identify iFR≤0.89/FFR≤0.80 may be different from the standard thresholds of ischemia.
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Affiliation(s)
- Pawel Kleczynski
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland.
| | - Artur Dziewierz
- 2(nd) Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, University Hospital, Krakow, Poland
| | - Lukasz Rzeszutko
- 2(nd) Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, University Hospital, Krakow, Poland
| | - Dariusz Dudek
- 2(nd) Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, University Hospital, Krakow, Poland
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
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12
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Ex vivo to in vivo extrapolation of syringic acid and ferulic acid as grape juice proxies for endothelium-dependent vasodilation: Redefining vasoprotective resveratrol of the French paradox. Food Chem 2021; 363:130323. [PMID: 34247035 DOI: 10.1016/j.foodchem.2021.130323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 05/24/2021] [Accepted: 06/05/2021] [Indexed: 02/06/2023]
Abstract
Resveratrol, in wines, has been implicated to be primarily responsible for the French paradox, remaining controversial. Herein, we elucidated the representative vasodilation-increasing polyphenols from concord grape juice (CGJ) using ex vivo-to-in vivo extrapolation (EVIVE). We verified the interference-free antioxidant response of CGJ post-dose supernatant of deproteinated serum (CPSDS, as ex vivo proxy) in isolated aortic rings, and in healthy, and H2O2-treated endothelial cells (H-ECs). Syringic acid and ferulic acid (SF) were detected in CGJ and post-dose rat serum (PRS). In isolated aortic rings and H-ECs, polyphenols alone, or in combination, at doses equivalent to those detected in PRS, quantitatively reflected endothelium-dependent vasodilation of CPSDS, as evidenced by nitric oxide (NO) formation-mediated antioxidation-sensitive activation of Src kinase with subsequent PI3/Akt-dependent phosphorylation of endothelial NO synthase. Using EVIVE, SF closely reflected CGJ in coronary flow-mediated vasodilation. Hence, SF application in precision ethnomedicine may redefine antioxidant-sensitive vasoprotective resveratrol of the French paradox.
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Patients with aortic stenosis exhibit early improved endothelial function following transcatheter aortic valve replacement: The eFAST study. Int J Cardiol 2021; 332:143-147. [PMID: 33775789 DOI: 10.1016/j.ijcard.2021.03.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) exhibit systemic endothelial dysfunction, which can be associated with myocardial ischaemia in absence of obstructive coronary disease. Transcatheter aortic valve replacement (TAVR) is used to treat severe AS in patients with high or prohibitive surgical risk. However, it remains unknown whether endothelial function recovers post-TAVR. We therefore sought to assess the early and late changes in flow-mediated dilation (FMD), a measure of endothelial function, following TAVR. METHODS Patients undergoing TAVR for severe AS had ultrasound assessment of brachial endothelial-independent and -dependent FMD. Measurements were performed pre-TAVR, at early follow-up (<48 h post-TAVR) and late follow-up (4-6 weeks post-TAVR). RESULTS 27 patients (mean age 82.0 ± 7.0; 33.3% female) were recruited; 37.0% had diabetes mellitus and 59.3% had hypertension. Brachial artery FMD increased from 4.2 ± 1.6% (pre-TAVR) to 9.7 ± 3.5% at early follow-up (p < 0.0001). At late follow-up, improvement compared with early follow-up was sustained (8.7 ± 1.9%, p = 0.27). Resting brachial arterial flow velocities decreased significantly at late follow-up (11.24 ± 5.16 vs. 7.73 ± 2.79 cm/s, p = 0.003). Concordantly, at late follow-up, there was decrease in resting wall shear stress (WSS; 14.8 ± 7.8 vs. 10.6 ± 4.8dyne/cm2, p = 0.01), peak WSS (73.1 ± 34.1 vs. 58.8 ± 27.8dyne/cm2, p = 0.03) and cumulative WSS (3543 ± 1852 vs. 2504 ± 1089dyne·s/cm2, p = 0.002). Additionally, a favourable inverse correlation between cumulative WSS and FMD was restored at late follow-up (r = -0.21 vs. r = 0.49). CONCLUSION Endothelial function in patients with AS improves early post-TAVR and this improvement is sustained. This likely occurs as a result of improved arterial haemodynamics, leading to lower localised WSS and release of vasoactive mediators that may also alleviate myocardial ischaemia.
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Michail M, Thakur U, Mehta O, Ramzy JM, Comella A, Ihdayhid AR, Cameron JD, Nicholls SJ, Hoole SP, Brown AJ. Non-hyperaemic pressure ratios to guide percutaneous coronary intervention. Open Heart 2020; 7:e001308. [PMID: 33004619 PMCID: PMC7534727 DOI: 10.1136/openhrt-2020-001308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023] Open
Abstract
The use of fractional flow reserve (FFR) in guiding revascularisation improves patient outcomes and has been well-established in clinical guidelines. Despite this, the uptake of FFR has been limited, likely attributable to the perceived increase in procedural time and use of hyperaemic agents that can cause patient discomfort. This has led to the development of instantaneous wave-free ratio (iFR), an alternative non-hyperaemic pressure ratio (NHPR). Since its inception, the use of iFR has been supported by an increasing body of evidence and is now guideline recommended. More recently, other commercially available NHPRs including diastolic hyperaemia-free ratio and resting full-cycle ratio have emerged. Studies have demonstrated that these indices, in addition to mean distal coronary artery pressure to mean aortic pressure ratio, are mathematically analogous (with specific nuances) to iFR. Additionally, there is increasing data demonstrating the equivalent diagnostic performance of alternative NHPRs in comparison with iFR and FFR. These NHPRs are now integral within most current pressure wire systems and are commonly available in the catheter laboratory. It is therefore key to understand the fundamental differences and evidence for NHPRs to guide appropriate clinical decision-making.
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Affiliation(s)
- Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Udit Thakur
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Ojas Mehta
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - John M Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Andrea Comella
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen P Hoole
- Department of Interventional Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Adam J Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
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Casadonte L, Baan J, Piek JJ, Siebes M. Usefulness of Proximal Coronary Wave Speed for Wave Intensity Analysis in Diseased Coronary Vessels. Front Cardiovasc Med 2020; 7:133. [PMID: 32850986 PMCID: PMC7426658 DOI: 10.3389/fcvm.2020.00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/29/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Wave speed is needed to separate net wave intensity into forward and backward traveling components. However, wave speed in diseased coronary arteries cannot be assessed from hemodynamic measurements obtained distal to a stenosis. Wave speed inherently depends on arterial wall properties which should be similar proximal and distal to a stenosis. Our hypothesis is that proximal wave speed can be used to separate net wave intensity obtained distal to a stenosis. Methods: We assessed coronary wave speed using the sum-of-squares single-point technique (SPc) based on simultaneous intracoronary pressure and flow velocity measurements in human coronary arteries. SPc at resting flow was determined in diseased coronary vessels of 12 patients both proximal and distal to the stenosis. In seven of these vessels, distal measurements were additionally obtained after revascularization by stent placement. SPc was also assessed at two axial locations in 14 reference vessels without a stenosis. Results: (1) No difference in SPc was present between proximal and distal locations in the reference vessels. (2) In diseased vessels with a focal stenosis, SPc at the distal location was paradoxically larger than SPc proximal to the stenosis (28.4 ± 3.7 m/s vs. 18.3 ± 1.8 m/s, p < 0.02), despite the lower distending pressure downstream of the stenosis. The corresponding separated wave energy tended to be underestimated when derived from SPc at the distal compared with the proximal location. (3) After successful revascularization, SPc at the distal location no longer differed from SPc at the proximal location prior to revascularization (21.9 ± 2.0 m/s vs. 20.8 ± 1.9 m/s, p = 0.48). Accordingly, no significant difference in separated wave energy was observed for forward or backward waves. Conclusion: In diseased coronary vessels, SPc assessed from distal hemodynamic signals is erroneously elevated. Our findings suggest that proximal wave speed can be used to separate wave intensity profiles obtained downstream of a stenosis. This approach may extend the application of wave intensity analysis to diseased coronary vessels.
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Affiliation(s)
- Lorena Casadonte
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | - Jan Baan
- Department of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | - Jan J. Piek
- Department of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | - Maria Siebes
- Department of Translational Physiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Maria Siebes
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Hemodynamic effects of aortic valve and heart rate on coronary perfusion. Clin Biomech (Bristol, Avon) 2020; 78:105075. [PMID: 32535477 DOI: 10.1016/j.clinbiomech.2020.105075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/29/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reduced coronary flow reserve in aortic stenosis and after transcatheter aortic valve implantation is usually attributed to physiological factors taking place during systole, such as an increase in coronary resistance, and backward waves intensity. In this paper, we suggest an additional factor related to the diastolic hemodynamics in the aortic root. METHODS We measured left ventricle, aortic and coronary pressure and coronary perfusion in in-vitro models of healthy, aortic stenosis and an artificial valve at different heart rates and cardiac output conditions, to isolate the effect of hemodynamic factors in the aortic root during diastole. FINDINGS Our results show that during diastole, coronary perfusion depends on the pressure gradient between the aorta and the coronary inlet. This aorta-coronary pressure gradient is influenced by the hemodynamic flow field in the aortic root. The ratio between the aorta-coronary pressure gradient magnitude in stress to that under rest conditions of a healthy model is ten times higher than the same ratio in the aortic stenosis model and twice higher as compared to the artificial valve model result. The coronary flow reserve of the healthy model is correspondingly higher compared to the artificial valve and the aortic stenosis models. These results are in agreement with the clinical evidence. INTERPRETATION This study supports the hypothesis of a hemodynamic mechanism in the aortic root that increases coronary flow during rest but reduces the coronary flow reserve in aortic stenosis and artificial valve cases. The results may provide valuable insights regarding valve design.
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17
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Fractional flow reserve in patients with coronary artery disease undergoing TAVI: a prospective analysis. Clin Res Cardiol 2019; 109:746-754. [PMID: 31679046 DOI: 10.1007/s00392-019-01563-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/17/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To determine the true prevalence of CAD in AS patients, to detect changes of the hemodynamic significance of coronary lesions following TAVI, to explore to what extent FFR-positive CAD might influence outcome and finally to develop a management algorithm for this patient subset. METHODS From May 2016 to March 2018, diagnostic coronary angiography was performed in 246 patients before TAVI. In the presence of coronary lesions with a diameter stenosis ≥ 50%, FFR was measured. In patients with positive FFR ≤ 0.80, a control angiography was performed 6-8 weeks after TAVI. RESULTS The study cohort was 81.0 ± 6.1 years old, 48.4% of the patients were male. 53.3% had concomitant CAD. 35.9% of these patients underwent PCI before TAVI due to functionally significant left main CAD and/or severe stenosis ≥ 90%. 31 patients underwent FFR measurements in cumulative 38 coronary lesions. Prior to TAVI, a negative FFR could be detected in 18 lesions, whereas a positive FFR was found in entirely 20 lesions. A control angiography and FFR measurement was performed in cumulative 13 lesions. Comparing the FFR values, there was no significant difference (0.77 ± 0.04 vs. 0.76 ± 0.08; p = 0.11). CONCLUSION Concomitant CAD was diagnosed in 53.3% of TAVI patients. FFR did not significantly change after TAVI, confirming the validity of FFR to evaluate coronary lesions in this specific clinical setting. Given the low rates of cardiac adverse events, it might therefore be considered to treat coronary stenoses not involving left main and those with a diameter stenosis < 90% after TAVI.
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Abstract
Regulation of coronary blood flow is maintained through a delicate balance of ventriculoarterial and neurohumoral mechanisms. The aortic valve is integral to the functions of these systems, and disease states that compromise aortic valve integrity have the potential to seriously disrupt coronary blood flow. Aortic stenosis (AS) is the most common cause of valvular heart disease requiring medical intervention, and the prevalence and associated socio-economic burden of AS are set to increase with population ageing. Valvular stenosis precipitates a cascade of structural, microcirculatory, and neurohumoral changes, which all lead to impairment of coronary flow reserve and myocardial ischaemia even in the absence of notable coronary stenosis. Coronary physiology can potentially be normalized through interventions that relieve severe AS, but normality is often not immediately achievable and probably requires continued adaptation. Finally, the physiological assessment of coronary artery disease in patients with AS represents an ongoing challenge, as the invasive physiological measures used in current cardiology practice are yet to be validated in this population. This Review discusses the key concepts of coronary pathophysiology in patients with AS through presentation of contemporary basic science and data from animal and human studies.
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Abstract
Aortic stenosis is a heterogeneous disorder. Variations in the pathological and physiological responses to pressure overload are incompletely understood and generate a range of flow and pressure gradient patterns, which ultimately cause varying microvascular effects. The impact of cardiac-coronary coupling depends on these pressure and flow effects. In this article, we explore important concepts concerning cardiac physiology and the coronary microcirculation in aortic stenosis and their impact on myocardial remodeling, aortic valve flow patterns, and clinical progression.
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Affiliation(s)
- Hannah Z.R. McConkey
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Michael Marber
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Canada (P.P.)
| | - Simon R. Redwood
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Bernard D. Prendergast
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
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20
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Stoller M, Gloekler S, Zbinden R, Tueller D, Eberli F, Windecker S, Wenaweser P, Seiler C. Left ventricular afterload reduction by transcatheter aortic valve implantation in severe aortic stenosis and its prompt effects on comprehensive coronary haemodynamics. EUROINTERVENTION 2019; 14:166-173. [PMID: 29553941 DOI: 10.4244/eij-d-17-00719] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS In this study we aimed to test the hypothesis that left ventricular (LV) afterload reduction in severe aortic valve stenosis (AS) by transcatheter aortic valve implantation (TAVI) acutely improves coronary haemodynamics. METHODS AND RESULTS This was a prospective, pathophysiologic study in 40 patients with severe AS undergoing TAVI. Endpoints were determined invasively immediately before and after TAVI without altering coronary stenotic lesions if present. Myocardial hyperaemia was induced by intravenous adenosine. The primary study endpoints were coronary flow reserve (thermodilution-derived CFR), and fractional flow reserve (FFR). The secondary study endpoint was coronary collateral flow index (CFI) as obtained during a one-minute coronary balloon occlusion. CFR was 1.9±0.9 before TAVI and 2.0±1.0 after TAVI (p=0.72). FFR was 0.90±0.08 before TAVI and 0.93±0.08 after TAVI (p=0.0021). The TAVI-induced increase in FFR was related to a significant decrease in hyperaemic mean aortic pressure from 71±16 mmHg before TAVI to 67±15 mmHg after TAVI (p=0.0099). Hyperaemic CFI increased from 0.127±0.083 before to 0.146±0.090 after TAVI (p=0.0508). CONCLUSIONS CFR appears not to be acutely affected by LV afterload reduction among patients with severe AS in response to TAVI. However, it acutely improves FFR; this occurs via lowering of mean aortic pressure. Hyperaemic coronary collateral flow index tends to augment in response to TAVI.
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Affiliation(s)
- Michael Stoller
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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21
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Scarsini R, Cantone R, Venturi G, De Maria GL, Variola A, Braggio P, Lunardi M, Pesarini G, Ferdeghini M, Piccoli A, Feola M, Kharbanda RK, Banning AP, Ribichini F. Correlation between intracoronary physiology and myocardial perfusion imaging in patients with severe aortic stenosis. Int J Cardiol 2019; 292:162-165. [PMID: 31029497 DOI: 10.1016/j.ijcard.2019.04.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/05/2019] [Accepted: 04/16/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Aortic stenosis (AS) is frequently associated with coronary artery disease (CAD). However, the best tool to functionally assess CAD in AS remains undetermined. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) have never been validated in AS. METHODS FFR, iFR and stress single photon emission computed tomography (SPECT) were performed in a consecutive series of 28 patients with severe AS and 41 borderline coronary lesions during the work-up for valve replacement. RESULTS Both FFR and iFR were correlated with an abnormal SPECT. At ROC analysis, FFR yielded an AUC = 0.91 with negative predictive value (NPV) = 95% in detecting ischemia according to SPECT. iFR showed significant worse agreement with myocardial perfusion imaging compared to FFR (59% vs 85%, p = 0.014). Specifically, a significant larger proportion of false positive measurements (negative SPECT and iFR < 0.89) was observed using iFR vs FFR: 39% vs 12%, p = 0.011. Using a pre-specified 0.82 cut-off, the iFR agreement with SPECT increased to 73%. CONCLUSIONS FFR yielded a good correlation with SPECT and a high NPV in detecting ischemia-provoking lesions. iFR diagnostic metrics were inferior compared with FFR and improved adopting a lower ischemic threshold.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy; Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom
| | - Rosaria Cantone
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Andrea Variola
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy; Division of Nuclear Cardiology, Department of Nuclear Medicine, University of Verona, Verona, Italy
| | - Paolo Braggio
- Division of Nuclear Cardiology, Department of Nuclear Medicine, University of Verona, Verona, Italy
| | - Mattia Lunardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Marco Ferdeghini
- Division of Nuclear Cardiology, Department of Nuclear Medicine, University of Verona, Verona, Italy
| | - Anna Piccoli
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; Biomolecular Medicine PhD Program, University of Verona, Verona, Italy
| | - Mauro Feola
- Division of Cardiology, Ospedale Mondovì, Cuneo, Italy
| | - Rajesh K Kharbanda
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
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Davies JE, Piek JJ. Time for caution interpreting coronary physiology in aortic stenosis? EUROINTERVENTION 2019; 14:132-134. [PMID: 29937425 DOI: 10.4244/eijv14i2a19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Justin E Davies
- Hammersmith Hospital, Imperial College NHS Trust, London, United Kingdom
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23
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Broyd CJ, Rigo F, Nijjer S, Sen S, Petraco R, Al-Lamee R, Foin N, Chukwuemeka A, Anderson J, Parker J, Malik IS, Mikhail GW, Francis DP, Parker K, Hughes AD, Mayet J, Davies JE. Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: Insights from serial coronary wave intensity analysis. Acta Physiol (Oxf) 2018; 224:e13109. [PMID: 29935058 DOI: 10.1111/apha.13109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 01/10/2023]
Abstract
AIM Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous haemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary "suction" force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave intensity analysis (WIA) to separate and measure the sequential effects of outflow tract obstruction relief and then LVH regression following intervention for aortic stenosis. METHODS Fifteen patients with unobstructed coronary arteries undergoing aortic valve intervention (11 surgical aortic valve replacement [SAVR], 4 TAVI) were successfully assessed before and after intervention, and at 6 and 12 months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial cuff system. RESULTS Immediately following intervention, a decline in the backward decompression wave (BDW) was noted (9.7 ± 5.7 vs 5.1 ± 3.6 × 103 W/m2 /s, P < 0.01). Over 12 months, LV mass index fell from 114 ± 19 to 82 ± 17 kg/m2 . Accompanying this, the BDW fraction increased to 32.8 ± 7.2% at 6 months (P = 0.01 vs post-procedure) and 34.7 ± 6.7% at 12 months (P < 0.001 vs post-procedure). CONCLUSION In aortic stenosis, both the outflow tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features.
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Affiliation(s)
| | - Fausto Rigo
- Division of Cardiology; dell'Angelo Hospital; Mestre-Venice Italy
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24
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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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25
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Benenati S, De Maria GL, Scarsini R, Porto I, Banning AP. Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:362-372. [DOI: 10.1016/j.carrev.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
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26
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Scarsini R, Pesarini G, Lunardi M, Piccoli A, Zanetti C, Cantone R, Bellamoli M, Ferrero V, Gottin L, Faggian G, Ribichini F. Observations from a real-time, iFR-FFR “hybrid approach” in patients with severe aortic stenosis and coronary artery disease undergoing TAVI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:355-359. [DOI: 10.1016/j.carrev.2017.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 02/02/2023]
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27
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Scarsini R, Pesarini G, Zivelonghi C, Piccoli A, Ferrero V, Lunardi M, Gottin L, Zanetti C, Faggian G, Ribichini F. Physiologic evaluation of coronary lesions using instantaneous wave-free ratio (iFR) in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EUROINTERVENTION 2018; 13:1512-1519. [DOI: 10.4244/eij-d-17-00542] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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28
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A numerical study of the hemodynamic effect of the aortic valve on coronary flow. Biomech Model Mechanobiol 2017; 17:319-338. [DOI: 10.1007/s10237-017-0962-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
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29
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Yacoub MH, Afifi A, Saad H, Aguib H, ElGuindy A. Current state of the art and future of myectomy. Ann Cardiothorac Surg 2017; 6:307-317. [PMID: 28944171 DOI: 10.21037/acs.2017.06.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical relief of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) requires more than septal myectomy. The procedure is currently the gold standard for all symptomatic HCM patients except those with comorbidities. The operation requires an individualized approach to restore the sophisticated functions of the left ventricular outflow tract (LVOT) without injury to the surrounding vital structures. The procedure should be tailored to deal with all the varied components of the obstruction including fibrous trigones, accessory tissues, and papillary muscle fusion. Preoperative multimodality imaging and numerical modeling combined with intraoperative transesophageal echocardiography (TEE) are essential to define existing anomalies as well as assess the adequacy of the repair. The mitral valve can be conserved in virtually all patients. The operation can be conducted with very low mortality and morbidity with predictable good outcomes both in the short and long term. Nevertheless, surgical relief of LVOTO is still grossly underused.
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Affiliation(s)
- Magdi H Yacoub
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed Afifi
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Hesham Saad
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Heba Aguib
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed ElGuindy
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
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30
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Mejía-Rentería H, van der Hoeven N, van de Hoef TP, Heemelaar J, Ryan N, Lerman A, van Royen N, Escaned J. Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests. Int J Cardiovasc Imaging 2017; 33:1041-1059. [PMID: 28501910 DOI: 10.1007/s10554-017-1136-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/08/2017] [Indexed: 01/10/2023]
Abstract
The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.
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Affiliation(s)
- Hernán Mejía-Rentería
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Tim P van de Hoef
- AMC Heart Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Nicola Ryan
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
| | | | | | - Javier Escaned
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain.
- Universidad Complutense de Madrid (UCM), Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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31
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Pesarini G, Scarsini R, Zivelonghi C, Piccoli A, Gambaro A, Gottin L, Rossi A, Ferrero V, Vassanelli C, Ribichini F. Functional Assessment of Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004088. [DOI: 10.1161/circinterventions.116.004088] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/26/2016] [Indexed: 01/09/2023]
Abstract
Background—
Aortic valve stenosis may influence fractional flow reserve (FFR) of concomitant coronary artery disease by causing hypertrophy and reducing the vasodilatory reserve of the coronary circulation. We sought to investigate whether FFR values might change after valve replacement.
Methods and Results—
The functional relevance of 133 coronary lesions was assessed by FFR in 54 patients with severe aortic valve stenosis before and after transcatheter aortic valve implantation (TAVI) during the same procedure. A linear mixed model was used to verify the interaction of TAVI effect with the FFR values. No significant overall change in FFR values was found before and after the aortic valve stenosis removal (0.89±0.10 versus 0.89±0.13;
P
=0.73). A different trend in FFR groups (positive if ≤0.8; negative if >0.8) was found after TAVI (
P
for interaction <0.001). Positive FFR values worsened after TAVI (0.71±0.11 versus 0.66±0.14). Conversely, negative FFR values improved after TAVI (0.92±0.06 versus 0.93±0.07). Similarly, FFR values in coronary arteries with lesions presenting percent diameter stenosis >50 worsened after TAVI (0.84±0.12 versus 0.82±0.16;
P
=0.02), whereas FFR values in arteries with mild lesions (percent diameter stenosis <50) tended toward improvement after TAVI (0.90±0.07 versus 0.91±0.09;
P
=0.69). Functional FFR variations after TAVI changed the indication to treat the coronary stenosis in 8 of 133 (6%) lesions.
Conclusions—
Coronary hemodynamics are influenced by aortic valve stenosis removal. Nevertheless, FFR variations after TAVI are minor and crossed the diagnostic cutoff of 0.8 in a small number of patients after valve replacement. Borderline coronary lesions might become functionally significant after valve replacement, although FFR-guided interventions were infrequent even in patients with angiographically significant lesions.
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Affiliation(s)
- Gabriele Pesarini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Roberto Scarsini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Carlo Zivelonghi
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Anna Piccoli
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Alessia Gambaro
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Leonardo Gottin
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Andrea Rossi
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Valeria Ferrero
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Corrado Vassanelli
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Flavio Ribichini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
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