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Eerdekens R, Anderson HVS, Johnson NP. How Do the Flow Components of Coronary Flow Reserve Change After Aortic Valve Replacement? Am J Cardiol 2024; 216:105-107. [PMID: 38401657 DOI: 10.1016/j.amjcard.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Rob Eerdekens
- Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas; Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - H V Skip Anderson
- Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas.
| | - Nils P Johnson
- Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
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Sabbah M, Olsen NT, Holmvang L, Tilsted HH, Pedersen F, Joshi FR, Sørensen R, Jabbari R, Arslani K, Sondergaard L, Engstrøm T, Lønborg JT. Long-term changes in coronary physiology after aortic valve replacement. EUROINTERVENTION 2023; 18:1156-1164. [PMID: 36239118 PMCID: PMC9940233 DOI: 10.4244/eij-d-22-00621] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/01/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND The detrimental effects of long-standing severe aortic stenosis (AS) often include left ventricular hypertrophy (LVH) and exhaustion of coronary flow reserve (CFR), the reversibility of which is unclear after valve replacement. AIMS Our aims were to 1) investigate whether CFR in the left anterior descending artery (LAD) would improve following valve replacement, and if the change was related to changes in hyperaemic coronary flow (QLAD) and minimal microvascular resistance (Rμ,LAD); and 2) investigate the relationship between changes in CFR and changes in left ventricular mass (LVM) and stroke work (LVSW). METHODS We measured intracoronary bolus thermodilution-derived CFR, and continuous thermodilution-derived QLAD and Rμ,LAD before and 6 months after aortic valve replacement. Cardiac magnetic resonance imaging was used to quantify left ventricular anatomy and function for the calculation of LVM and LVSW. Results: Thirty-four patients were included (17 patients had transcatheter aortic valve implantation; 14 had surgical valve replacement with a bioprosthesis and 3 with a mechanical prosthesis) who underwent invasive assessment in the LAD. CFR increased from 2.5 (interquartile range [IQR] 1.5-3.3) at baseline to 3.1 (IQR 2.2-5.1) at follow-up (p=0.005), despite no significant change in QLAD (230±106 mL/min to 250±101 mL/min; p=0.26) or Rμ,LAD (347 [IQR 247-463] to 287 [IQR 230-456]; p=0.20). When indexed for LVM, QLAD was 39% (IQR 8-98%) higher at follow-up compared with baseline (p<0.001). The improvement in CFR was correlated with ΔLVSW, r= -0.39; p=0.047. Conclusions: CFR in the LAD increased significantly at follow-up although global hyperaemic flow and minimal microvascular resistance remained unchanged. Thus, a decrease in resting flow was the cause of CFR improvement. CFR improvement was associated with reduction in LVSW.
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Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niels T Olsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hans-Henrik Tilsted
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Francis Richard Joshi
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ketina Arslani
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Sondergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Thomsen Lønborg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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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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Coronary Microcirculation in Aortic Stenosis: Pathophysiology, Invasive Assessment, and Future Directions. J Interv Cardiol 2020; 2020:4603169. [PMID: 32774184 PMCID: PMC7396014 DOI: 10.1155/2020/4603169] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 01/09/2023] Open
Abstract
With the increasing prevalence of aortic stenosis (AS) due to a growing elderly population, a proper understanding of its physiology is paramount to guide therapy and define severity. A better understanding of the microvasculature in AS could improve clinical care by predicting left ventricular remodeling or anticipate the interplay between epicardial stenosis and myocardial dysfunction. In this review, we combine five decades of literature regarding microvascular, coronary, and aortic valve physiology with emerging insights from newly developed invasive tools for quantifying microcirculatory function. Furthermore, we describe the coupling between microcirculation and epicardial stenosis, which is currently under investigation in several randomized trials enrolling subjects with concomitant AS and coronary disease. To clarify the physiology explained previously, we present two instructive cases with invasive pressure measurements quantifying coexisting valve and coronary stenoses. Finally, we pose open clinical and research questions whose answers would further expand our knowledge of microvascular dysfunction in AS. These trials were registered with NCT03042104, NCT03094143, and NCT02436655.
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Zelis JM, Tonino PAL, Johnson NP. Why Can Fractional Flow Reserve Decrease After Transcatheter Aortic Valve Implantation? J Am Heart Assoc 2020; 9:e04905. [PMID: 32102613 PMCID: PMC7335563 DOI: 10.1161/jaha.120.015806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jo M Zelis
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Pim A L Tonino
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Nils P Johnson
- Division of Cardiology Department of Medicine Weatherhead PET Center McGovern Medical School at UTHealth and Memorial Hermann Hospital Houston TX
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Liu FS, Wang SY, Shiau YC, Wu YW. The clinical value and safety of ECG-gated dipyridamole myocardial perfusion imaging in patients with aortic stenosis. Sci Rep 2019; 9:12443. [PMID: 31455862 PMCID: PMC6712027 DOI: 10.1038/s41598-019-48901-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/15/2019] [Indexed: 12/31/2022] Open
Abstract
The role of vasodilator myocardial perfusion imaging (MPI) for aortic stenosis (AS) is controversial due to safety and accuracy concerns. In addition, its utility after aortic valve (AV) interventions remains unclear. Patients with AS who underwent thallium-201-gated dipyridamole MPI using a cadmium-zinc-telluride camera were retrospectively reviewed and divided into three groups: mild AS, moderate-to-severe AS, and prior AV interventions. Patients with coronary artery disease with ≥50% stenosis, severe arrhythmia, left ventricular ejection fraction (LVEF) <40%, left bundle branch block or no follow-up were excluded. Relationships between the severity of AS, clinical characteristics, hemodynamic response, serious adverse events (SAE) and MPI parameters were analyzed. None of the 47 patients had SAE, including significant hypotension or LVEF reduction. The moderate-to-severe AS group had higher summed stress scores (SSSs) and depressed LVEF than the mild AS group, however there were no differences after AV interventions. SSS was positively correlated with AV mean pressure gradient, post-stress lung-heart ratio (LHRs), and post-stress end-diastolic volume (EDVs) (P < 0.05). In multivariate analysis, LHRs and EDVs were independent contributors to SSS. Dipyridamole-induced ischemia and LV dysfunction is common, and dipyridamole stress could be a safe diagnostic tool in evaluation and follow-up in patients with AS.
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Affiliation(s)
- Fang-Shin Liu
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shan-Ying Wang
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Yu-Chien Shiau
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yen-Wen Wu
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan. .,Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan. .,National Yang-Ming University School of Medicine, Taipei, Taiwan. .,Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan.
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Meimoun P, Czitrom D. [Coronary microvascular dysfunction and aortic stenosis: an update]. Ann Cardiol Angeiol (Paris) 2014; 63:353-361. [PMID: 25261167 DOI: 10.1016/j.ancard.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 06/03/2023]
Abstract
The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - D Czitrom
- Service de cardiologie, institut mutualiste Montsouris, 75014 Paris, France
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Broyd CJ, Sen S, Mikhail GW, Francis DP, Mayet J, Davies JE. Myocardial ischemia in aortic stenosis: insights from arterial pulse-wave dynamics after percutaneous aortic valve replacement. Trends Cardiovasc Med 2013; 23:185-91. [PMID: 23395429 DOI: 10.1016/j.tcm.2012.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/01/2012] [Accepted: 12/03/2012] [Indexed: 01/09/2023]
Abstract
Wave-intensity analysis is a technique that can qualify both the direction and magnitude of the forces accelerating and decelerating coronary blood flow and is derived from simultaneously acquired measures of coronary pressure and velocity using invasive intracoronary wires. Using this technique during TAVI, the dominant force (or 'wave') acting to increase the coronary blood flow which originates from microvascular relaxation is shown to be elevated in severe aortic stenosis and decreased post-implantation. Additionally, with increasing heart rate a progressive fall in the magnitude of this wave is noted and after TAVI this effect is reversed (returning towards the physiological norm). The potential causes of myocardial ischemia in aortic stenosis are clearly multi-factorial but this observation suggests a decoupling between the aorta and myocardium in aortic stenosis, the effects of which are magnified during increased heart rate.
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Affiliation(s)
- Christopher J Broyd
- International Centre for Circulatory Health, National Heart and Lung Institute, 59-61 North Wharf Road, London W2 1LA, UK.
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Meimoun P, Germain AL, Elmkies F, Benali T, Boulanger J, Espanel C, Clerc J, Zemir H, Luycx-Bore A, Tribouilloy C. Factors Associated with Noninvasive Coronary Flow Reserve in Severe Aortic Stenosis. J Am Soc Echocardiogr 2012; 25:835-41. [DOI: 10.1016/j.echo.2012.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Indexed: 01/27/2023]
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Nemes A, Forster T. [Functional vascular alterations associated with aortic valve stenosis]. Orv Hetil 2011; 152:993-9. [PMID: 21642051 DOI: 10.1556/oh.2011.29145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Degenerative changes, atherosclerotic process and calcification of valvular leaflets are mostly responsible for valvular aortic valve stenosis, but congenital bicuspid aortic valve and rheumatic fever in history are also known predisposing factors. Aortic valve stenosis is frequently associated with different functional vascular alterations. The aim of this review is to demonstrate these vascular alterations evaluated by non-invasive methods and underlying physiologic and pathophysiologic processes.
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Affiliation(s)
- Attila Nemes
- Szegedi Tudományegyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika és Kardiológiai Központ Szeged Korányi.
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11
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Perwaiz MK, Schmidt FM, Hammoudeh F, Neupane N, Gulati N, Enriquez D. Pain in right thigh: a benign presentation of a life-threatening disease. J Cardiovasc Med (Hagerstown) 2010; 12:837-8. [PMID: 21107275 DOI: 10.2459/jcm.0b013e3283416c7f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Nemes A, Balázs E, Csanády M, Forster T. Long-term prognostic role of coronary flow velocity reserve in patients with aortic valve stenosis - insights from the SZEGED Study. Clin Physiol Funct Imaging 2009; 29:447-52. [DOI: 10.1111/j.1475-097x.2009.00893.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Zingone B. Impaired coronary flow reserve with aortic stenosis despite aortic valve replacement. J Cardiovasc Med (Hagerstown) 2008; 9:869-71. [DOI: 10.2459/jcm.0b013e3283007cfc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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