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Caglioni S, Mele D, Milzi A, Bergamaschi L, Pavon AG, Landi A. Impact of Coronary Microvascular Dysfunction in Takotsubo Syndrome: Cause, Consequence or Both? Rev Cardiovasc Med 2024; 25:163. [PMID: 39076465 PMCID: PMC11267194 DOI: 10.31083/j.rcm2505163] [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: 12/08/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 07/31/2024] Open
Abstract
Takotsubo syndrome (TTS) is an acute cause of heart failure characterized by a reversible left ventricular (LV) impairment usually induced by a physical or emotional trigger. TTS is not always a benign disease since it is associated with a relatively higher risk of life-threatening complications, such as cardiogenic shock, ventricular arrhythmias, respiratory failure, cardiopulmonary resuscitation and death. Despite notable advancements in the management of patients with TTS, physiopathological mechanisms underlying transient LV dysfunction remain largely unknown. Since TTS carries similar prognostic implications than acute myocardial infarction, the identification of mechanisms and predictors of worse prognosis remain key to establish appropriate treatments. The greater prevalence of TTS among post-menopausal women and the activation of the neuro-cardiac axis triggered by physical or emotional stressors paved the way forward to several studies focused on coronary microcirculation and impaired blood flow as the main physiopathological mechanisms of TTS. However, whether microvascular dysfunction is the cause or a consequence of transient LV impairment remains still unsettled. This review provides an up-to-date summary of available evidence supporting the role of microvascular dysfunction in TTS pathogenesis, summarizing contemporary invasive and non-invasive diagnostic techniques for its assessment. We will also discuss novel techniques focused on microvascular dysfunction in TTS which may support clinicians for the implementation of tailored treatments.
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Affiliation(s)
- Serena Caglioni
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, 44124 Cona, Italy
| | - Daniela Mele
- Cardiology Unit, IRCCS Galeazzi, Sant’Ambrogio Hospital, 20157 Milan, Italy
| | - Andrea Milzi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland
| | - Luca Bergamaschi
- Cardiology Unit, IRCCS Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences -DIMEC, University of Bologna, 40138 Bologna, Italy
| | - Anna Giulia Pavon
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland
| | - Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, 6900 Lugano, Switzerland
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Yan M, Shang H, Guo X, Hao L, Hou S, Zheng H. The diagnostic role of resting myocardial blood flow in STEMI patients after revascularization. Front Cardiovasc Med 2024; 11:1364772. [PMID: 38576422 PMCID: PMC10993732 DOI: 10.3389/fcvm.2024.1364772] [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: 01/03/2024] [Accepted: 02/27/2024] [Indexed: 04/06/2024] Open
Abstract
Background The value of semiquantitative resting myocardial perfusion imaging (MPI) in coronary artery disease (CAD) is limited. At present, quantitative MPI can be performed by a new cadmium zinc tellurium single-photon emission computed tomography (CZT-SPECT) scan. The quantitative index of resting myocardial blood flow (MBF) has received little attention, and its manifestations and clinical value in the presence of unstable coronary blood flow have not been clarified. Purpose In patients with ST-segment elevation myocardial infarction (STEMI), whether resting MBF can provide additional value of blood flow than semi-quantitative resting MPI is not sure. We also explored the influencing factors of resting MBF. Methods This was a retrospective clinical study. We included 75 patients with STEMI in the subacute phase who underwent resting MPI and dynamic scans after reperfusion therapy. General patient information, STEMI-related data, MPI, gated MPI (G-MPI), and resting MBF data were collected and recorded. According to the clinically provided culprit vessels, the resting MBF was divided into ischemic MBF and non-ischemic MBF. The paired Wilcoxon signed-rank test was used for resting MBF. The receiver operating characteristic (ROC) curves were used to determine the optimal threshold for ischemia, and multiple linear regression analysis was used to analyze the influencing factors of resting MBF. Results There was a statistically significant difference between the ischemic MBF and non-ischemic MBF [0.59 (0.47-0.72) vs. 0.76 (0.64-0.93), p < 0.0001]. The ROC curve analysis revealed that resting MBF could identify ischemia to a certain extent, with a cutoff value of 0.5975, area under the curve (AUC) = 0.666, sensitivity = 55.8%, and specificity = 68.7%. Male sex and summed rest score (SRS) were influencing factors for resting MBF. Conclusion To a certain extent, resting MBF can suggest residual ischemia after reperfusion therapy in patients with STEMI. There was a negative correlation between male sex, SRS, and ischemic MBF. A lower resting MBF may be associated with more severe myocardial ischemia.
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Affiliation(s)
- Ming Yan
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hua Shang
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaorui Guo
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Luping Hao
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shuang Hou
- Department of Electronic Science and Technology, School of Electronic and Information Engineering, Beijing Jiaotong University, Beijing, China
| | - Hongming Zheng
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Gutiérrez-Barrios A, Cañadas-Pruaño D, Alfaro LM, Gheorghe L, Silva E, Noval-Morillas I, Pino CCC, Rueda RZ, Calle-Pérez G, Vázquez-García R, Toro-Cebada R. Coronary Flow Reserve and Myocardial Resistance Reserve Changes After Transcatheter Aortic Valve Implantation in Aortic Stenosis. Am J Cardiol 2024; 214:109-114. [PMID: 38232809 DOI: 10.1016/j.amjcard.2024.01.005] [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: 11/12/2023] [Revised: 12/09/2023] [Accepted: 01/01/2024] [Indexed: 01/19/2024]
Abstract
Aortic valve stenosis (AS) induces an alteration in hemodynamic conditions that are responsible for coronary microvasculature impairment. Relief of AS by transcatheter aortic valve implantation (TAVI) is expected to improve the coronary artery hemodynamic. We aimed to assess the midterm effects of TAVI in coronary flow reserve (CFR) and myocardial resistance reserve (MRR) by a continuous intracoronary thermodilution technique. At-rest and hyperemic coronary flow was measured by a continuous thermodilution technique in 23 patients with AS and compared with that in 17 matched controls, and repeated 6 ± 3 months after TAVI in 11 of the patients with AS. In patients with AS, absolute coronary flow at rest was significantly greater, and absolute resistance at rest was significantly less, than in controls (p <0.01 for both), causing less CFR and MRR (1.73 ± 0.4 vs 2.85 ± 1.1, p <0.01 and 1.95 ± 0.4 vs 3.22 ± 1.4, p <0.01, respectively). TAVI implantation yielded a significant 35% increase in CFR (p >0.01) and a 39% increase in MRR (p <0.01) driven by absolute coronary flow at rest reduction (p = 0.03). In patients with AS, CFR and MRR determined by continuous thermodilution are significantly impaired. At 6-month follow-up, TAVI improves these indexes and partially relieves the pathophysiologic alterations, leading to a partial restoration of CFR and MRR.
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Affiliation(s)
- Alejandro Gutiérrez-Barrios
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain.
| | - Dolores Cañadas-Pruaño
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | | | - Livia Gheorghe
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | - Etelvino Silva
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | - Inmaculada Noval-Morillas
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | | | - Ricardo Zayas Rueda
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | - Germán Calle-Pérez
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | - Rafael Vázquez-García
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
| | - Rocio Toro-Cebada
- Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), University of Cadiz, Cadiz, Spain
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Belmonte M, Gallinoro E, Pijls NHJ, Bertolone DT, Keulards DCJ, Viscusi MM, Storozhenko T, Mizukami T, Mahendiran T, Seki R, Fournier S, de Vos A, Adjedj J, Barbato E, Sonck J, Damman P, Keeble T, Fawaz S, Gutiérrez-Barrios A, Paradies V, Bouisset F, Kern MJ, Fearon WF, Collet C, De Bruyne B. Measuring Absolute Coronary Flow and Microvascular Resistance by Thermodilution: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:699-709. [PMID: 38325996 DOI: 10.1016/j.jacc.2023.12.014] [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: 11/14/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Abstract
Diagnosing coronary microvascular dysfunction remains challenging, primarily due to the lack of direct measurements of absolute coronary blood flow (Q) and microvascular resistance (Rμ). However, there has been recent progress with the development and validation of continuous intracoronary thermodilution, which offers a simplified and validated approach for clinical use. This technique enables direct quantification of Q and Rμ, leading to precise and accurate evaluation of the coronary microcirculation. To ensure consistent and reliable results, it is crucial to follow a standardized protocol when performing continuous intracoronary thermodilution measurements. This document aims to summarize the principles of thermodilution-derived absolute coronary flow measurements and propose a standardized method for conducting these assessments. The proposed standardization serves as a guide to ensure the best practice of the method, enhancing the clinical assessment of the coronary microcirculation.
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Affiliation(s)
- Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Cardiology Department, Galeazzi-Sant'Ambrogio Hospital, Milan, Italy
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands.
| | | | - Danielle C J Keulards
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Michele Mattia Viscusi
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | | | | | - Thabo Mahendiran
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ruiko Seki
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Annemiek de Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Julien Adjedj
- Department of Cardiology, Institut Arnault Tzanck, Saint-Laurent-du-Var, France
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Thomas Keeble
- Essex Cardiothoracic Centre, Mid South Essex NHS Foundation Trust, Basildon, Essex, United Kingdom; Medical Technology Research Centre, Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Samer Fawaz
- Essex Cardiothoracic Centre, Mid South Essex NHS Foundation Trust, Basildon, Essex, United Kingdom; Medical Technology Research Centre, Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Alejandro Gutiérrez-Barrios
- Cardiology Department, Hospital Puerta del Mar, Cádiz, Spain; Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz, Cádiz, Spain
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Morton J Kern
- Veteran's Administration Long Beach Health Care System, Long Beach, California, USA
| | - William F Fearon
- Department of Medicine, Division of Cardiology, Stanford Medical Center Palo Alto, Palo Alto, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.
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Fawaz S, Munhoz D, Mahendiran T, Gallinoro E, Mizukami T, Khan SA, Simpson RFG, Svanerud J, Cook CM, Davies JR, Karamasis GV, De Bruyne B, Keeble TR. Assessing the Impact of Prolonged Averaging of Coronary Continuous Thermodilution Traces. Diagnostics (Basel) 2024; 14:285. [PMID: 38337801 PMCID: PMC10855808 DOI: 10.3390/diagnostics14030285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/05/2024] [Accepted: 01/11/2024] [Indexed: 02/12/2024] Open
Abstract
Continuous Thermodilution is a novel method of quantifying coronary flow (Q) in mL/min. To account for variability of Q within the cardiac cycle, the trace is smoothened with a 2 s moving average filter. This can sometimes be ineffective due to significant heart rate variability, ventricular extrasystoles, and deep inspiration, resulting in a fluctuating temperature trace and ambiguity in the location of the "steady state". This study aims to assess whether a longer moving average filter would smoothen any fluctuations within the continuous thermodilution traces resulting in improved interpretability and reproducibility on a test-retest basis. Patients with ANOCA underwent repeat continuous thermodilution measurements. Analysis of traces were performed at averages of 10, 15, and 20 s to determine the maximum acceptable average. The maximum acceptable average was subsequently applied as a moving average filter and the traces were re-analysed to assess the practical consequences of a longer moving average. Reproducibility was then assessed and compared to a 2 s moving average. Of the averages tested, only 10 s met the criteria for acceptance. When the data was reanalysed with a 10 s moving average filter, there was no significant improvement in reproducibility, however, it resulted in a 12% diagnostic mismatch. Applying a longer moving average filter to continuous thermodilution data does not improve reproducibility. Furthermore, it results in a loss of fidelity on the traces, and a 12% diagnostic mismatch. Overall, current practice should be maintained.
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Affiliation(s)
- Samer Fawaz
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
| | - Daniel Munhoz
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, 80138 Naples, Italy
| | - Thabo Mahendiran
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20157 Milan, Italy
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo 142-0064, Japan
| | - Sarosh A. Khan
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
| | - Rupert F. G. Simpson
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
| | | | - Christopher M. Cook
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
| | - John R. Davies
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
| | - Grigoris V. Karamasis
- School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Thomas R. Keeble
- Essex Cardiothoracic Centre, Basildon Hospital, Nether Mayne, Basildon SS16 5NL, UK
- Medical Technology Research Centre (MTRC), Anglia-Ruskin University, Chelmsford CM1 1SQ, UK
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6
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Paolisso P, Gallinoro E, Belmonte M, Bertolone DT, Bermpeis K, De Colle C, Shumkova M, Leone A, Caglioni S, Esposito G, Fabbricatore D, Moya A, Delrue L, Penicka M, De Bruyne B, Barbato E, Bartunek J, Vanderheyden M. Coronary Microvascular Dysfunction in Patients With Heart Failure: Characterization of Patterns in HFrEF Versus HFpEF. Circ Heart Fail 2024; 17:e010805. [PMID: 38108151 DOI: 10.1161/circheartfailure.123.010805] [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: 04/21/2023] [Accepted: 10/18/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is involved in heart failure (HF) onset and progression, independently of HF phenotype and obstructive coronary artery disease. Invasive assessment of CMD might provide insights into phenotyping and prognosis of patients with HF. We aimed to assess absolute coronary flow, absolute microvascular resistance, myocardial perfusion, coronary flow reserve, and microvascular resistance reserve in patients with HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF). METHODS Single-center, prospective study of 56 consecutive patients with de novo HF with nonobstructive coronary artery disease divided into HF with preserved ejection fraction (n=21) and HFrEF (n=35). CMD was invasively assessed by continuous intracoronary thermodilution and defined as coronary flow reserve <2.5. Left ventricular and left anterior descending artery-related myocardial mass was quantified by echocardiography and coronary computed tomography angiography. Myocardial perfusion (mL/min per g) was calculated as the ratio between absolute coronary flow and left anterior descending artery-related mass. RESULTS Patients with HFrEF showed a higher left ventricular and left anterior descending artery-related myocardial mass compared with HF with preserved ejection fraction (P<0.010). Overall, 52% of the study population had CMD, with a similar prevalence between the 2 groups. In HFrEF, CMD was characterized by lower absolute microvascular resistance and higher absolute coronary flow at rest (functional CMD; P=0.002). CMD was an independent predictor of a lower rate of left ventricular reverse remodeling at follow-up. In patients with HF with preserved ejection fraction, CMD was mainly due to higher absolute microvascular resistance and lower absolute coronary flow during hyperemia (structural CMD; P≤0.030). CONCLUSIONS Continuous intracoronary thermodilution allows the definition and characterization of patterns with distinct CMD in patients with HF and could identify patients with HFrEF with a higher rate of left ventricular reverse remodeling at follow-up.
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Affiliation(s)
- Pasquale Paolisso
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Cardiology Unit, Galeazzi-Sant'Ambrogio Hospital, Scientific Institute for Research, Hospitalization, and Health Care (IRCCS), Milan, Italy (E.G.)
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Konstantinos Bermpeis
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Cristina De Colle
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Monika Shumkova
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Attilio Leone
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Serena Caglioni
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Italy (S.C.)
| | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Davide Fabbricatore
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Ana Moya
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Leen Delrue
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Martin Penicka
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Cardiology, Lausanne University Hospital, Switzerland (B.D.B.)
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy (E.B.)
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Marc Vanderheyden
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
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7
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Ciaramella L, Di Serafino L, Mitrano L, De Rosa ML, Carbone C, Rea FS, Monaco S, Scalamogna M, Cirillo P, Esposito G. Invasive Assessment of Coronary Microcirculation: A State-of-the-Art Review. Diagnostics (Basel) 2023; 14:86. [PMID: 38201395 PMCID: PMC10795746 DOI: 10.3390/diagnostics14010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
A significant proportion of patients presenting with signs and symptoms of myocardial ischemia have no "significant" epicardial disease; thereby, the assessment of coronary microcirculation gained an important role in improving diagnosis and guiding therapy. In fact, coronary microvascular dysfunction (CMD) could be found in a large proportion of these patients, supporting both symptoms and signs of myocardial ischemia. However, CMD represents a diagnostic challenge for two main reasons: (1) the small dimension of the coronary microvasculature prevents direct angiographic visualization, and (2) despite the availability of specific diagnostic tools, they remain invasive and underused in the current clinical practice. For these reasons, CMD remains underdiagnosed, and most of the patients remain with no specific treatment and quality-of-life-limiting symptoms. Of note, recent evidence suggests that a "full physiology" approach for the assessment of the whole coronary vasculature may offer a significant benefit in terms of symptom improvement among patients presenting with ischemia and non-obstructive coronary artery disease. We analyze the pathophysiology of coronary microvascular dysfunction, providing the readers with a guide for the invasive assessment of coronary microcirculation, together with the available evidence supporting its use in clinical practice.
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Affiliation(s)
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy; (L.C.); (L.M.); (M.L.D.R.); (C.C.); (F.S.R.); (S.M.); (M.S.); (P.C.); (G.E.)
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8
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Mangiacapra F, Colaiori I, Di Gioia G, Pellicano M, Heyse A, Paolucci L, Peace A, Bartunek J, de Bruyne B, Barbato E. Effects of ticagrelor and prasugrel on coronary microcirculation in elective percutaneous coronary intervention. Heart 2023; 110:115-121. [PMID: 37316163 DOI: 10.1136/heartjnl-2022-321868] [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: 01/14/2023] [Accepted: 05/29/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To compare the effects of ticagrelor and prasugrel on absolute coronary blood flow (Q) and microvascular resistance (R) in patients with stable coronary artery disease (CAD) treated with elective percutaneous coronary intervention (PCI) (NCT05643586). Besides being at least as effective as prasugrel in inhibiting platelet aggregation, ticagrelor has been shown to have additional properties potentially affecting coronary microcirculation. METHODS We randomly assigned 50 patients to ticagrelor (180 mg) or prasugrel (60 mg) at least 12 hours before intervention. Continuous thermodilution was used to measure Q and R before and after PCI. Platelet reactivity was measured before PCI. Troponin I was measured before, 8 and 24 hours after PCI. RESULTS At baseline, fractional flow reserve, Q and R were similar in two study groups. Patients in the ticagrelor group showed higher post-PCI Q (242±49 vs 205±53 mL/min, p=0.015) and lower R values (311 (263, 366) vs 362 (319, 382) mm Hg/L/min, p=0.032). Platelet reactivity showed a negative correlation with periprocedural variation of Q values (r=-0.582, p<0.001) and a positive correlation with periprocedural variation of R values (r=0.645, p<0.001). The periprocedural increase in high-sensitivity troponin I was significantly lower in the ticagrelor compared with the prasugrel group (5 (4, 9) ng/mL vs 14 (10, 24) ng/mL, p<0.001). CONCLUSIONS In patients with stable CAD undergoing PCI, pretreatment with a loading dose of ticagrelor compared with prasugrel improves post-procedural coronary flow and microvascular function and seems to reduce the related myocardial injury.
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Affiliation(s)
- Fabio Mangiacapra
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Iginio Colaiori
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | | | - Alex Heyse
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | - Luca Paolucci
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Jozef Bartunek
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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9
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Gallinoro E, Bertolone DT, Mizukami T, Paolisso P, Bermpeis K, Munhoz D, Sakai K, Seki R, Ohashi H, Esposito G, Caglioni S, Mileva N, Leone A, Candreva A, Belmonte M, Storozhenko T, Viscusi MM, Vanderheyden M, Wyffels E, Bartunek J, Sonck J, Barbato E, Collet C, De Bruyne B. Continuous vs Bolus Thermodilution to Assess Microvascular Resistance Reserve. JACC Cardiovasc Interv 2023; 16:2767-2777. [PMID: 38030361 DOI: 10.1016/j.jcin.2023.09.027] [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: 05/29/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Coronary flow reserve (CFR) and microvascular resistance reserve (MRR) can, in principle, be derived by any method assessing coronary flow. OBJECTIVES The aim of this study was to compare CFR and MRR as derived by continuous (CFRcont and MRRcont) and bolus thermodilution (CFRbolus and MRRbolus). METHODS A total of 175 patients with chest pain and nonobstructive coronary artery disease were studied. Bolus and continuous thermodilution measurements were performed in the left anterior descending coronary artery. MRR was calculated as the ratio of CFR to fractional flow reserve and corrected for changes in systemic pressure. In 102 patients, bolus and continuous thermodilution measurements were performed in duplicate to assess test-retest reliability. RESULTS Mean CFRbolus was higher than CFRcont (3.47 ± 1.42 and 2.67 ± 0.81 [P < 0.001], mean difference 0.80, upper limit of agreement 3.92, lower limit of agreement -2.32). Mean MRRbolus was also higher than MRRcont (4.40 ± 1.99 and 3.22 ± 1.02 [P < 0.001], mean difference 1.2, upper limit of agreement 5.08, lower limit of agreement -2.71). The correlation between CFR and MRR values obtained using both methods was significant but weak (CFR, r = 0.28 [95% CI: 0.14-0.41]; MRR, r = 0.26 [95% CI: 0.16-0.39]; P < 0.001 for both). The precision of both CFR and MRR was higher when assessed using continuous thermodilution compared with bolus thermodilution (repeatability coefficients of 0.89 and 2.79 for CFRcont and CFRbolus, respectively, and 1.01 and 3.05 for MRRcont and MRRbolus, respectively). CONCLUSIONS Compared with bolus thermodilution, continuous thermodilution yields lower values of CFR and MRR accompanied by an almost 3-fold reduction of the variability in the measured results.
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Affiliation(s)
- Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Division of University Cardiology, IRCCS Galeazzi - Sant'Ambrogio Hospital, Milan, Italy
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | | | - Daniel Munhoz
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Koshiro Sakai
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Ruiko Seki
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | | | - Niya Mileva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Attilio Leone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Alessandro Candreva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Cardiology, Zurich University Hospital, Zurich, Switzerland; PoliTo(BIO) Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | | | | | | | | | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.
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10
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Jansen TPJ, de Vos A, Paradies V, Dimitriu‐Leen A, Crooijmans C, Elias‐Smale S, Rodwell L, Maas AHEM, Smits PC, Pijls N, van Royen N, Damman P. Continuous Versus Bolus Thermodilution-Derived Coronary Flow Reserve and Microvascular Resistance Reserve and Their Association With Angina and Quality of Life in Patients With Angina and Nonobstructive Coronaries: A Head-to-Head Comparison. J Am Heart Assoc 2023; 12:e030480. [PMID: 37577948 PMCID: PMC10492956 DOI: 10.1161/jaha.123.030480] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023]
Abstract
Background Coronary flow reserve (CFR) and microvascular resistance reserve (MRR) are physiological parameters to assess coronary microvascular dysfunction. CFR and MRR can be assessed using bolus or continuous thermodilution, and the correlation between these methods has not been clarified. Furthermore, their association with angina and quality of life is unknown. Methods and Results In total, 246 consecutive patients with angina and nonobstructive coronary arteries from the multicenter Netherlands Registry of Invasive Coronary Vasomotor Function Testing (NL-CFT) were investigated. The 36-item Short Form Health Survey Quality of Life and Seattle Angina questionnaires were completed by 153 patients before the invasive measurements. CFR and MRR were measured consecutively with bolus and continuous thermodilution. Mean continuous thermodilution-derived coronary flow reserve (CFRabs) was significantly lower than mean bolus thermodilution-derived coronary flow reserve (CFRbolus) (2.6±1.0 versus 3.5±1.8; P<0.001), with a modest correlation (ρ=0.305; P<0.001). Mean continuous thermodilution-derived microvascular resistance reserve (MRRabs) was also significantly lower than mean bolus thermodilution-derived MRR (MRRbolus) (3.1±1.1 versus 4.2±2.5; P<0.001), with a weak correlation (ρ=0.280; P<0.001). CFRbolus and MRRbolus showed no correlation with any of the angina and quality of life domains, whereas CFRabs and MRRabs showed a significant correlation with physical limitation (P=0.005, P=0.009, respectively) and health (P=0.026, P=0.012). In a subanalysis in patients in whom spasm was excluded, the correlation further improved (MRRabs versus physical limitation: ρ=0.363; P=0.041, MRRabs versus physical health: ρ=0.482; P=0.004). No association with angina frequency and stability was found. Conclusions Absolute flow measurements using continuous thermodilution to calculate CFRabs and MRRabs weakly correlate with, and are lower than, the surrogates CFRbolus and MRRbolus. Absolute flow parameters showed a relationship with physical complaints. No relationship with angina frequency and stability was found.
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Affiliation(s)
- Tijn P. J. Jansen
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Annemiek de Vos
- Department of CardiologyCatharina HospitalEindhovenThe Netherlands
| | - Valeria Paradies
- Department of CardiologyMaasstad HospitalRotterdamThe Netherlands
| | | | - Caïa Crooijmans
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Suzette Elias‐Smale
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Laura Rodwell
- Section Biostatistics, Department for Health EvidenceRadboud Institute of Health Sciences, Radboud University Medical CentreNijmegenThe Netherlands
| | - Angela H. E. M. Maas
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Pieter C. Smits
- Department of CardiologyMaasstad HospitalRotterdamThe Netherlands
| | - Nico Pijls
- Department of CardiologyCatharina HospitalEindhovenThe Netherlands
| | - Niels van Royen
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Peter Damman
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
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11
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Boerhout CKM, Beijk MAM, Damman P, Piek JJ, van de Hoef TP. Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review. Korean Circ J 2023; 53:519-534. [PMID: 37525496 PMCID: PMC10435829 DOI: 10.4070/kcj.2023.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 08/02/2023] Open
Abstract
Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.
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Affiliation(s)
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medica Centre, Nijmegen, The Netherlands
| | - Jan J Piek
- Heart Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Division Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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12
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Maurina M, Benedetti A, Stefanini G, Condorelli G, Collet C, Zivelonghi C, Smits PC, Paradies V. Coronary Vascular (DYS) Function and Invasive Physiology Assessment: Insights into Bolus and Continuous Thermodilution Methods. J Clin Med 2023; 12:4864. [PMID: 37510979 PMCID: PMC10381553 DOI: 10.3390/jcm12144864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
A considerable number of patients with angina or myocardial ischemia have no significant coronary artery disease on invasive angiography. In recent years, several steps towards a better comprehension of the pathophysiology of these conditions, angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), have been made. Nevertheless, several gaps in knowledge still remain. This review is intended to provide a comprehensive overview of ANOCA and INOCA, with a particular focus on pathophysiology, recent diagnostic innovations, gaps in knowledge and treatment modalities.
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Affiliation(s)
- Matteo Maurina
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Alice Benedetti
- HartCentrum, Antwerpen Hospital Network (ZNA) Middelheim, 2020 Antwerp, Belgium
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
| | - Carlo Zivelonghi
- HartCentrum, Antwerpen Hospital Network (ZNA) Middelheim, 2020 Antwerp, Belgium
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, 3015 GD Rotterdam, The Netherlands
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13
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Scarsini R, Portolan L, Della Mora F, Marin F, Mainardi A, Ruzzarin A, Levine MB, Banning AP, Ribichini F, Garcia Garcia HM, De Maria GL. Angiography-Derived and Sensor-Wire Methods to Assess Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction. JACC Cardiovasc Imaging 2023:S1936-878X(23)00089-X. [PMID: 37052555 DOI: 10.1016/j.jcmg.2023.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 04/14/2023]
Abstract
ST-segment elevation myocardial infarction (STEMI) treatment with primary percutaneous coronary intervention has dramatically impacted prognosis. However, despite satisfactory angiographic result, occurrence or persistence of coronary microvascular dysfunction after revascularization still affects long-term outcomes. The diagnostic and therapeutic value of understanding the status of coronary microcirculation is gaining attention in the cardiology community. However, current methods to assess microvascular function (namely, cardiac magnetic resonance and invasive wire-based coronary physiology) remain, at least in part, limited by technical and logistic aspects. On the other hand, angiography-based indices of microcirculatory resistance are emerging as valid and user-friendly tools with potential impact on prognostic stratification of patients with STEMI. This review provides an overview about conventional and novel methods to assess coronary microvascular dysfunction in patients with STEMI. The authors also provide a proposed procedural algorithm to facilitate optimal use of wire-based and angiography-based indices in the acute setting of STEMI.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federico Marin
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Andrea Mainardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Ruzzarin
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Molly B Levine
- Interventional Cardiology, MedStar Washington Hospital Centre, Washington, DC, USA
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
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14
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Grancini L, Diana D, Centola A, Monizzi G, Mastrangelo A, Olivares P, Montorsi P, Alushi B, Bartorelli AL, Galassi AR. The SALINE Technique for the Treatment of the No-Reflow Phenomenon during Percutaneous Coronary Intervention in STEMI. J Clin Med 2023; 12:jcm12062405. [PMID: 36983405 PMCID: PMC10057061 DOI: 10.3390/jcm12062405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Primary percutaneous coronary intervention (pPCI) performed for STEMI may be complicated by the "no-reflow" phenomenon. AIMS A super-selective intracoronary injection of saline solution through a thrombus aspiration catheter (SALINE technique), was investigated for the treatment of no-reflow as compared with the standard care of therapy (SCT). METHODS Among the 1471 patients with STEMI undergoing pPCI between May 2015 and June 2020, 168 patients developed no-reflow. Primary endpoints were the incidence of ST-segment resolution (STR) ≥ 70% at 90 min after PCI and the rate of flow restoration (TIMI flow grade 3 with an MBG > 1). The secondary endpoint was the incidence of major adverse cardiac and cerebrovascular events at 3 years follow-up. RESULTS After propensity score matching analysis, patients treated with SALINE showed STR ≥ 70% in twelve out of the sixteen patients (75.0%), compared to only three patients out of the sixteen in the SCT control group (19.0%), (p < 0.004). SALINE was associated with a higher probability of final TIMI flow grade 3 with an MBG > 1, as shown in fourteen out of sixteen patients (87.5%), as compared to only seven out of sixteen patients in the SCT group (43.8%), (p < 0.03). MACCE at 3 years follow-up occurred in only one patient (6.3%) in the SALINE group, as compared to eight patients (50%) in the SCT group (p = 0.047). CONCLUSIONS The SALINE technique showed to be a safe and effective strategy to reduce "no-reflow" in STEMI patients as assessed by significant STR, improvement of TIMI flow grade, and better 3-year outcomes.
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Affiliation(s)
- Luca Grancini
- Ospedale Galeazzi Sant'Ambrogio, IRCCS, 20157 Milan, Italy
| | - Davide Diana
- Department of Promise, University of Palermo, 90133 Palermo, Italy
| | - Alice Centola
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
| | | | | | | | - Piero Montorsi
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Brunilda Alushi
- Department of Cardiology, Campus Benjamin Franklin, Charite' Medical University Berlin, 12203 Berlin, Germany
- Department of Internal Medicine, Cardiology and Angiology, Zollernalb Klinik Balingen, 72336 Balingen, Germany
| | - Antonio L Bartorelli
- Ospedale Galeazzi Sant'Ambrogio, IRCCS, 20157 Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, 20122 Milan, Italy
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15
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Sabbah M, Lønborg J, Olsen NT, Engstrøm T. Reply: Coronary physiology in severe aortic stenosis: solely a matter of increased coronary resting flow? EUROINTERVENTION 2023; 18:1296. [PMID: 36939106 PMCID: PMC10015291 DOI: 10.4244/eij-d-22-01031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 03/21/2023]
Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jacob Lønborg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niels Thue Olsen
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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16
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Crooijmans C, Jansen TPJ, Konst RE, Woudstra J, Appelman Y, den Ruijter HM, Onland-Moret NC, Meeder JG, de Vos AMJ, Paradies V, Woudstra P, Sjauw KD, van 't Hof A, Meuwissen M, Winkler P, Boersma E, van de Hoef TP, Maas AHEM, Dimitriu-Leen AC, van Royen N, Elias-Smale SE, Damman P. Design and rationale of the NetherLands registry of invasive Coronary vasomotor Function Testing (NL-CFT). Int J Cardiol 2023; 379:1-8. [PMID: 36863419 DOI: 10.1016/j.ijcard.2023.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/02/2023] [Accepted: 02/12/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Angina without angiographic evidence of obstructive coronary artery disease (ANOCA) is a highly prevalent condition with insufficient pathophysiological knowledge and lack of evidence-based medical therapies. This affects ANOCA patients prognosis, their healthcare utilization and quality of life. In current guidelines, performing a coronary function test (CFT) is recommended to identify a specific vasomotor dysfunction endotype. The NetherLands registry of invasive Coronary vasomotor Function testing (NL-CFT) has been designed to collect data on ANOCA patients undergoing CFT in the Netherlands. METHODS The NL-CFT is a web-based, prospective, observational registry including all consecutive ANOCA patients undergoing clinically indicated CFT in participating centers throughout the Netherlands. Data on medical history, procedural data and (patient reported) outcomes are gathered. The implementation of a common CFT protocol in all participating hospitals promotes an equal diagnostic strategy and ensures representation of the entire ANOCA population. A CFT is performed after ruling out obstructive coronary artery disease. It comprises of both acetylcholine vasoreactivity testing as well as bolus thermodilution assessment of microvascular function. Optionally, continuous thermodilution or Doppler flow measurements can be performed. Participating centers can perform research using own data, or pooled data will be made available upon specific request via a secure digital research environment, after approval of a steering committee. CONCLUSION NL-CFT will be an important registry by enabling both observational and registry based (randomized) clinical trials in ANOCA patients undergoing CFT.
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Affiliation(s)
- C Crooijmans
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - T P J Jansen
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - R E Konst
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | - J Woudstra
- Dept. of Cardiology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Y Appelman
- Dept. of Cardiology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - H M den Ruijter
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - N C Onland-Moret
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J G Meeder
- Dept. of Cardiology, Viecuri Medical Center, Venlo, the Netherlands
| | - A M J de Vos
- Dept. of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - V Paradies
- Dept. of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - P Woudstra
- Dept. of Cardiology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - K D Sjauw
- Dept. of Cardiology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - A van 't Hof
- Dept. of Cardiology, MUMC, Maastricht, the Netherlands; Dept. of Cardiology, Zuyderland, Heerlen, the Netherlands; CArdiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - M Meuwissen
- Dept. of Cardiology, Amphia Hospital, Breda, the Netherlands
| | - P Winkler
- Dept. of Cardiology, Zuyderland, Heerlen, the Netherlands
| | - E Boersma
- Dept. of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - T P van de Hoef
- Laboratory of Experimental Cardiology, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A H E M Maas
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | | | - N van Royen
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands
| | | | - P Damman
- Dept. of Cardiology, Radboudumc, Nijmegen, the Netherlands.
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17
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de Vos A, Jansen TPJ, van 't Veer M, Dimitriu-Leen A, Konst RE, Elias-Smale S, Paradies V, Rodwell L, van den Oord S, Smits P, van Royen N, Pijls N, Damman P. Microvascular Resistance Reserve to Assess Microvascular Dysfunction in ANOCA Patients. JACC Cardiovasc Interv 2023; 16:470-481. [PMID: 36858668 DOI: 10.1016/j.jcin.2022.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) is a new index to assess coronary microvascular (dys)function, which can be easily measured invasively using continuous thermodilution. In contrast to coronary flow reserve (CFR), MRR is independent of epicardial coronary disease and hemodynamic variations. Its measurement is accurate, reproducible, and operator independent. OBJECTIVES The aim of this study was to establish the range of normal values for MRR and to determine an optimal cutoff point. METHODS In this exploratory study in 214 patients with angina and no obstructive coronary artery disease, after excluding significant epicardial disease, all physiological parameters, such as fractional flow reserve, index of microvascular resistance, CFR, absolute blood flow, absolute microvascular resistance, and MRR, were measured. On the basis of concordant positive or concordant negative results of index of microvascular resistance and CFR, subgroups of patients were defined with high probability of either normal (n = 122) or abnormal (n = 24) microcirculatory function, and MRR was studied in these groups. RESULTS Mean MRR in the "normal" group was 3.4 compared with a mean MRR of 1.9 in the "abnormal" group; these values were significantly different between the groups. MRR >2.7 ruled out coronary microvascular dysfunction (CMD) with a certainty of 96%, whereas MRR <2.1 indicated the presence of CMD with a similar high certainty of 96%. CONCLUSIONS MRR is a suitable index to distinguish the presence or absence of CMD in patients with angina and no obstructive coronary artery disease. The present data indicate that an MRR of 2.7 virtually excludes the presence of CMD, while an MRR value <2.1 confirms its presence.
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Affiliation(s)
- Annemiek de Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands.
| | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcel van 't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Regina E Konst
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stijn van den Oord
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pieter Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nico Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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18
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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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19
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Paolisso P, Gallinoro E, Vanderheyden M, Esposito G, Bertolone DT, Belmonte M, Mileva N, Bermpeis K, De Colle C, Fabbricatore D, Candreva A, Munhoz D, Degrieck I, Casselman F, Penicka M, Collet C, Sonck J, Mangiacapra F, de Bruyne B, Barbato E. Absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis. HEART (BRITISH CARDIAC SOCIETY) 2022; 109:47-54. [PMID: 35977812 DOI: 10.1136/heartjnl-2022-321348] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Development of left ventricle (LV) hypertrophy in aortic stenosis (AS) is accompanied by adaptive coronary flow regulation. We aimed to assess absolute coronary flow, microvascular resistance, coronary flow reverse (CFR) and microvascular resistance reserve (MRR) in patients with and without AS. METHODS Absolute coronary flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and 29 controls, without AS, matched for age, gender, diabetes and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and left anterior descending artery (LAD)-specific mass were quantified by echocardiography and cardiac-CT. RESULTS Patients with AS presented a significantly positive LV remodelling with lower global longitudinal strain and global work efficacy compared with controls. Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS (p=0.001). Compared with matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (p=0.009), resulting into lower CFR and MRR in the AS cohort compared with controls (p<0.005 for both). No differences were found in hyperaemic flow and resting and hyperaemic resistances. Hyperaemic myocardial perfusion (calculated as the ratio between the absolute coronary flow subtended to the LAD, expressed in mL/min/g), but not resting, was significantly lower in the AS group (p=0.035). CONCLUSIONS In patients with severe AS and non-obstructive coronary artery disease, with the progression of LV hypertrophy, the compensatory mechanism of increased resting flow maintains adequate perfusion at rest, but not during hyperaemia. As a consequence, both CFR and MRR are significantly impaired.
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Affiliation(s)
- Pasquale Paolisso
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | | | - Giuseppe Esposito
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Dario Tino Bertolone
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Marta Belmonte
- Hartcentrum OLV Aalst, Aalst, Belgium.,Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Lombardia, Italy
| | | | | | - Cristina De Colle
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Davide Fabbricatore
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | - Daniel Munhoz
- Hartcentrum OLV Aalst, Aalst, Belgium.,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Ivan Degrieck
- Cardiovascular and Thoracic Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Filip Casselman
- Cardiovascular and Thoracic Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Martin Penicka
- Cardiology, Hartcentrum OLV Aalst, Aalst, Flanderen, Belgium
| | | | | | | | | | - Emanuele Barbato
- Hartcentrum OLV Aalst, Aalst, Belgium .,Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
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20
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Candreva A, Gallinoro E, Fernandez Peregrina E, Sonck J, Keulards DCJ, Van't Veer M, Mizukami T, Pijls NHJ, Collet C, De Bruyne B. Automation of intracoronary continuous thermodilution for absolute coronary flow and microvascular resistance measurements. Catheter Cardiovasc Interv 2022; 100:199-206. [PMID: 35723684 DOI: 10.1002/ccd.30244] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/06/2022] [Accepted: 05/15/2022] [Indexed: 11/10/2022]
Abstract
AIM Microvascular resistance reserve (MRR) as derived from continuous intracoronary thermodilution specifically quantifies microvasculature function. As originally described, the technique necessitates reinstrumentation of the artery and manual reprogramming of the infusion pump when performing resting and hyperemic measurements. To simplify and to render this procedure operator-independent, we developed a fully automated method. The aim of the present study is to validate the automated procedure against the originally described one. METHODS AND RESULTS For the automated procedure, an infusion pump was preprogrammed to allow paired resting-hyperemic thermodilution assessment without interruption. To validate the accuracy of this new approach, 20 automated measurements were compared to those obtained in the same vessels with conventional paired resting-hyperemic thermodilution measurements (i.e., with a sensor pullback at each infusion rate and manual reprogramming of the infusion pump). A close correlation between the conventional and the automated measuring technique was found for resting flow (Qrest : r = 0.89, mean bias = 2.52; SD = 15.47), hyperemic flow (Qhyper : r = 0.88, mean bias = -2.65; SD = 27.96), resting microvascular resistance (Rμ-rest : r = 0.90, mean bias = 52.14; SD = 228.29), hyperemic microvascular resistance Rμ-hyper : r = 0.92, mean bias = 12.95; SD = 57.80), and MRR (MRR: r = 0.89, mean bias = 0.04, SD = 0.59). Procedural time was significantly shorter with the automated method (5'25″ ± 1'23″ vs. 4'36″ ± 0'33″, p = 0.013). CONCLUSION Continuous intracoronary thermodilution-derived measurements of absolute flow, absolute resistance, and MRR can be fully automated. This further shortens and simplifies the procedure when performing paired resting-hyperemic measurements.
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Affiliation(s)
- Alessandro Candreva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Cardiology, Zurich University Hospital, Zurich, Switzerland.,Department of Mechanical and Aerospace Engineering, PoliToBIO Med Lab, Politecnico di Torino, Turin, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Estefania Fernandez Peregrina
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Interventional Cardiology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Danielle C J Keulards
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.,Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Marcel Van't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.,Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.,Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
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21
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Lodi Rizzini M, Candreva A, Chiastra C, Gallinoro E, Calò K, D'Ascenzo F, De Bruyne B, Mizukami T, Collet C, Gallo D, Morbiducci U. Modelling coronary flows: impact of differently measured inflow boundary conditions on vessel-specific computational hemodynamic profiles. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 221:106882. [PMID: 35597205 DOI: 10.1016/j.cmpb.2022.106882] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVES The translation of hemodynamic quantities based on wall shear stress (WSS) or intravascular helical flow into clinical biomarkers of coronary atherosclerotic disease is still hampered by the assumptions/idealizations required by the computational fluid dynamics (CFD) simulations of the coronary hemodynamics. In the resulting budget of uncertainty, inflow boundary conditions (BCs) play a primary role. Accordingly, in this study we investigated the impact of the approach adopted for in vivo coronary artery blood flow rate assessment on personalized CFD simulations where blood flow rate is used as inflow BC. METHODS CFD simulations were carried out on coronary angiograms by applying personalized inflow BCs derived from four different techniques assessing in vivo surrogates of flow rate: continuous thermodilution, intravascular Doppler, frame count-based 3D contrast velocity, and diameter-based scaling law. The impact of inflow BCs on coronary hemodynamics was evaluated in terms of WSS- and helicity-based quantities. RESULTS As main findings, we report that: (i) coronary flow rate values may differ based on the applied flow derivation technique, as continuous thermodilution provided higher flow rate values than intravascular Doppler and diameter-based scaling law (p = 0.0014 and p = 0.0023, respectively); (ii) such intrasubject differences in flow rate values lead to different surface-averaged values of WSS magnitude and helical blood flow intensity (p<0.0020); (iii) luminal surface areas exposed to low WSS and helical flow topological features showed robustness to the flow rate values. CONCLUSIONS Although the absence of a clinically applicable gold standard approach prevents a general recommendation for one coronary blood flow rate derivation technique, our findings indicate that the inflow BC may impact computational hemodynamic results, suggesting that a standardization would be desirable to provide comparable results among personalized CFD simulations of the coronary hemodynamics.
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Affiliation(s)
- Maurizio Lodi Rizzini
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Alessandro Candreva
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy; Department of Cardiology, Zurich University Hospital, Zurich, Switzerland
| | - Claudio Chiastra
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | | | - Karol Calò
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Fabrizio D'Ascenzo
- Hemodynamic Laboratory, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Diego Gallo
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy.
| | - Umberto Morbiducci
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
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22
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When "Slow Flow" Is Not "Low Flow". JACC Cardiovasc Interv 2022; 15:e119-e121. [PMID: 35490131 DOI: 10.1016/j.jcin.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/23/2022]
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23
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Tar B, Ágoston A, Üveges Á, Szabó GT, Szűk T, Komócsi A, Czuriga D, Csippa B, Paál G, Kőszegi Z. Pressure- and 3D-Derived Coronary Flow Reserve with Hydrostatic Pressure Correction: Comparison with Intracoronary Doppler Measurements. J Pers Med 2022; 12:jpm12050780. [PMID: 35629202 PMCID: PMC9146986 DOI: 10.3390/jpm12050780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose: To develop a method of coronary flow reserve (CFR) calculation derived from three-dimensional (3D) coronary angiographic parameters and intracoronary pressure data during fractional flow reserve (FFR) measurement. Methods: Altogether 19 coronary arteries of 16 native and 3 stented vessels were reconstructed in 3D. The measured distal intracoronary pressures were corrected to the hydrostatic pressure based on the height differences between the levels of the vessel orifice and the sensor position. Classical fluid dynamic equations were applied to calculate the flow during the resting state and vasodilatation based on morphological data and intracoronary pressure values. 3D-derived coronary flow reserve (CFRp-3D) was defined as the ratio between the calculated hyperemic and the resting flow and was compared to the CFR values simultaneously measured by the Doppler sensor (CFRDoppler). Results: Haemodynamic calculations using the distal coronary pressures corrected for hydrostatic pressures showed a strong correlation between the individual CFRp-3D values and the CFRDoppler measurements (r = 0.89, p < 0.0001). Hydrostatic pressure correction increased the specificity of the method from 46.1% to 92.3% for predicting an abnormal CFRDoppler < 2. Conclusions: CFRp-3D calculation with hydrostatic pressure correction during FFR measurement facilitates a comprehensive hemodynamic assessment, supporting the complex evaluation of macro-and microvascular coronary artery disease.
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Affiliation(s)
- Balázs Tar
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - András Ágoston
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - Áron Üveges
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - Gábor Tamás Szabó
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | - Tibor Szűk
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | | | - Dániel Czuriga
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (G.P.)
| | - György Paál
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (G.P.)
| | - Zsolt Kőszegi
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
- Correspondence:
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24
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Maitre-Ballesteros L, Riou L, Marliere S, Canu M, Vautrin E, Piliero N, Ormezzano O, Bouvaist H, Broisat A, Ghezzi C, Fagret D, Vanzetto G, Djaïleb L, Barone-Rochette G. Coronary Physiology: Delivering Precision Medicine? Rev Cardiovasc Med 2022; 23:158. [PMID: 39077613 PMCID: PMC11273948 DOI: 10.31083/j.rcm2305158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 07/31/2024] Open
Abstract
Coronary physiological assessment is now widely used to assess epicardial coronary lesions in cath lab. Based on clinical evidence, fractional flow reserve (FFR) is the gold standard method to select whether epicardial coronary lesions need revascularization. While additional epicardial indexes, such as instantaneous wave-free ratio (iFR), are also used for revascularization decision-making, several indexes are now also available to explore the coronary microcirculation. Therefore, coronary physiological assessment now allows to explore the entire coronary tree and offer the potential of precision medicine for patients affected by coronary artery disease (CAD). This paper will provide review of the epicardial and microvascular indexes available for the assessment of coronary physiology. More specifically, the already demonstrated contributions of these indexes in the management of CAD and the role they could play in precision medicine will be reviewed with special emphasis on chronic coronary syndrome.
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Affiliation(s)
| | - Laurent Riou
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
| | - Stephanie Marliere
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Marjorie Canu
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Estelle Vautrin
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Nicola Piliero
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Oliviez Ormezzano
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Helene Bouvaist
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
| | - Alexis Broisat
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
| | - Catherine Ghezzi
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
| | - Daniel Fagret
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
| | - Gérald Vanzetto
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
- French Alliance Clinical Trial, French Clinical Research Infrastructure Network, 75018 Paris, France
| | - Loïc Djaïleb
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
| | - Gilles Barone-Rochette
- Department of Cardiology, University Hospital, 38000 Grenoble Alpes, France
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France
- French Alliance Clinical Trial, French Clinical Research Infrastructure Network, 75018 Paris, France
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25
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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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26
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Lim PO. Angina with coronary microvascular dysfunction and its physiological assessment: a review with cases. THE BRITISH JOURNAL OF CARDIOLOGY 2022; 29:13. [PMID: 36212789 PMCID: PMC9534121 DOI: 10.5837/bjc.2022.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Imagine that it is possible to know, the actual coronary blood flow. Would this not remove any doubt, if a chest pain is the heart's fault?
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27
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Bertolone DT, Gallinoro E, Esposito G, Paolisso P, Bermpeis K, De Colle C, Fabbricatore D, Mileva N, Valeriano C, Munhoz D, Belmonte M, Vanderheyden M, Bartunek J, Sonck J, Wyffels E, Collet C, Mancusi C, Morisco C, De Luca N, De Bruyne B, Barbato E. Contemporary Management of Stable Coronary Artery Disease. High Blood Press Cardiovasc Prev 2022; 29:207-219. [PMID: 35147890 PMCID: PMC9050764 DOI: 10.1007/s40292-021-00497-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/30/2021] [Indexed: 10/28/2022] Open
Abstract
Coronary artery disease (CAD) continues to be the leading cause of mortality and morbidity in developed countries. Assessment of pre-test probability (PTP) based on patient's characteristics, gender and symptoms, help to identify more accurate patient's clinical likelihood of coronary artery disease. Consequently, non-invasive imaging tests are performed more appropriately to rule in or rule out CAD rather than invasive coronary angiography (ICA). Coronary computed tomography angiography (CCTA) is the first-line non-invasive imaging technique in patients with suspected CAD and could be used to plan and guide coronary intervention. Invasive coronary angiography remains the gold-standard method for the identification and characterization of coronary artery stenosis. However, it is recommended in patients where the imaging tests are non-conclusive, and the clinical likelihood is very high, remembering that in clinical practice, approximately 30 to 70% of patients with symptoms and/or signs of ischemia, referred to coronary angiography, have non obstructive coronary artery disease (INOCA). In this contest, physiology and imaging-guided revascularization represent the cornerstone of contemporary management of chronic coronary syndromes (CCS) patients allowing us to focus specifically on ischemia-inducing stenoses. Finally, we also discuss contemporary medical therapeutic approach for secondary prevention. The aim of this review is to provide an updated diagnostic and therapeutic approach for the management of patients with stable coronary artery disease.
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Affiliation(s)
- Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Cristina De Colle
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Davide Fabbricatore
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Niya Mileva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | - Daniel Munhoz
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | | | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Costantino Mancusi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Nicola De Luca
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium. .,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
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28
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Mangiacapra F, Viscusi MM, Verolino G, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. Invasive Assessment of Coronary Microvascular Function. J Clin Med 2021; 11:jcm11010228. [PMID: 35011968 PMCID: PMC8745537 DOI: 10.3390/jcm11010228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
The critical role of the coronary microvascular compartment and its invasive functional assessment has become apparent in light of the significant proportion of patients presenting signs and symptoms of myocardial ischemia, despite the absence of epicardial disease, or after the adequate treatment of it. However, coronary microvascular dysfunction (CMD) represents a diagnostic challenge because of the small dimensions of the coronary microvasculature, which prevents direct angiographic visualization. Several diagnostic tools are now available for the invasive assessment of the coronary microvascular function, which, in association with the physiological indices used to investigate the epicardial department, may provide a comprehensive evaluation of the coronary circulation as a whole. Recent evidence suggests that the physiology-guided management of CMD, although apparently costly and time-consuming, may offer a net clinical benefit in terms of symptom improvement among patients with angina and ischemic heart disease. However, despite the results of several observational studies, the prognostic effect of the physiology-driven management of CMD within this population is currently a matter of debate, and therefore represents an unmet clinical need that urgently deserves further investigation.
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29
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Gallinoro E, Paolisso P, Candreva A, Bermpeis K, Fabbricatore D, Esposito G, Bertolone D, Fernandez Peregrina E, Munhoz D, Mileva N, Penicka M, Bartunek J, Vanderheyden M, Wyffels E, Sonck J, Collet C, De Bruyne B, Barbato E. Microvascular Dysfunction in Patients With Type II Diabetes Mellitus: Invasive Assessment of Absolute Coronary Blood Flow and Microvascular Resistance Reserve. Front Cardiovasc Med 2021; 8:765071. [PMID: 34738020 PMCID: PMC8562107 DOI: 10.3389/fcvm.2021.765071] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/22/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Coronary microvascular dysfunction (CMD) is an early feature of diabetic cardiomyopathy, which usually precedes the onset of diastolic and systolic dysfunction. Continuous intracoronary thermodilution allows an accurate and reproducible assessment of absolute coronary blood flow and microvascular resistance thus allowing the evaluation of coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR), a novel index specific for microvascular function, which is independent from the myocardial mass. In the present study we compared absolute coronary flow and resistance, CFR and MRR assessed by continuous intracoronary thermodilution in diabetic vs. non-diabetic patients. Left atrial reservoir strain (LASr), an early marker of diastolic dysfunction was compared between the two groups. Methods: In this observational retrospective study, 108 patients with suspected angina and non-obstructive coronary artery disease (NOCAD) consecutively undergoing elective coronary angiography (CAG) from September 2018 to June 2021 were enrolled. The invasive functional assessment of microvascular function was performed in the left anterior descending artery (LAD) with intracoronary continuous thermodilution. Patients were classified according to the presence of DM. Absolute resting and hyperemic coronary blood flow (in mL/min) and resistance (in WU) were compared between the two cohorts. FFR was measured to assess coronary epicardial lesions, while CFR and MRR were calculated to assess microvascular function. LAS, assessed by speckle tracking echocardiography, was used to detect early myocardial structural changes potentially associated with microvascular dysfunction. Results: The median FFR value was 0.83 [0.79-0.87] without any significant difference between the two groups. Absolute resting and hyperemic flow in the left anterior descending coronary were similar between diabetic and non-diabetic patients. Similarly, resting and hyperemic resistances did not change significantly between the two groups. In the DM cohort the CFR and MRR were significantly lower compared to the control group (CFR = 2.38 ± 0.61 and 2.88 ± 0.82; MRR = 2.79 ± 0.87 and 3.48 ± 1.02 for diabetic and non-diabetic patients respectively, [p < 0.05 for both]). Likewise, diabetic patients had a significantly lower reservoir, contractile and conductive LAS (all p < 0.05). Conclusions: Compared with non-diabetic patients, CFR and MRR were lower in patients with DM and non-obstructive epicardial coronary arteries, while both resting and hyperemic coronary flow and resistance were similar. LASr was lower in diabetic patients, confirming the presence of a subclinical diastolic dysfunction associated to the microcirculatory impairment. Continuous intracoronary thermodilution-derived indexes provide a reliable and operator-independent assessment of coronary macro- and microvasculature and might potentially facilitate widespread clinical adoption of invasive physiologic assessment of suspected microvascular disease.
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Affiliation(s)
- Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli', Naples, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Davide Fabbricatore
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Dario Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Daniel Munhoz
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
- Discipline of Cardiology, Department of Internal Clinical Medicine, University of Campinas, Campinas, Brazil
| | - Niya Mileva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | | | | | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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30
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De Bruyne B, Pijls NHJ, Gallinoro E, Candreva A, Fournier S, Keulards DCJ, Sonck J, Van't Veer M, Barbato E, Bartunek J, Vanderheyden M, Wyffels E, De Vos A, El Farissi M, Tonino PAL, Muller O, Collet C, Fearon WF. Microvascular Resistance Reserve for Assessment of Coronary Microvascular Function: JACC Technology Corner. J Am Coll Cardiol 2021; 78:1541-1549. [PMID: 34620412 DOI: 10.1016/j.jacc.2021.08.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023]
Abstract
The need for a quantitative and operator-independent assessment of coronary microvascular function is increasingly recognized. We propose the theoretical framework of microvascular resistance reserve (MRR) as an index specific for the microvasculature, independent of autoregulation and myocardial mass, and based on operator-independent measurements of absolute values of coronary flow and pressure. In its general form, MRR equals coronary flow reserve (CFR) divided by fractional flow reserve (FFR) corrected for driving pressures. In 30 arteries, pressure, temperature, and flow velocity measurements were obtained simultaneously at baseline (BL), during infusion of saline at 10 mL/min (rest) and 20 mL/min (hyperemia). A strong correlation was found between continuous thermodilution-derived MRR and Doppler MRR (r = 0.88; 95% confidence interval: 0.72-0.93; P < 0.001). MRR was independent from the epicardial resistance, the lower the FFR value, the greater the difference between MRR and CFR. Therefore, MRR is proposed as a specific, quantitative, and operator-independent metric to quantify coronary microvascular dysfunction.
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Affiliation(s)
- Bernard De Bruyne
- Cardiovascular Center Aalst, Aalst, Belgium; Lausanne University Centre Hospital, Lausanne, Switzerland.
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, Aalst, Belgium; Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy. https://twitter.com/Egallinoro
| | - Alessandro Candreva
- Cardiovascular Center Aalst, Aalst, Belgium. https://twitter.com/alecandreva
| | | | | | - Jeroen Sonck
- Cardiovascular Center Aalst, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy. https://twitter.com/jeroen_sonck
| | - Marcel Van't Veer
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Emanuele Barbato
- Cardiovascular Center Aalst, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy. https://twitter.com/EmanueleBarba13
| | | | | | | | - Annemiek De Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Mohamed El Farissi
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Olivier Muller
- Lausanne University Centre Hospital, Lausanne, Switzerland
| | - Carlos Collet
- Cardiovascular Center Aalst, Aalst, Belgium. https://twitter.com/ColletCarlos
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, California, USA
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31
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Jansen TPJ, Konst RE, Elias-Smale SE, van den Oord SC, Ong P, de Vos AMJ, van de Hoef TP, Paradies V, Smits PC, van Royen N, Damman P. Assessing Microvascular Dysfunction in Angina With Unobstructed Coronary Arteries: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1471-1479. [PMID: 34593129 DOI: 10.1016/j.jacc.2021.08.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/28/2022]
Abstract
Coronary microvascular dysfunction is a highly prevalent condition of both structural and functional coronary disorders in patients with angina and nonobstructive coronary artery disease (ANOCA). Current diagnostic modalities to assess microvascular function are related to prognosis, but these modalities have several technical shortcomings and lack the opportunity to determine true coronary blood flow and microvascular resistance. Intracoronary continuous thermodilution assessment of absolute coronary flow (Q) and microvascular resistance (R) was recently shown to be safe and feasible in ANOCA. Further exploration and implementation could lead to a better understanding and treatment of patients with ANOCA. This review discuss the coronary pathophysiology of microvascular dysfunction, provides an overview of noninvasive and invasive diagnostics, and focuses on the novel continuous thermodilution method. Finally, how these measurements of absolute Q and R could be integrated and how this would affect future clinical care are discussed.
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Affiliation(s)
| | | | | | | | - Peter Ong
- Robert Bosch Hospital, Stuttgart, Germany
| | | | | | | | | | - Niels van Royen
- Radboudumc, Nijmegen, the Netherlands. https://twitter.com/NielsRoyen
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32
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Basics of Coronary Thermodilution. JACC Cardiovasc Interv 2021; 14:595-605. [PMID: 33736767 DOI: 10.1016/j.jcin.2020.12.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 01/15/2023]
Abstract
Coronary microvascular dysfunction is a highly prevalent condition in both obstructive and nonobstructive coronary artery disease. Intracoronary thermodilution is a promising technique to investigate coronary microvascular (dys)function in vivo and to assess its most important metric: microvascular resistance. Here, the authors provide a practical review of bolus and continuous thermodilution for the measurement of coronary flow and microvascular resistance. The authors describe the basic principles of indicator-dilution theory and of coronary thermodilution and detail the practicalities of their application in the catheterization laboratory. Finally, the authors discuss contemporary clinical applications of coronary thermodilution-based microvascular assessment in humans and future perspectives.
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