Assessment of Microcirculatory Remodeling With Intracoronary Flow Velocity and Pressure Measurements

Escaned, Javier; Flores, Álex; García‐Pavía, Pablo; Segovia, Javier; Torres-Jiménez, Javier; Aragoncillo, Paloma; Salas, Clara; Alfonso, Fernándo; Hernández, Rosana; Angiolillo, Dominick J.; Jiménez‐Quevedo, Pilar; Bañuelos, Camino; Alonso‐Pulpón, Luis; Macaya, Carlos

doi:10.1161/circulationaha.108.834739

Cited by 85 publications

(37 citation statements)

References 42 publications

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“…20,21 These factors may explain why some studies have found a relationship between clinical outcome and CFR and others have not. 4,22,23 In our study, CFR measured at baseline and 1 year did not predict longer-term clinical outcome after heart transplantation. For these reasons, one could argue that measuring CFR invasively in this setting should be abandoned.…”

Section: Importance Of Microvascular Dysfunctioncontrasting

confidence: 67%

Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation

et al. 2016

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This study included patients from 2 consecutive prospective trials at Stanford University Medical Center between 2002 and 2014. The aim of the first study was to evaluate the role of cytomegalovirus in the development of CAV (1 PO1-AI50153). The second study evaluated the role of the angiotensin-converting enzyme inhibitor ramipril in the development of CAV (5 R01 HL093475-02; ClinicalTrials.gov number NCT01078363). Patients were included if they were >18 years old, received their first cardiac transplantation, survived >1 year, and were willing and able to provide informed written consent. All patients underwent a baseline coronary angiogram with measurement of FFR, coronary flow reserve (CFR), and IMR and performance of IVUS of the left anterior descending artery (LAD) within 8 weeks and 1 year after transplantation. The study protocols were approved by the Stanford University Institutional Review Board on Human Subjects Research, and informed consent was obtained from all patients before enrollment. Immunosuppressive RegimenAll patients received standard immunosuppressive therapy, including induction therapy with daclizumab, an anti-interleukin-2 monoclonal antibody, OKT3, or antithymocyte globulin. Corticosteroid therapy Background-The aim of this study is to determine the prognostic value of invasively assessing coronary physiology early after heart transplantation. Methods and Results-Seventy-four cardiac transplant recipients had fractional flow reserve, coronary flow reserve, index of microcirculatory resistance (IMR), and intravascular ultrasound performed down the left anterior descending coronary artery soon after (baseline) and 1 year after heart transplantation. The primary end point was the cumulative survival free of death or retransplantation at a mean follow-up of 4.5±3.5 years. The cumulative event-free survival was significantly lower in patients with a fractional flow reserve <0.90 at baseline (42% versus 79%; P=0.01) or an IMR ≥20 measured 1 year after heart transplantation (39% versus 69%; P=0.03). Patients in whom IMR decreased or did not change from baseline to 1 year had higher event-free survival compared with patients with an increase in IMR (66% versus 36%; P=0.03). Fractional flow reserve <0.90 at baseline (hazard ratio, 0.13; 95% confidence interval, 0.02-0.81; P=0.03), IMR ≥20 at 1 year (hazard ratio, 3.93; 95% confidence interval, 1.08-14.27; P=0.04), and rejection during the first year (hazard ratio, 6.00; 95% confidence interval, 1.56-23.09; P=0.009) were independent predictors of death/retransplantation, whereas intravascular ultrasound parameters were not. Conclusions-Invasive measures of coronary physiology (fractional flow reserve and IMR) determined early after heart transplantation are significant predictors of late death or retransplantation.

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Section: Importance Of Microvascular Dysfunctioncontrasting

confidence: 67%

Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation

et al. 2016

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“…In epicardial vessels, both focal and diffuse atheromatous narrowings increase vascular resistance, with an added component of vasoconstriction triggered by endothelial dysfunction. 5 At a microcirculatory level, increased resistance may result from structural remodeling (arteriolar obliteration and capillary rarefaction), 15 vasoconstriction of large arteriole resulting from endothelial dysfunction or alpha-adrenergic stimulation, 16,17 and extravascular compression of capillaries and venules. 18 Despite that, assessment of IHD in clinical practice largely focuses in the identification of ischemia-generating epicardial stenoses that can be targeted with revascularization.…”

Section: Fractional Flow Reserve and Myocardial Flow Impairment In Ismentioning

confidence: 99%

Disturbed Coronary Hemodynamics in Vessels With Intermediate Stenoses Evaluated With Fractional Flow Reserve

et al. 2013

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Background— In chronic ischemic heart disease, focal stenosis, diffuse atherosclerotic narrowings, and microcirculatory dysfunction (MCD) contribute to limit myocardial flow. The prevalence of these ischemic heart disease levels in fractional flow reserve (FFR) interrogated vessels remains largely unknown. Methods and Results— Using intracoronary measurements, 91 coronaries (78 patients) with intermediate stenoses were classified in 4 FFR and coronary flow reserve (CFR) agreement groups, using FFR>0.80 and CFR<2 as cutoffs. Index of microcirculatory resistance (IMR) and atherosclerotic burden (Gensini score) were also assessed. MCD was assumed when IMR≥29.1 (75 th percentile). Fifty-four (59.3%) vessels had normal FFR, from which only 20 (37%) presented both normal CFR and IMR. Among vessels with FFR>0.80, most (63%) presented disturbed hemodynamics: abnormal CFR in 28 (52%) and MCD in 18 (33%). Vessels with FFR>0.80 presented higher IMR [adjusted mean 27.6 (95% confidence interval, 23.4–31.8)] than those with FFR≤0.80 [17.3 (95% confidence interval, 13.0–21.7), p=0.001]. Atherosclerotic burden was inversely correlated with CFR ( r =−0.207, P =0.055), and in vessels with FFR>0.80 and CFR<2 (n=28, 39%), IMR had a wide dispersion (7–72.7 U), suggesting a combination of diffuse atherosclerotic narrowings and MCD. Vessels with FFR≤0.80 and normal CFR presented the lowest IMR, suggesting a preserved microcirculation. Conclusions— A substantial number of coronary arteries with stenoses showing an FFR>0.80 present disturbed hemodynamics. Integration of FFR, CFR, and IMR supports the existence of differentiated patterns of ischemic heart disease that combine focal and diffuse coronary narrowings with variable degrees of MCD.

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“…A previous study had reported that increased P zf may reflect accentuation of microvascular tone and decreased perfusion bed mass, which is caused by nonviable tissue (8,38,39). Tanaka et al (37) described this relationship during hyperemia.…”

Section: H404 Assessment Of Coronary Microcirculation In a Swine Modelmentioning

confidence: 96%

“…However, in many cases (12,40), the severity of myocardium ischemia correlates poorly with epicardial stenosis. Therefore, intracoronary physiological techniques have been developed to provide physiological evaluations for patients who undergo coronary angiography (8,34). Recently, the medical community's interest in coronary microcirculation has grown with the increasing awareness that microvascular dysfunction occurs in a number of myocardial disease states and has important prognostic implications (19,20).…”

mentioning

confidence: 99%

Assessment of coronary microcirculation in a swine animal model

Zhang

Takarada

Molloi

2011

American Journal of Physiology-Heart and Circulatory Physiology

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Coronary microvascular dysfunction has important prognostic implications. Several hemodynamic indexes, such as coronary flow reserve (CFR), microvascular resistance, and zero-flow pressure (Pzf), were used to establish the most reliable index to assess coronary microcirculation. Fifteen swine were instrumented with a flow probe, and a pressure wire was advanced into the distal left anterior descending artery. Adenosine was used to produce maximum hyperemia. Microspheres were used to create microvascular dysfunction. An occluder was used to produce stenosis. Blood flow from the probe (Q p), aortic pressure, distal coronary pressure, and right atrium pressure were recorded. Angiographic flow (Q a) was calculated using a time-density curve. Flow probe-based CFR and angiographic CFR were calculated using Q p and Q a, respectively. Flow probe-based (NMRqh) and angiographic normalized microvascular resistance (NMRah) were determined using Q p and Q a, respectively, during hyperemia. Pzf was calculated using Q p and distal coronary pressure. Two series of receiver operating characteristic curves were generated: normal epicardial artery model (N model) and stenosis model (S model). The areas under the receiver operating characteristic curves for flow probe-based CFR, angiographic CFR, NMRqh, NMRah, and Pzf were 0. 855, 0.836, 0.976, 0.956, and 0.855 in N model and 0.737, 0.700, 0.935, 0.889, and 0.698 in S model. Both NMRqh and NMRah were significantly more reliable than CFR and Pzf in detecting the microvascular deterioration. Compared with CFR and Pzf, NMR provided a more accurate assessment of microcirculation. This improved accuracy was more prevalent when stenosis existed. Moreover, NMRah is potentially a less invasive method for assessing coronary microcirculation.angiography; blood flow; cardiovascular imaging; coronary microvascular function CORONARY ANGIOGRAPHY, a routine examination for patients with heart disease, provides an assessment of stenosis severity by visualizing the opacified arterial lumen. However, in many cases (12,40), the severity of myocardium ischemia correlates poorly with epicardial stenosis. Therefore, intracoronary physiological techniques have been developed to provide physiological evaluations for patients who undergo coronary angiography (8,34). Recently, the medical community's interest in coronary microcirculation has grown with the increasing awareness that microvascular dysfunction occurs in a number of myocardial disease states and has important prognostic implications (19,20). With this recognition comes the need for a method to accurately assess the functional capacity of coronary microcirculation for diagnostic purposes and to monitor the effects of therapeutic interventions targeted at reversing the extent of coronary microvascular dysfunction. To assess changes in the microcirculatory bed, several indexes have been proposed, such as coronary flow reserve (CFR), microvascular resistance (MR), and zero-flow pressure (P zf ). In the early 1990s, Gould et al. (14) introduced CFR...

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Assessment of Microcirculatory Remodeling With Intracoronary Flow Velocity and Pressure Measurements

Abstract: Background-Intracoronary

Cited by 85 publications

References 42 publications

Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation

Invasive Assessment of Coronary Physiology Predicts Late Mortality After Heart Transplantation

Disturbed Coronary Hemodynamics in Vessels With Intermediate Stenoses Evaluated With Fractional Flow Reserve

Assessment of coronary microcirculation in a swine animal model

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