Assessment of myocardial viability using coronary zero flow pressure after successful angioplasty in patients with acute anterior myocardial infarction

Shimada, Kenei; Sakanoue, Yuji; Kobayashi, Y.; Ehara, Shoichi; Hirose, Masaru; Nakamura, Yasuhiro; Fukuda, Daiju; Yamagishi, Hiroyuki; Yoshiyama, Minoru; Takeuchi, Kazuhide; Yoshikawa, Junichi

doi:10.1136/heart.89.1.71

Cited by 32 publications

(16 citation statements)

References 35 publications

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“…25,26 The relationship between PZF and the development of MVI in our study receives support from previous research, reporting a relationship between PZF after primary PCI and amount of viable myocardium assessed with PET or CMR. 26,30 Further research is warranted to clarify whether IHDVPS and PZF can provide complementary information to HMR. At present, the clinical applicability of IHDVPS and PZF in the setting of acute STEMI is hampered by the difficulties associated with acquiring high-quality, artifact-free Doppler tracings that are required to generate pressure-velocity loops suitable for analysis.…”

Section: Measurements Of Coronary Flow and Microvascular Resistance Isupporting

confidence: 59%

“…28,29 The latter aspect is key in our study population because, as illustrated by CMR imaging, both edema and intramyocardial hemorrhage develop in a variable extent during STEMI and might cause microcirculatory compression. 25,26 The relationship between PZF and the development of MVI in our study receives support from previous research, reporting a relationship between PZF after primary PCI and amount of viable myocardium assessed with PET or CMR. 26,30 Further research is warranted to clarify whether IHDVPS and PZF can provide complementary information to HMR.…”

supporting

confidence: 59%

“…25 Other authors have found a significant relationship between impaired microcirculatory conductance and estimates of myocardial salvage in STEMI. 26,27 Although in our study the expected inverse relationship between resistance (HMR) and conductance (IHDVPS) was confirmed, we did not identify IHDVPS as a predictor of MVI. PZF, derived from pressure-velocity loop analysis, informs on the effect of intraventricular and interstitial myocardial pressure over collapsible elements of the microcirculation.…”

Section: Measurements Of Coronary Flow and Microvascular Resistance Imentioning

confidence: 56%

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Doppler-Derived Intracoronary Physiology Indices Predict the Occurrence of Microvascular Injury and Microvascular Perfusion Deficits After Angiographically Successful Primary Percutaneous Coronary Intervention

Teunissen

Waard

Hollander

et al. 2015

Circ: Cardiovascular Interventions

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Background-A total of40% to 50% of patients with ST-segment-elevation myocardial infarction develop microvascular injury (MVI) despite angiographically successful primary percutaneous coronary intervention (PCI). We investigated whether hyperemic microvascular resistance (HMR) immediately after angiographically successful PCI predicts MVI at cardiovascular magnetic resonance and reduced myocardial blood flow at positron emission tomography (PET). Methods and Results-Sixty patients with ST-segment-elevation myocardial infarction were included in this prospective study. Immediately after successful PCI, intracoronary pressure-flow measurements were performed and analyzed off-line to calculate HMR and indices derived from the pressure-velocity loops, including pressure at zero flow. Cardiovascular magnetic resonance and H 2 15O PET imaging were performed 4 to 6 days after PCI. Using cardiovascular magnetic resonance, MVI was defined as a subendocardial recess of myocardium with low signal intensity within a gadoliniumenhanced area. Myocardial perfusion was quantified using H 2 15 O PET. Reference HMR values were obtained in 16 stable patients undergoing coronary angiography. Complete data sets were available in 48 patients of which 24 developed MVI. Adequate pressure-velocity loops were obtained in 29 patients. HMR in the culprit artery in patients with MVI was significantly higher than in patients without MVI (MVI, 3.33±1.50 mm Hg/cm per second versus no MVI, 2.41±1.26 mm Hg/cm per second; P=0.03). MVI was associated with higher pressure at zero flow (45.68±13.16 versus 32.01±14.98 mm Hg; P=0.015). Multivariable analysis showed HMR to independently predict MVI (P=0.04). The optimal cutoff value for HMR was 2.5 mm Hg/cm per second. High HMR was associated with decreased myocardial blood flow on PET (myocardial perfusion reserve <2.0, 3.18±1.42 mm Hg/cm per second versus myocardial perfusion reserve ≥2.0, 2.24±1.19 mm Hg/cm per second; P=0.04). 1 CMRdefined MVI is assessed by T2-weighted imaging and late gadolinium enhancement. MVI refers to the areas within the infarcted myocardium where wash-in of contrast medium is severely impaired, as opposed to the wash-in (and delayed wash-out) of the contrast medium in the remaining areas of the infarct. It has been postulated that within these areas devoid of contrast, the microvasculature is obstructed, hence the term microvascular obstruction. Recently, however, it was shown that CMR-defined microvascular obstruction actually contains intramyocardial hemorrhage and complete microvascular destruction. Conclusions-Doppler2 Therefore, the term MVI seems to be more appropriate.The occurrence of MVI is linked to negative remodeling and left ventricular dysfunction, leading to decreased longterm survival, increased morbidity, and reduced quality of life as compared with patients with ST-segment-elevation myocardial infarction (STEMI) without MVI.3 MVI is related to ischemia-reperfusion damage and can potentially be reversed by pharmacological treatment in addition to the stand...

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Section: Measurements Of Coronary Flow and Microvascular Resistance Isupporting

confidence: 59%

supporting

confidence: 59%

Section: Measurements Of Coronary Flow and Microvascular Resistance Imentioning

confidence: 56%

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Doppler-Derived Intracoronary Physiology Indices Predict the Occurrence of Microvascular Injury and Microvascular Perfusion Deficits After Angiographically Successful Primary Percutaneous Coronary Intervention

Teunissen

Waard

Hollander

et al. 2015

Circ: Cardiovascular Interventions

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“…P zf is the arterial pressure at which blood flow would cease. In 2003, Shimada et al (31) speculated that P zf increases with the severity of injured coronary microvasculature, particularly the capillaries (28). However, previous studies have not compared these indexes.…”

mentioning

confidence: 96%

“…P zf appears to be an accurate index for evaluating microcirculation, because only Q p and P d are used during the diastolic phase to calculate P zf . In diastole, coronary flow depends on coronary pressure without regards to cardiac contraction, and the diastolic relationship between coronary flow and pressure permits analysis (17,28,31). However, sometimes it is hard to perform P zf on patients using Doppler wires because of the large variance.…”

Section: H404 Assessment Of Coronary Microcirculation In a Swine Modelmentioning

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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