Coronary Microvascular Resistance Index Immediately After Primary Percutaneous Coronary Intervention as a Predictor of the Transmural Extent of Infarction in Patients With ST-Segment Elevation Anterior Acute Myocardial Infarction

Kitabata, Hironori; Imanishi, Toshio; Kubo, Takashi; Takarada, Shigeho; Kashiwagi, Manabu; Matsumoto, Hiroki; Tsujioka, Hiroto; Ikejima, Hideyuki; Arita, Yu; Okochi, Keishi; Kuroi, Akio; Ueno, S.; Kataiwa, Hideaki; Tanimoto, Takashi; Yamano, Takashi; Hirata, Kumiko; Nakamura, Nobuo; Tanaka, Atsushi; Mizukoshi, Masato; Akasaka, Takashi

doi:10.1016/j.jcmg.2008.11.013

Cited by 55 publications

(58 citation statements)

References 28 publications

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“…Furthermore, age has been identified as a factor that may affect microvascular resistance (4,14). An elevated HMR, as assessed with a dual-sensor guidewire immediately after PCI, has been associated with microvascular dysfunction in patients with STsegment elevation myocardial infarction, and predictive values have been established for extent of transmural infarction and recovery of left ventricular function (2,15,39). HMR may thus be a useful parameter for early risk stratification in patients with acute myocardial infarction.…”

Section: Discussionmentioning

confidence: 99%

“…Coronary microvascular dysfunction has important emerging implications in clinical diagnosis, risk stratification, and prognosis of cardiac patients (3,15,28,39). Assessment of small vessel disease requires quantification of coronary microvascular resistance, especially in the absence of epicardial disease or with a moderate stenosis resistance.…”

Section: Discussionmentioning

confidence: 99%

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Minimal effect of collateral flow on coronary microvascular resistance in the presence of intermediate and noncritical coronary stenoses

Verhoeff

Hoef

Spaan

et al. 2012

American Journal of Physiology-Heart and Circulatory Physiology

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-Depending on stenosis severity, collateral flow can be a confounding factor in the determination of coronary hyperemic microvascular resistance (HMR). Under certain assumptions, the calculation of HMR can be corrected for collateral flow by incorporating the wedge pressure (P w) in the calculation. However, although P w Ͼ 25 mmHg is indicative of collateral flow, Pw does in part also reflect myocardial wall stress neglected in the assumptions. Therefore, the aim of this study was to establish whether adjusting HMR by P w is pertinent for a diagnostically relevant range of stenosis severities as expressed by fractional flow reserve (FFR). Accordingly, intracoronary pressure and Doppler flow velocity were measured a total of 95 times in 29 patients distal to a coronary stenosis before and after stepwise percutaneous coronary intervention. HMR was calculated without (HMR) and with Pw-based adjustment for collateral flow (HMRC). FFR ranged from 0.3 to 1. HMR varied between 1 and 5 and HMRC between 0.5 and 4.2 mmHg·cm Ϫ1 ·s. HMR was about 37% higher than HMRC for stenoses with FFR Ͻ 0.6, but for FFR Ͼ 0.8, the relative difference was reduced to 4.4 Ϯ 3.4%. In the diagnostically relevant range of FFR between 0.6 and 0.8, this difference was 16.5 Ϯ 10.4%. In conclusion, P w-based adjustment likely overestimates the effect of potential collateral flow and is not needed for the assessment of coronary HMR in the presence of a flow-limiting stenosis characterized by FFR between 0.6 and 0.8 or for nonsignificant lesions. wedge pressure; fractional flow reserve; coronary circulation CORONARY MICROVASCULAR DYSFUNCTION is increasingly being recognized as a major contributor to myocardial ischemia (3) and is likely associated with an altered coronary hyperemic microvascular resistance (HMR). Hence, a reliable assessment of microvascular resistance is needed that accurately reflects the status of the microcirculation and supports further development of diagnostic tools for microvascular disease.Resistance of a vascular compartment is defined as the ratio between the pressure drop over it and flow through it. Application of the resistance concept to the coronary circulation is challenging in the clinical setting, since volume flow cannot practically be measured directly and coronary back pressure is governed by multiple factors including microvascular conductance and extravascular compressive forces (16,17,32,37). At present, two guidewire-based systems are capable of the combined measurement of pressure and a surrogate of flow through a coronary stenosis. In the first system, flow velocity is measured by a Doppler crystal next to a pressure sensor (31, 35). The second system exploits the temperature sensitivity of the pressure sensor to determine the mean transit time of a temperature change induced by a bolus of saline (10). The corresponding indexes of HMR are respectively defined as the mean distal pressure (P d ) divided by mean distal flow velocity (35) The entrance of the microcirculation is not uniquely defined. Colla...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Minimal effect of collateral flow on coronary microvascular resistance in the presence of intermediate and noncritical coronary stenoses

Verhoeff

Hoef

Spaan

et al. 2012

American Journal of Physiology-Heart and Circulatory Physiology

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“…The recently developed novel dual-sensor (pressure and Doppler velocity) guidewire (PressureWire™ Certus, St Jude Medical) may provide more precise information about microvascular damage. 27 Effectiveness of DP Reperfusion therapy is the established treatment for patients with STEMI and its success is evaluated by the TIMI flow grade on the final coronary angiogram. 28 However, clinical studies using contrast echocardiography 29, 30 and Doppler flowmetry 31 have revealed the existence of poor myocardial reperfusion, 32 and those reports reemphasize the importance of restoring microvascular circulation, except for epicardial coronary flow.…”

Section: Distal Protection and Imr In Amimentioning

confidence: 99%

Distal Protection During Primary Coronary Intervention Can Preserve the Index of Microcirculatory Resistance in Patients With Acute Anterior ST-Segment Elevation Myocardial Infarction

Ito

Nanto

Doi

et al. 2011

Circ J

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Background:The objective of this study was to investigate whether a distal protection (DP) device can preserve the index of microcirculatory resistance (IMR) after primary percutaneous coronary intervention (PCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI). Methods and Results:The study group of 36 consecutive patients with anterior STEMI were randomized into 2 groups of primary PCI with or without DP: stenting without DP (non-DP group, n=17) and with DP (DP group, n=19). The DP in all cases was Filtrap (Nipro, Japan). Following final coronary angiography after successful PCI, IMR was measured using PressureWire™ Certus (St Jude Medical, USA) at maximal hyperemia. The averaged IMR of the 36 patients with STEMI after primary PCI was 31.6 U. The IMR in the DP group was significantly lower than that in the non-DP group (26.6±25.8 U vs. 37.2±23.2 U, P=0.03242).Conclusions: DP as an adjunctive therapy of PCI for acute anterior STEMI may have beneficial effects on myocardial microcirculation because of preservation of IMR. (Circ J 2011; 75: 94 - 98)

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“…This study provides a method to measure NMR without using a velocity wire, which can potentially be used to evaluate microvascular conditions during coronary arteriography. coronary microvasculation CORONARY MICROVASCULAR DYSFUNCTION occurs in a number of myocardial disease states and has important prognostic implications in different clinical settings, including acute coronary syndromes, diabetic coronary disease, hypertrophic cardiomyopathy, and transplant cardiac allograft vasculopathy (25,26,39). Intracoronary physiological techniques have been advocated and several indexes for the assessment of changes in the microcirculatory bed have been proposed (2, 11, 51), such as coronary flow reserve (CFR) (9, 13, 34) and microvascular resistance (MR) (12,39,49).…”

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confidence: 99%

Quantification of coronary microvascular resistance using angiographic images for volumetric blood flow measurement: in vivo validation

Zhang

Takarada

Molloi

2011

American Journal of Physiology-Heart and Circulatory Physiology

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Zhang Z, Takarada S, Molloi S. Quantification of coronary microvascular resistance using angiographic images for volumetric blood flow measurement: in vivo validation. Am J Physiol Heart Circ Physiol 300: H2096 -H2104, 2011. First published March 11, 2011 doi:10.1152/ajpheart.01123.2010.-Structural coronary microcirculation abnormalities are important prognostic determinants in clinical settings. However, an assessment of microvascular resistance (MR) requires a velocity wire. A first-pass distribution analysis technique to measure volumetric blood flow has been previously validated. The aim of this study was the in vivo validation of the MR measurement technique using first-pass distribution analysis. Twelve anesthetized swine were instrumented with a transit-time ultrasound flow probe on the proximal segment of the left anterior descending coronary artery (LAD). Microspheres were injected into the LAD to create a model of microvascular dysfunction. Adenosine (400 g·kg Ϫ1 ·min Ϫ1 ) was used to produce maximum hyperemia. A region of interest in the LAD arterial bed was drawn to generate time-density curves using angiographic images. Volumetric blood flow measurements (Q a) were made using a time-density curve and the assumption that blood was momentarily replaced with contrast agent during the injection. Blood flow from the flow probe (Qp), coronary pressure (Pa), and right atrium pressure (Pv) were continuously recorded. Flow probe-based normalized MR (NMRp) and angiography-based normalized MR (NMRa) were calculated using Qp and Qa, respectively. In 258 measurements, Qa showed a strong correlation with the gold standard Qp (Qa ϭ 0.90 Qp ϩ 6.6 ml/min, r 2 ϭ 0.91, P Ͻ 0.0001). NMRa correlated linearly with NMRp (NMRa ϭ 0.90 NMRp ϩ 0.02 mmHg·ml Ϫ1 ·min Ϫ1 , r 2 ϭ 0.91, P Ͻ 0.0001). Additionally, the BlandAltman analysis showed a close agreement between NMRa and NMRp. In conclusion, a technique based on angiographic image data for quantifying NMR was validated using a swine model. This study provides a method to measure NMR without using a velocity wire, which can potentially be used to evaluate microvascular conditions during coronary arteriography. coronary microvasculation CORONARY MICROVASCULAR DYSFUNCTION occurs in a number of myocardial disease states and has important prognostic implications in different clinical settings, including acute coronary syndromes, diabetic coronary disease, hypertrophic cardiomyopathy, and transplant cardiac allograft vasculopathy (25,26,39). Intracoronary physiological techniques have been advocated and several indexes for the assessment of changes in the microcirculatory bed have been proposed (2, 11, 51), such as coronary flow reserve (CFR) (9, 13, 34) and microvascular resistance (MR) (12,39,49). Many previous study findings suggest that MR is a useful variable for directly assessing microcirculatory function. In 1974, Gould et al. (19, 20, 21) postulated a hypothesis that minimum MR is independent of epicardial stenosis severity. Recently, Fearon and colleagues (1,7,12,14...

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Coronary Microvascular Resistance Index Immediately After Primary Percutaneous Coronary Intervention as a Predictor of the Transmural Extent of Infarction in Patients With ST-Segment Elevation Anterior Acute Myocardial Infarction

Abstract: MVRI measured immediately after primary PCI is a useful predictor for the TEI in patients with anterior acute MI.

Cited by 55 publications

References 28 publications

Minimal effect of collateral flow on coronary microvascular resistance in the presence of intermediate and noncritical coronary stenoses

Minimal effect of collateral flow on coronary microvascular resistance in the presence of intermediate and noncritical coronary stenoses

Distal Protection During Primary Coronary Intervention Can Preserve the Index of Microcirculatory Resistance in Patients With Acute Anterior ST-Segment Elevation Myocardial Infarction

Quantification of coronary microvascular resistance using angiographic images for volumetric blood flow measurement: in vivo validation

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