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Groenland FT, Ziedses des Plantes AC, Scoccia A, Neleman T, Masdjedi K, Kardys I, Diletti R, Van Mieghem NM, Daemen J. Post percutaneous coronary intervention physiology in patients presenting with ST-segment elevation myocardial infarction. IJC HEART & VASCULATURE 2023; 49:101319. [PMID: 38143782 PMCID: PMC10746447 DOI: 10.1016/j.ijcha.2023.101319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Frederik T.W. Groenland
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Alessandra Scoccia
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Cardiology, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Isabella Kardys
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M. Van Mieghem
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of (Interventional) Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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2
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Albistur S, Torrado J, Niell N, Mila R. Microvascular dysfunction following deferred stenting strategy in ST-segment elevation myocardial infarction: a case report. Eur Heart J Case Rep 2023; 7:ytad564. [PMID: 38034941 PMCID: PMC10686532 DOI: 10.1093/ehjcr/ytad564] [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: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 12/02/2023]
Abstract
Background ST-segment elevation myocardial infarction (STEMI) has traditionally been managed with immediate reperfusion of the culprit artery, primarily through percutaneous coronary intervention and stent placement. Emerging data are highlighting the crucial importance of post-infarct microcirculatory function assessment. Case summary This report presents a patient with an inferior STEMI who was successfully reperfused without stent implantation. Tools such as optical coherence tomography, fractional flow reserve, and positron emission tomography computed tomography N-13 ammonia were utilized, offering comprehensive insights into the anatomical and functional characteristics of both the epicardial vessel and microcirculation. Discussion The recovery of the reversible component of microcirculatory dysfunction, observable as early as 5 days post-infarction, might carry significant implications for clinical decision-making. Such insights can potentially influence contemporary treatment strategies, including the consideration of deferred stenting. This case underscores the significance of post-infarct microcirculatory function and its potential impact on therapeutic approaches.
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Affiliation(s)
- Sebastian Albistur
- Department of Cardiology, Centro Cardiovascular Universitario-Hospital de Clínicas, Avda. Italia S/N, Montevideo 11600, Uruguay
| | - Juan Torrado
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nicolás Niell
- Nuclear Medicine Department, Centro Uruguayo de Imagenología Molecular, Montevideo, Uruguay
| | - Rafael Mila
- Department of Cardiology, Centro Cardiovascular Universitario-Hospital de Clínicas, Avda. Italia S/N, Montevideo 11600, Uruguay
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Bellino M, Silverio A, Esposito L, Cancro FP, Ferruzzi GJ, Di Maio M, Rispoli A, Vassallo MG, Di Muro FM, Galasso G, De Luca G. Moving toward Precision Medicine in Acute Coronary Syndromes: A Multimodal Assessment of Non-Culprit Lesions. J Clin Med 2023; 12:4550. [PMID: 37445584 DOI: 10.3390/jcm12134550] [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: 06/07/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with acute coronary syndrome and multivessel disease experience several recurrent adverse events that lead to poor outcomes. Given the complexity of treating these patients, and the extremely high risk of long-term adverse events, the assessment of non-culprit lesions becomes crucial. Recently, two trials have shown a possible clinical benefit into treat non-culprit lesions using a fraction flow reserve (FFR)-guided approach, compared to culprit-lesion-only PCI. However, the most recent FLOW Evaluation to Guide Revascularization in Multivessel ST-elevation Myocardial Infarction (FLOWER-MI) trial did not show a benefit of the use of FFR-guided PCI compared to an angiography-guided approach. Otherwise, intracoronary imaging using optical coherence tomography (OCT), intravascular ultrasound (IVUS), or near-infrared spectroscopy (NIRS) could provide both quantitative and qualitative assessments of non-culprit lesions. Different studies have shown how the characterization of coronary lesions with intracoronary imaging could lead to clinical benefits in these peculiar group of patients. Moreover, non-invasive evaluations of NCLs have begun to take ground in this context, but more insights through adequately powered and designed studies are needed. The aim of this review is to outline the available techniques, both invasive and non-invasive, for the assessment of multivessel disease in patients with STEMI, and to provide a systematic guidance on the assessment and approach to these patients.
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Affiliation(s)
- Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Francesco Paolo Cancro
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Germano Junior Ferruzzi
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Antonella Rispoli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Maria Giovanna Vassallo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Francesca Maria Di Muro
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Clinica Medica, Careggi University Hospital, 50139 Florence, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU "Policlinico G. Martino", Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, 20161 Milan, Italy
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4
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Sezer M, Tas A, Demirtakan ZG, Broyd CJ, Ozcan A, Hasdemir H, Kocaaga M, Sezer I, Sonsoz MR, Atici A, Ozcan I, Umman B, Bugra Z, Davies JE, Escaned J, van Royen N, Umman S. Coronary microcirculation in nonculprit vessel territory in reperfused acute myocardial infarction. Microvasc Res 2023; 147:104495. [PMID: 36739961 DOI: 10.1016/j.mvr.2023.104495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an ongoing debate on the extension of reperfusion-related microvascular damage (MVD) throughout the remote noninfarcted myocardial regions in patients with ST-elevation myocardial infarction (STEMI) that undergo primary percutaneous intervention (pPCI). The aim of this study was to elucidate the impact of reperfusion on remote microcirculatory territory by analyzing hemodynamic alterations in the nonculprit-vessel in relation to reperfusion. METHODS A total of 20 patients with STEMI undergoing pPCI were included. Peri-reperfusion temporal changes in hemodynamic parameters were obtained in angiographically normal nonculprit vessels before and 1-h after reopening of the culprit vessel. Intracoronary pressure and flow velocity data were compared using pairwise analyses (before and 1-h after reperfusion). RESULTS In the non-culprit vessel, compared to the pre-reperfusion state, mean resting average peak velocity (33.4 ± 9.4 to 25.0 ± 4.9 cm/s, P < 0.001) and mean hyperemic average peak velocity (53.5 ± 14.4 to 42.1 ± 10.66 cm/s, P = 0.001) significantly decreased; whereas baseline (3.2 ± 1.0 to 4.0 ± 1.0 mmHg.cm-1.s, P < 0.001) and hyperemic microvascular resistance (HMR) (1.9 ± 0.6 to 2.4 ± 0.7 mmHg.cm-1.s, P < 0.001) and mean zero flow pressure (Pzf) values (32.5 ± 6.9 to 37.6 ± 8.3 mmHg, P = 0.003) significantly increased 1-h after reperfusion. In particular, the magnitude of changes in HMR and Pzf values following reperfusion were more prominent in patients with larger infarct size and with higher extent of MVD in the culprit vessel territory. CONCLUSION Reperfusion-related microvascular injury extends to involve remote myocardial territory in relation to the magnitude of the adjacent infarction and infarct-zone MVD. (GUARD Clinical TrialsNCT02732080).
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Affiliation(s)
- Murat Sezer
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Acibadem International Hospital, Istanbul, Turkey.
| | - Ahmet Tas
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | | | - Alp Ozcan
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hakan Hasdemir
- Department of Cardiology, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Mehmet Kocaaga
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Irem Sezer
- Department of Cardiology, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Mehmet R Sonsoz
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Adem Atici
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilke Ozcan
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Berrin Umman
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zehra Bugra
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Justin E Davies
- National Heart & Lung Institute, Hammersmith Campus, Imperial College London, UK
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, the Netherlands
| | - Sabahattin Umman
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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5
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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: 0] [Impact Index Per Article: 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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6
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Saito Y, Kobayashi Y. Complete revascularization in acute myocardial infarction: a clinical review. Cardiovasc Interv Ther 2023; 38:177-186. [PMID: 36609898 PMCID: PMC9823266 DOI: 10.1007/s12928-022-00907-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023]
Abstract
In patients with ST segment elevation and non-ST elevation myocardial infarction (MI), multivessel (MV) coronary artery disease is found in approximately 50%, leading to worse clinical outcomes. Recent data have suggested that complete revascularization with MV percutaneous coronary intervention is associated with a reduced risk of major adverse cardiovascular events as compared to culprit vessel-only revascularization. However, the optimal timing of MV intervention, appropriate non-culprit lesion assessment, and the best revascularization strategy in specific subsets such as cardiogenic shock remain to be established. This review article summarizes current evidence on revascularization strategies in patients with acute MI and MV disease.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan.
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
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7
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Piccolo R, Manzi L, Simonetti F, Leone A, Angellotti D, Immobile Molaro M, Verde N, Cirillo P, Di Serafino L, Franzone A, Spaccarotella CAM, Esposito G. Management of Non-Culprit Lesions in STEMI Patients with Multivessel Disease. J Clin Med 2023; 12:jcm12072572. [PMID: 37048655 PMCID: PMC10095226 DOI: 10.3390/jcm12072572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/19/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Multivessel disease is observed in approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Data from randomized clinical trials has shown that complete revascularization in the STEMI setting improves clinical outcomes by reducing the risk of reinfarction and urgent revascularization. However, the timing and modality of revascularization of non-culprit lesions are still debated. PCI of non-culprit lesions can be performed during the index primary PCI or as a staged procedure and can be guided by angiography, functional assessment, or intracoronary imaging. In this review, we summarize the available evidence about the management of non-culprit lesions in STEMI patients with or without cardiogenic shock.
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8
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Demirkiran A, Robbers LFHJ, van der Hoeven NW, Everaars H, Hopman LHGA, Janssens GN, Berkhof HJ, Lemkes JS, van de Bovenkamp AA, van Leeuwen MAH, Nap A, van Loon RB, de Waard GA, van Rossum AC, van Royen N, Nijveldt R. The Dynamic Relationship Between Invasive Microvascular Function and Microvascular Injury Indicators, and Their Association With Left Ventricular Function and Infarct Size at 1-Month After Reperfused ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2022; 15:892-902. [PMID: 36305318 DOI: 10.1161/circinterventions.122.012081] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The invasive microvascular function indices, coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR), exhibit a dynamic pattern after ST-segment-elevation myocardial infarction. The effects of microvascular injury on the evolution of the microvascular function and the prognostic significance of the evolution of microvascular function are unknown. We investigated the relationship between the temporal changes of CFR and IMR, and cardiovascular magnetic resonance-derived microvascular injury characteristics in reperfused ST-segment-elevation myocardial infarction patients, and their association with 1-month left ventricular ejection fraction and infarct size (IS). METHODS In 109 ST-segment-elevation myocardial infarction patients who underwent angiography for primary percutaneous coronary intervention (PPCI) and at 1-month follow-up, invasive assessment of CFR and IMR were performed in the culprit artery during both procedures. Cardiovascular magnetic resonance was performed 2 to 7 days after PPCI and at 1 month and provided assessment of left ventricular ejection fraction, IS, microvascular obstruction, and intramyocardial hemorrhage. RESULTS CFR and IMR significantly changed over 1 month (both, P<0.001). The absolute IMR change over 1 month (ΔIMR) showed association with both microvascular obstruction and intramyocardial hemorrhage presence (both, P=0.01). ΔIMR differed between patients with/without microvascular obstruction (P=0.02) and with/without intramyocardial hemorrhage (P=0.04) but not ΔCFR for both. ΔIMR demonstrated association with both left ventricular ejection fraction and IS at 1 month (P<0.001, P=0.001, respectively), but not ΔCFR for both. Receiver-operating characteristics curve analysis of ΔIMR showed a larger area under the curve than post-PPCI CFR and IMR, and ΔCFR to be associated with both 1-month left ventricular ejection fraction >50% and extensive IS (the highest quartile). CONCLUSIONS In reperfused ST-segment-elevation myocardial infarction patients, CFR and IMR significantly improved 1 month after PPCI; the temporal change in IMR is closely related to the presence/absence of microvascular damage and IS. ΔIMR exhibits a stronger association for 1-month functional outcome than post-PPCI CFR, IMR, or ΔCFR.
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Affiliation(s)
- Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Lourens F H J Robbers
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Nina W van der Hoeven
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Hans J Berkhof
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (H.J.B.)
| | - Jorrit S Lemkes
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Arno A van de Bovenkamp
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | | | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Ramon B van Loon
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.)
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (N.v.R., R.N.)
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands (A.D., L.F.H.J.R.' N.W.v.d.H., H.E., L.H.G.A.H.' G.N.J., J.S.L., A.A.v.d.B., A.N., R.B.v.L., G.A.d.W., A.C.v.R., R.N.).,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (N.v.R., R.N.)
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9
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Omar A, Senguttuvan NB, Ueyama H, Kuno T, Beerkens F, Rahim M, Elmariah H, Takagi H, Abdulkader RS, Yallanki HP, Pelliccia F, Mylavarapu DP, Claessen B, Pasceri V, Dangas G. Meta-Analysis Comparing Fractional Flow Reserve and Angiography-Guided Complete Revascularization of Nonculprit Artery for ST-Elevation Myocardial Infarction. Am J Cardiol 2022; 183:8-15. [PMID: 36115726 DOI: 10.1016/j.amjcard.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/21/2022] [Accepted: 08/06/2022] [Indexed: 11/28/2022]
Abstract
This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.
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Affiliation(s)
- Ali Omar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein Medical College, New York, New York
| | - Frans Beerkens
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mehek Rahim
- Department of Medicine, Hackensack University Medical Center, Hackensack, New Jersey
| | - Hesham Elmariah
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | | | - Hanumath Prasad Yallanki
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | | | - Durga Prasad Mylavarapu
- Department of Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Bimmer Claessen
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Vincenzo Pasceri
- Department of Cardiology, University Sapienza of Rome, Rome, Italy
| | - George Dangas
- Department of Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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10
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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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11
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Clinical use of physiological lesion assessment using pressure guidewires: an expert consensus document of the Japanese association of cardiovascular intervention and therapeutics-update 2022. Cardiovasc Interv Ther 2022; 37:425-439. [PMID: 35543896 DOI: 10.1007/s12928-022-00863-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 01/10/2023]
Abstract
Fractional flow reserve and instantaneous wave-free ratio are widely accepted and recommended in Western and Japanese guidelines for appropriate percutaneous coronary intervention. There are, however, many differences in clinical situations between Japan and Western countries. Therefore, the Task Force on coronary physiology of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has proposed an expert consensus document to summarize current evidence and suggest the practical use of physiological lesion assessment in Japan.
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12
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Flores CH, Díez-Delhoyo F, Sanz-Ruiz R, Vázquez-Álvarez ME, Tamargo Delpon M, Soriano Triguero J, Elízaga Corrales J, Fernández-Avilés F, Gutiérrez Ibañes E. Microvascular dysfunction of the non-culprit circulation predicts poor prognosis in patients with ST-segment elevation myocardial infarction. IJC HEART & VASCULATURE 2022; 39:100997. [PMID: 35310375 PMCID: PMC8927849 DOI: 10.1016/j.ijcha.2022.100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
Microvascular and endothelial dysfunction is present in the non-culprit territory in up to 93% of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. Whether an impaired coronary physiology in the non-culprit territory correlates with long-term prognosis is yet to be determined. At a median follow-up of 4 years, we found that cardiovascular events and death occurred more frequently in patients with a low coronary flow reserve (CFR) in the non-culprit artery. Other parameters such as the index of microvascular resistance (IMR) or endothelial dysfunction were not independent predictors of adverse outcomes.
Background Endothelial and microvascular dysfunction are frequently found in the non-culprit territory in patients with acute myocardial infarction (AMI). We aimed to determine whether an impaired coronary physiology of the non-culprit territory impacts long-term prognosis. Methods FISIOIAM was an observational single-center study which included patients with AMI and another coronary artery lesion in a different territory. Intracoronary physiology of the non-culprit artery was analyzed early after primary percutaneous coronary intervention of the culprit artery, using fractional flow reserve (FFR), index of microcirculatory resistance (IMR), coronary flow reserve (CFR), endothelium-dependent CFR (eCFR) and macrovascular endothelial function . Patients were followed for a composite outcome of cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and hospitalization due to heart failure or unstable angina. Results A total of 84 patients (mean age: 62 ± 10 years) were included and functional abnormalities were detected in 93% of them. During follow-up (median of 1422 days; interquartile range, 1287–1634), 13.1% of the patients experienced at least one adverse cardiovascular event. Kaplan-Meier analysis revealed that patients with a CFR < 2 had a higher risk of events (Hazard Ratio, HR: 4.97, 95% Confidence Interval, CI, 1.32–18.75), whereas other parameters such as FFR, IMR, eCFR, and macrovascular endothelial function had no effect. A low CFR was an independent predictor of cardiovascular events, even after adjustment for age and traditional cardiovascular risk factors (adjusted HR: 6.62, 95% CI, 1.30–33.70). Conclusions The presence of abnormal coronary microvascular function as measured by a CFR < 2 in the non-culprit territory predicts future risk of adverse cardiovascular events.
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13
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Heusch G. Coronary blood flow in heart failure: cause, consequence and bystander. Basic Res Cardiol 2022; 117:1. [PMID: 35024969 PMCID: PMC8758654 DOI: 10.1007/s00395-022-00909-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 01/31/2023]
Abstract
Heart failure is a clinical syndrome where cardiac output is not sufficient to sustain adequate perfusion and normal bodily functions, initially during exercise and in more severe forms also at rest. The two most frequent forms are heart failure of ischemic origin and of non-ischemic origin. In heart failure of ischemic origin, reduced coronary blood flow is causal to cardiac contractile dysfunction, and this is true for stunned and hibernating myocardium, coronary microembolization, myocardial infarction and post-infarct remodeling, possibly also for the takotsubo syndrome. The most frequent form of non-ischemic heart failure is dilated cardiomyopathy, caused by genetic mutations, myocarditis, toxic agents or sustained tachyarrhythmias, where alterations in coronary blood flow result from and contribute to cardiac contractile dysfunction. Hypertrophic cardiomyopathy is caused by genetic mutations but can also result from increased pressure and volume overload (hypertension, valve disease). Heart failure with preserved ejection fraction is characterized by pronounced coronary microvascular dysfunction, the causal contribution of which is however not clear. The present review characterizes the alterations of coronary blood flow which are causes or consequences of heart failure in its different manifestations. Apart from any potentially accompanying coronary atherosclerosis, all heart failure entities share common features of impaired coronary blood flow, but to a different extent: enhanced extravascular compression, impaired nitric oxide-mediated, endothelium-dependent vasodilation and enhanced vasoconstriction to mediators of neurohumoral activation. Impaired coronary blood flow contributes to the progression of heart failure and is thus a valid target for established and novel treatment regimens.
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Affiliation(s)
- Gerd Heusch
- grid.5718.b0000 0001 2187 5445Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
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14
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Peper J, Becker LM, van Kuijk JP, Leiner T, Swaans MJ. Fractional Flow Reserve: Patient Selection and Perspectives. Vasc Health Risk Manag 2021; 17:817-831. [PMID: 34934324 PMCID: PMC8684425 DOI: 10.2147/vhrm.s286916] [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: 08/13/2021] [Accepted: 11/30/2021] [Indexed: 01/10/2023] Open
Abstract
The aim of this review was to discuss the current practice and patient selection for invasive FFR, new techniques to estimate invasive FFR and future of coronary physiology tests. We elaborate on the indication and application of FFR and on the contraindications and concerns in certain patient populations.
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Affiliation(s)
- Joyce Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonie M Becker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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15
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Chang CC, Chuang MJ, Lee YH, Tsai YL, Lu YW, Chou RH, Wu CH, Lu TM, Huang PH, Lin SJ. Vessel fractional flow reserve in assessment of non-culprit lesions in ST elevation myocardial infarction. Open Heart 2021; 8:openhrt-2021-001691. [PMID: 34341096 PMCID: PMC8330569 DOI: 10.1136/openhrt-2021-001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/13/2021] [Indexed: 11/07/2022] Open
Abstract
Objectives We sought to evaluate the physiology of non-culprit lesions by using vessel fractional flow reserve (vFFR) among patients with ST elevation myocardial infarction (STEMI) and multivessel disease (MVD). Methods From January 2017 to December 2019, 354 patients with STEMI in the Taipei Veterans General Hospital Acute Myocardial Infarction Registry were screened. Patients who underwent successful primary percutaneous coronary intervention (PCI) for culprit lesions, with at least one non-culprit lesion with stenosis of ≥50%, were eligible. vFFR was computed retrospectively. Results A total of 156 patients with 217 non-culprit lesions were eligible for this study. Aortic root pressure and two good angiograms were available for 139 non-culprit lesions for vFFR analysis. Based on the vFFR analysis, 59 non-culprit lesions (43.2%) had a vFFR value >0.80, and PCI was deferred in 45 lesions (76.3%). Meanwhile, 80 non-culprit lesions (56.8%) had a vFFR value ≤0.80; however, PCI was only performed in 31 lesions (38.7%) (p=0.142). The incidence of vessel-oriented composite endpoint was numerically higher in non-culprit lesions with vFFR ≤0.80 than those with vFFR >0.80 (6.3% vs 1.7%, HR: 3.59, 95% CI: 0.42 to 30.8, p=0.243). Conclusion Functional incomplete revascularisation is common among patients with STEMI and MVD. The adoption of vFFR to assess non-culprit lesions may reclassify the coronary revascularisation strategy that is usually guided by angiography only in this acute setting.
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Affiliation(s)
- Chun Chin Chang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ming Ju Chuang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yin Hao Lee
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi Lin Tsai
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya Wen Lu
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ruey Hsing Chou
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng Hsueh Wu
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tse Min Lu
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Healthcare and services center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po Hsun Huang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shing Jong Lin
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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16
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Influence of lesion and disease subsets on the diagnostic performance of the quantitative flow ratio in real-world patients. Sci Rep 2021; 11:2995. [PMID: 33542310 PMCID: PMC7862355 DOI: 10.1038/s41598-021-82235-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
The quantitative flow ratio (QFR) is a novel angiography-based computational method assessing functional ischemia caused by coronary stenosis. This study aimed to evaluate the diagnostic performance of quantitative flow ratio (QFR) in patients with angina and acute myocardial infarction (AMI) and to identify the conditions with low diagnostic performance. We assessed the QFR for 1077 vessels under fractional flow ratio (FFR) evaluation in 915 patients with angina and AMI. The diagnostic accuracies of the QFR for identifying an FFR ≤ 0.8 were 95.98% (95% confidence interval [CI] 94.52 to 97.14%) for the angina group and 92.42% (95% CI 86.51 to 96.31%) for the AMI group. The diagnostic accuracy of the QFR in the borderline FFR zones (> 0.75, ≤ 0.85) (91.23% [95% CI 88.25 to 93.66%]) was significantly lower than that in others (difference: 4.32; p = 0.001). The condition accompanying both AMI and the borderline FFR zone showed the lowest QFR diagnostic accuracy in our data (83.93% [95% CI 71.67 to 92.38]). The diagnostic accuracy was reduced for tandem lesions (p = 0.04, not correcting for multiple testing). Our study found that the QFR method yielded a high overall diagnostic performance in real-world patients. However, low diagnostic accuracy has been observed in borderline FFR zones with AMI, and the hybrid FFR approach needs to be considered.
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17
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Thim T, van der Hoeven NW, Musto C, Nijveldt R, Götberg M, Engstrøm T, Smits PC, Oldroyd KG, Gershlick AH, Escaned J, Baptista SB, Raposo L, van Royen N, Maeng M. Evaluation and Management of Nonculprit Lesions in STEMI. JACC Cardiovasc Interv 2020; 13:1145-1154. [PMID: 32438985 DOI: 10.1016/j.jcin.2020.02.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
Nonculprit lesions are frequently observed in patients with ST-segment elevation myocardial infarction. Results from recent randomized clinical trials suggest that complete revascularization after ST-segment elevation myocardial infarction improves outcomes. In this state-of-the-art paper, the authors review these trials and consider how best to determine which nonculprit lesions require revascularization and when this should be performed.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Carmine Musto
- Department of Interventional Cardiology, San Camillo Hospital, Rome, Italy
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pieter C Smits
- Department of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Keith G Oldroyd
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Anthony H Gershlick
- University of Leicester, University Hospitals of Leicester, Leicester Biomedical Research Unit, Leicester, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Sergio Bravo Baptista
- University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Luis Raposo
- Cardiology Department, Santa Cruz Hospital-CHLO, Lisbon, Portugal
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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18
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Kirigaya H, Okada K, Hibi K, Maejima N, Iwahashi N, Matsuzawa Y, Akiyama E, Minamimoto Y, Kosuge M, Ebina T, Tamura K, Kimura K. Diagnostic performance and limitation of quantitative flow ratio for functional assessment of intermediate coronary stenosis. J Cardiol 2020; 77:492-499. [PMID: 33246845 DOI: 10.1016/j.jjcc.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/29/2020] [Accepted: 10/24/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study aimed to simultaneously investigate diagnostic performance and limitation of quantitative flow reserve (QFR) for assessing functionally significant coronary stenosis, focusing on factors affecting diagnostic accuracy of QFR. METHODS This study evaluated 1) QFR diagnostic accuracy compared with fractional flow reserve (FFR) in patients with stable coronary artery disease (Cohort-A, n = 95) and 2) QFR reproducibility for non-culprit lesions (NCLs) assessment between acute and staged (14±5 days later) procedures in patients with ST-segment elevation myocardial infarction (STEMI) (Cohort-B, n = 65). All coronary angiography image acquisition was performed before the introduction of QFR system into our institution. RESULTS Cohort-A showed good correlation (r = 0.80, p<0.0001) between QFR and FFR; diagnostic accuracy of QFR for FFR ≤0.80 was 85.2% (sensitivity 80.4%, specificity 91.0%, positive predictive value 91.1%, negative predictive value 80.0%). There were 14 lesions showing discordance between QFR and FFR, which was primarily attributable to inadequate lesion visualization due to vessel overlap/tortuosity and/or insufficient intra-coronary contrast-media injection. In Cohort-B, there was also excellent correlation between acute and staged QFR; classification agreement of acute and staged QFR was 92.3%. Five lesions showed discordance between acute and staged QFR, 4 were due to limited image acquisition and/or high coronary flow velocity at acute phase of STEMI and 1 was borderline ischemia. CONCLUSIONS QFR-derived physiological assessment of intermediate coronary stenosis is feasible, even in the acute setting of STEMI. Adjusting some technical factors may further improve the diagnostic performance of QFR.
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Affiliation(s)
- Hidekuni Kirigaya
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kozo Okada
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan.
| | - Nobuhiko Maejima
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Eiichi Akiyama
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Yugo Minamimoto
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Toshiaki Ebina
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
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19
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Padro T, Manfrini O, Bugiardini R, Canty J, Cenko E, De Luca G, Duncker DJ, Eringa EC, Koller A, Tousoulis D, Trifunovic D, Vavlukis M, de Wit C, Badimon L. ESC Working Group on Coronary Pathophysiology and Microcirculation position paper on 'coronary microvascular dysfunction in cardiovascular disease'. Cardiovasc Res 2020; 116:741-755. [PMID: 32034397 DOI: 10.1093/cvr/cvaa003] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022] Open
Abstract
Although myocardial ischaemia usually manifests as a consequence of atherosclerosis-dependent obstructive epicardial coronary artery disease, a significant percentage of patients suffer ischaemic events in the absence of epicardial coronary artery obstruction. Experimental and clinical evidence highlight the abnormalities of the coronary microcirculation as a main cause of myocardial ischaemia in patients with 'normal or near normal' coronary arteries on angiography. Coronary microvascular disturbances have been associated with early stages of atherosclerosis even prior to any angiographic evidence of epicardial coronary stenosis, as well as to other cardiac pathologies such as myocardial hypertrophy and heart failure. The main objectives of the manuscript are (i) to provide updated evidence in our current understanding of the pathophysiological consequences of microvascular dysfunction in the heart; (ii) to report on the current knowledge on the relevance of cardiovascular risk factors and comorbid conditions for microcirculatory dysfunction; and (iii) to evidence the relevance of the clinical consequences of microvascular dysfunction. Highlighting the clinical importance of coronary microvascular dysfunction will open the field for research and the development of novel strategies for intervention will encourage early detection of subclinical disease and will help in the stratification of cardiovascular risk in agreement with the new concept of precision medicine.
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Affiliation(s)
- Teresa Padro
- Cardiovascular Program-ICCC, Research Institute Hospital Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain.,Cardiovascular Research Chair, Autonomous University Barcelona (UAB), Barcelona, Spain
| | - Olivia Manfrini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Raffaele Bugiardini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - John Canty
- Division of Cardiology, Department of Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - Edina Cenko
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Maggiore della Carità Hospital, Eastern Piedmont University, Novara, Italy
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Science Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Akos Koller
- Department of Translational Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary.,Department of Physiology, New York Medical College, Valhalla, NY, USA
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, University of Athens Medical School, Athens, Greece
| | - Danijela Trifunovic
- Department of Cardiology, University Clinical Center of Serbia; and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Vavlukis
- University Clinic of Cardiology, Medical Faculty, Ss' Cyril and Methodius University, Skopje, Republic of Macedonia
| | - Cor de Wit
- Institut für Physiologie, Universität zu Lübeck, Lübeck, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Lina Badimon
- Cardiovascular Program-ICCC, Research Institute Hospital Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain.,Cardiovascular Research Chair, Autonomous University Barcelona (UAB), Barcelona, Spain
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20
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Michail M, Thakur U, Mehta O, Ramzy JM, Comella A, Ihdayhid AR, Cameron JD, Nicholls SJ, Hoole SP, Brown AJ. Non-hyperaemic pressure ratios to guide percutaneous coronary intervention. Open Heart 2020; 7:openhrt-2020-001308. [PMID: 33004619 PMCID: PMC7534727 DOI: 10.1136/openhrt-2020-001308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023] Open
Abstract
The use of fractional flow reserve (FFR) in guiding revascularisation improves patient outcomes and has been well-established in clinical guidelines. Despite this, the uptake of FFR has been limited, likely attributable to the perceived increase in procedural time and use of hyperaemic agents that can cause patient discomfort. This has led to the development of instantaneous wave-free ratio (iFR), an alternative non-hyperaemic pressure ratio (NHPR). Since its inception, the use of iFR has been supported by an increasing body of evidence and is now guideline recommended. More recently, other commercially available NHPRs including diastolic hyperaemia-free ratio and resting full-cycle ratio have emerged. Studies have demonstrated that these indices, in addition to mean distal coronary artery pressure to mean aortic pressure ratio, are mathematically analogous (with specific nuances) to iFR. Additionally, there is increasing data demonstrating the equivalent diagnostic performance of alternative NHPRs in comparison with iFR and FFR. These NHPRs are now integral within most current pressure wire systems and are commonly available in the catheter laboratory. It is therefore key to understand the fundamental differences and evidence for NHPRs to guide appropriate clinical decision-making.
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Affiliation(s)
- Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia .,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Udit Thakur
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Ojas Mehta
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - John M Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Andrea Comella
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Stephen P Hoole
- Department of Interventional Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Adam J Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Victoria, Australia
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21
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Thim T, Götberg M, Fröbert O, Nijveldt R, van Royen N, Baptista SB, Koul S, Kellerth T, Bøtker HE, Terkelsen CJ, Christiansen EH, Jakobsen L, Kristensen SD, Maeng M. Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy). BMC Res Notes 2020; 13:410. [PMID: 32873327 PMCID: PMC7466494 DOI: 10.1186/s13104-020-05252-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/21/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate agreement between instantaneous wave free ratio (iFR) and fractional flow reserve (FFR) for the functional assessment of nonculprit coronary stenoses at staged follow-up after ST-segment elevation myocardial infarction (STEMI). Results We measured iFR and FFR at staged follow-up in 112 STEMI patients with 146 nonculprit stenoses. Median interval between STEMI and follow-up was 16 (interquartile range 5–32) days. Agreement between iFR and FFR was 77% < 5 days after STEMI and 86% after ≥ 5 days (p = 0.19). Among cases with disagreement, the proportion of cases with hemodynamically significant iFR and non-significant FFR were different when assessed < 5 days (5 in 8, 63%) versus ≥ 5 days (3 in 15, 20%) after STEMI (p = 0.04). Overall classification agreement between iFR and FFR was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between iFR and FFR.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Matthias Götberg
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University, Örebro, Sweden
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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22
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Mejía-Rentería H, Lee JM, van der Hoeven NW, Gonzalo N, Jiménez-Quevedo P, Nombela-Franco L, Núñez-Gil IJ, Salinas P, Del Trigo M, Cerrato E, van Royen N, Knaapen P, Koo BK, Macaya C, Fernández-Ortiz A, Escaned J. Coronary Microcirculation Downstream Non-Infarct-Related Arteries in the Subacute Phase of Myocardial Infarction: Implications for Physiology-Guided Revascularization. J Am Heart Assoc 2020; 8:e011534. [PMID: 31014181 PMCID: PMC6512122 DOI: 10.1161/jaha.118.011534] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Concerns exist about reliability of pressure‐wire‐guided coronary revascularization of non‐infarct‐related arteries (non‐IRA). We investigated whether physiological assessment of non‐IRA during the subacute phase of myocardial infarction might be flawed by microcirculatory dysfunction. Methods and Results We analyzed non‐IRA that underwent fractional flow reserve, coronary flow reserve, and the index of microcirculatory resistance assessment. Microcirculation and hyperemic response were evaluated in 49 acute myocardial infarction patients (59 non‐IRA) and compared with a matched control group of 46 stable angina (SA) patients (59 vessels). Time between acute myocardial infarction to physiological interrogation was 5.9±2.4 days. Fractional flow reserve was similar in both groups (0.79±0.11 in non‐IRA versus 0.80±0.13 in SA vessels, P=0.527). Lower coronary flow reserve values were found in non‐IRA compared with SA vessels (1.77 [1.25–2.76] versus 2.44 [1.63–4.00], P=0.018), primarily driven by an increased baseline flow in non‐IRA (rest mean transit time 0.58 [0.32–0.83] versus 0.65 s [0.39–1.20], P=0.045), whereas the hyperemic flow was similar (hyperemic mean transit time 0.26 [0.20–0.42] versus 0.26 s [0.18–0.35], P=0.873). No differences were found regarding index of microcirculatory resistance (15.6 [10.4–21.8] in non‐IRA versus 16.7 [11.6–23.6] U in SA vessels, P=0.559). During adenosine infusion, the hyperemic response was similar in both groups (non‐IRA versus SA vessels) in terms of the resistive reserve ratio (3.1±2.1 versus 3.7±2.2, P=0.118). Conclusions In the subacute phase of myocardial infarction, non‐IRA show an increased baseline flow that may cause abnormal coronary flow reserve despite preserved hyperemic flow. In non‐IRA, microcirculatory resistance and adenosine‐induced hyperemic response are similar to those found in SA patients. From a physiological perspective, these findings support the use of fractional flow reserve to interrogate non‐IRA during the subacute phase of myocardial infarction. See Editorial Koh and Samady
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Affiliation(s)
- Hernán Mejía-Rentería
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Joo Myung Lee
- 2 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | | | - Nieves Gonzalo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pilar Jiménez-Quevedo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Luis Nombela-Franco
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Iván J Núñez-Gil
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Pablo Salinas
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - María Del Trigo
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | - Enrico Cerrato
- 4 Interventional Cardiology San Luigi Gonzaga University Hospital Orbassano and Rivoli Infermi Hospital Turin Italy
| | - Niels van Royen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Paul Knaapen
- 3 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Bon-Kwon Koo
- 5 Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea.,6 Institute on Aging Seoul National University Seoul Korea
| | - Carlos Macaya
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
| | | | - Javier Escaned
- 1 Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid Madrid Spain
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23
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van der Hoeven NW, Janssens GN, de Waard GA, Everaars H, Broyd CJ, Beijnink CWH, van de Ven PM, Nijveldt R, Cook CM, Petraco R, Ten Cate T, von Birgelen C, Escaned J, Davies JE, van Leeuwen MAH, van Royen N. Temporal Changes in Coronary Hyperemic and Resting Hemodynamic Indices in Nonculprit Vessels of Patients With ST-Segment Elevation Myocardial Infarction. JAMA Cardiol 2020; 4:736-744. [PMID: 31268466 DOI: 10.1001/jamacardio.2019.2138] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Percutaneous coronary intervention (PCI) of nonculprit vessels among patients with ST-segment elevation myocardial infarction (STEMI) is associated with improved clinical outcome compared with culprit vessel-only PCI. Fractional flow reserve (FFR) and coronary flow reserve are hyperemic indices used to guide revascularization. Recently, instantaneous wave-free ratio was introduced as a nonhyperemic alternative to FFR. Whether these indices can be used in the acute setting of STEMI continues to be investigated. Objective To assess the value of hemodynamic indices in nonculprit vessels of patients with STEMI from the index event to 1-month follow-up. Design, Setting, and Participants This substudy of the Reducing Micro Vascular Dysfunction in Revascularized STEMI Patients by Off-target Properties of Ticagrelor (REDUCE-MVI) randomized clinical trial enrolled 98 patients with STEMI who had an angiographic intermediate stenosis in at least 1 nonculprit vessel. Patient enrollment was between May 1, 2015, and September 19, 2017. After successful primary PCI, nonculprit intracoronary hemodynamic measurements were performed and repeated at 1-month follow-up. Cardiac magnetic resonance imaging was performed from 2 to 7 days and 1 month after primary PCI. Main Outcomes and Measures The value of nonculprit instantaneous wave-free ratio, FFR, coronary flow reserve, hyperemic index of microcirculatory resistance, and resting microcirculatory resistance from the index event to 1-month follow-up. Results Of 73 patients with STEMI included in the final analysis, 59 (80.8%) were male, with a mean (SD) age of 60.8 (9.9) years. Instantaneous wave-free ratio (SD) did not change significantly (0.93 [0.07] vs 0.94 [0.06]; P = .12) and there was no change in resting distal pressure/aortic pressure (mean [SD], 0.94 [0.06] vs 0.95 [0.06]; P = .25) from the acute moment to 1-month follow-up. The FFR decreased (mean [SD], 0.88 [0.07] vs 0.86 [0.09]; P = .001) whereas coronary flow reserve increased (mean [SD], 2.9 [1.4] vs 4.1 [2.2]; P < .001). Hyperemic index of microcirculatory resistance decreased and resting microcirculatory resistance increased from the acute moment to follow-up. The decrease in distal pressure from rest to hyperemia was smaller at the acute moment vs follow-up (mean [SD], 10.6 [11.2] mm Hg vs 14.1 [14.2] mm Hg; P = .05). This blunted acute hyperemic response correlated with final infarct size (ρ, -0.29; P = .02). The resistive reserve ratio was lower at the acute moment vs follow-up (mean [SD], 3.4 [1.7] vs 5.0 [2.7]; P < .001). Conclusions and Relevance In the acute setting of STEMI, nonculprit coronary flow reserve was reduced and FFR was augmented, whereas instantaneous wave-free ratio was not altered. These results may be explained by an increased hyperemic microvascular resistance and a blunted adenosine responsiveness at the acute moment that was associated with infarct size.
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Affiliation(s)
- Nina W van der Hoeven
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | | | - Casper W H Beijnink
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands.,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Christopher M Cook
- Department of Cardiology, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Ricardo Petraco
- Department of Cardiology, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Tim Ten Cate
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos El Instituto de Investigación Sanitaria del Hospital Clinic San Carlos and Universidad Complutense de Madrid, Madrid, Spain
| | - Justin E Davies
- Department of Cardiology, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Maarten A H van Leeuwen
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands.,Department of Cardiology, Isala Heart Center, Zwolle, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands.,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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24
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Lee SH, Kim HK, Lee JM, Hong YJ, Lim KS, Kim HB, Choi KH, Shin ES, Nam CW, Doh JH, Yang JH, Song YB, Hahn JY, Choi SH, Jeong MH, Samady H, Escaned J. Coronary Circulatory Indexes in Non-Infarct-Related Vascular Territories in a Porcine Acute Myocardial Infarction Model. JACC Cardiovasc Interv 2020; 13:1155-1167. [PMID: 32438986 DOI: 10.1016/j.jcin.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/21/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate temporal changes in coronary hemodynamic and physiological indexes in the non-infarct-related artery (IRA), which might be affected by adjacent infarcted myocardium, using an experimental animal model of acute myocardial infarction. BACKGROUND There has been debate on the reliability of fractional flow reserve and resting pressure-derived indexes, including instantaneous wave-free ratio, in the non-IRA in patients with acute ST-segment elevation myocardial infarction. METHODS In Yorkshire swine, acute myocardial infarction was simulated with selective balloon occlusion at the left circumflex coronary artery as the IRA for 30 min. Non-IRA stenosis was created using bare-metal stent implantation in the left anterior descending coronary artery 4 weeks before the experiments. Serial changes in systemic hemodynamic status, coronary pressure, and Doppler-derived coronary flow velocity were measured in a nonoccluded left anterior descending coronary artery as the non-IRA from baseline, balloon occlusion of the left circumflex coronary artery, and 15 min after reperfusion of the left circumflex coronary artery. RESULTS Among the 6 experimental subjects, the median diameter stenosis of the non-IRA was 33.9% (interquartile range: 21.7% to 46.1%). During balloon occlusion of the IRA, there were transient significant changes in both resting and hyperemic aortic pressure, distal coronary pressure, averaged peak velocity, transstenotic pressure gradient, and microvascular resistance of the non-IRA (p < 0.020 for all). After reperfusion of the IRA, the resting averaged peak velocity (p = 0.002) and resting transstenotic pressure gradient (p = 0.004) were significantly increased and resting microvascular resistance (p = 0.004) was significantly decreased compared with their values in the baseline phase. However, the hyperemic averaged peak velocity (p = 0.479), hyperemic transstenotic pressure gradient (p = 0.778), and hyperemic microvascular resistance (p = 0.816) were not significantly different compared with those in the baseline phase. After reperfusion, fractional flow reserve in the non-IRA was not significantly different (0.94 ± 0.01 vs. 0.93 ± 0.01; p = 0.353), while coronary flow reserve (1.93 ± 0.07 vs. 1.36 ± 0.07; p = 0.025) and instantaneous wave-free ratio (0.97 ± 0.01 vs. 0.93 ± 0.01; p = 0.001) were significantly lower than baseline values. CONCLUSIONS In a porcine model of acute myocardial infarction, occlusion of the IRA induced significant changes in systemic hemodynamic status and coronary circulatory indexes of the non-IRA. However, after reperfusion of the IRA, fractional flow reserve did not change significantly, whereas coronary flow reserve and instantaneous wave-free ratio showed significant changes compared with baseline values.
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Young Joon Hong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea.
| | - Kyung Seob Lim
- Futuristic Animal Resource & Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju, Korea
| | - Han Byul Kim
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan Medical Center, Ulsan Hospital, Ulsan, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Ho Jeong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Madrid, Spain
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25
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Anderson HV“S. Acute Coronary Physiology. JACC Cardiovasc Interv 2020; 13:1168-1170. [DOI: 10.1016/j.jcin.2020.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
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26
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Instantaneous wave-free ratio cutoff values for nonculprit stenosis classification in patients with ST-segment elevation myocardial infarction (an iSTEMI substudy). Coron Artery Dis 2020; 31:411-416. [PMID: 32168054 DOI: 10.1097/mca.0000000000000879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The instantaneous wave-free ratio cutoff value of <0.90 for hemodynamic significance of coronary stenoses has been validated in stable patients. We examined different cutoff values in the evaluation of nonculprit stenoses in patients with ST-segment elevation myocardial infarction. METHODS We measured instantaneous wave-free ratio across nonculprit stenoses in the acute setting and at follow-up in 120 patients with ST-segment elevation myocardial infarction and 157 nonculprit stenoses, of which, 113 patients with 147 nonculprit stenoses completed follow-up. METHODS The prevalence of nonculprit stenosis hemodynamic significance was 52% in the acute setting and 41% at follow-up. With follow-up, instantaneous wave-free ratio as reference, acute instantaneous wave-free ratio >0.90 had a negative predictive value of 89%. Acute instantaneous wave-free ratio <0.90 had a positive predictive value of 68%. Acute instantaneous wave-free ratio >0.93 had a negative predictive value of 100%. Acute instantaneous wave-free ratio <0.86 and <0.83 had positive predictive values of 71 and 77%. Using acute instantaneous wave-free ratio <0.90 as cutoff for hemodynamic significance yielded the highest degree of classification agreement between acute and follow-up instantaneous wave-free ratio. CONCLUSIONS In patients with ST-segment elevation myocardial infarction, acute instantaneous wave-free ratio with the cutoff values <0.90 for hemodynamic significance appears optimal in the evaluation of nonculprit stenoses and has a high negative predictive value and a moderate positive predictive value.
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27
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Clarke JRD, Duarte Lau F, Zarich SW. Determining the Significance of Coronary Plaque Lesions: Physiological Stenosis Severity and Plaque Characteristics. J Clin Med 2020; 9:jcm9030665. [PMID: 32131474 PMCID: PMC7141262 DOI: 10.3390/jcm9030665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 01/10/2023] Open
Abstract
The evaluation of coronary lesions has evolved in recent years. Physiologic-guided revascularization (particularly with pressure-derived fractional flow reserve (FFR)) has led to superior outcomes compared to traditional angiographic assessment. A greater importance, therefore, has been placed on the functional significance of an epicardial lesion. Despite the improvements in the limitations of angiography, insights into the relationship between hemodynamic significance and plaque morphology at the lesion level has shown that determining the implications of epicardial lesions is rather complex. Investigators have sought greater understanding by correlating ischemia quantified by FFR with plaque characteristics determined on invasive and non-invasive modalities. We review the background of the use of these diagnostic tools in coronary artery disease and discuss the implications of analyzing physiological stenosis severity and plaque characteristics concurrently.
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Affiliation(s)
- John-Ross D. Clarke
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: or ; Tel.: +1-203-260-4510
| | - Freddy Duarte Lau
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Stuart W. Zarich
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
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28
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Mitsis A, Spirito A, Valgimigli M. Complete revascularisation in STEMI: consider the benefits but do not forget the risks! ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S331. [PMID: 32016049 DOI: 10.21037/atm.2019.09.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Andreas Mitsis
- Department of Cardiology, Swiss Cardiovascular Centre, Bern University Hospital, Bern, Switzerland
| | - Alessandro Spirito
- Department of Cardiology, Swiss Cardiovascular Centre, Bern University Hospital, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Centre, Bern University Hospital, Bern, Switzerland
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29
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Sorop O, van de Wouw J, Merkus D, Duncker DJ. Coronary Microvascular Dysfunction in Cardiovascular Disease: Lessons from Large Animal Models. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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30
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Fractional Flow Reserve and Instantaneous Wave-Free Ratio for Nonculprit Stenosis in Patients With Acute Myocardial Infarction. JACC Cardiovasc Interv 2019; 11:1848-1858. [PMID: 30236358 DOI: 10.1016/j.jcin.2018.06.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The aim of this study was to compare the changes of fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) with severity of epicardial coronary stenosis between nonculprit vessel of acute myocardial infarction (AMI) and stable ischemic heart disease (SIHD). BACKGROUND There has been debate regarding the reliability of FFR or iFR for nonculprit stenosis in the acute stage of AMI. METHODS A total of 100 AMI patients underwent comprehensive physiologic assessment including FFR, iFR, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) for nonculprit vessel stenosis after primary percutaneous coronary intervention (PCI) for culprit vessel. The changes in FFR and iFR for diameter stenosis (%DS) of nonculprit vessel stenosis were compared with FFR and iFR measured in 203 patients with SIHD. RESULTS From 40% to 80% stenosis, FFR and iFR measured in nonculprit vessel of AMI patient showed significant decrease with worsening stenosis severity (all p values < 0.001). Nonculprit vessels of AMI patients showed lower CFR than SIHD; however, IMR was not different between the nonculprit vessel of AMI and SIHD patients. FFR and iFR were not significantly different between the nonculprit vessel of AMI and SIHD patients in all %DS groups from 40% to 80% (all p values > 0.05). In addition, percent difference of FFR and iFR according to the increase in %DS was also not significantly different between nonculprit vessel of AMI or SIHD. There was no significant interaction between clinical presentation and the changes of FFR and iFR for worsening %DS (interaction p value = 0.698 and 0.257, respectively). CONCLUSIONS Changes in FFR and iFR for the nonculprit stenosis of AMI patients were not significantly different from those in SIHD patients. These data support the use of invasive physiological parameters to guide treatment of nonculprit stenoses in the acute stage of successfully revascularized AMI.
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Ihdayhid AR, Koh JS, Ramzy J, Kumar A, Michail M, Brown A, Samady H. The Role of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Measurements in Patients with Acute Coronary Syndrome. Curr Cardiol Rep 2019; 21:159. [PMID: 31768835 DOI: 10.1007/s11886-019-1233-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The role of fractional flow reserve to guide revascularization in patients with stable angina is well established. The instantaneous wave-free ratio (iFR) is an emerging adenosine-free resting index that is non-inferior to FFR and has potential to streamline the functional evaluation of coronary artery disease. The feasibility and utility of intracoronary physiology in patients with acute coronary syndrome (ACS) is unclear. This review will discuss the physiological principles and validity of using FFR and iFR in patients presenting with ACS. We will also provide an overview of the available evidence for their role in guiding revascularization in this patient group. RECENT FINDINGS The use of intracoronary physiology in culprit lesions of patients presenting with STEMI is not recommended and its accuracy is uncertain in patients with NSTEMI. In contrast, the physiological assessment of non-culprit vessels with FFR and IFR is a reliable measure of lesion-specific ischemia. Recent studies have demonstrated that FFR-guided revascularization of non-culprit lesions improves clinical outcomes although the role of iFR in this patient cohort is unknown. Physiology-guided revascularization of non-culprit ACS lesions improves clinical outcomes. Future studies investigating the complementary role of plaque morphology, biomechanics, and systemic inflammation may provide clinicians with a more comprehensive framework to guide treatment decisions.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - John Ramzy
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Arnav Kumar
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA
| | - Michael Michail
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia.,Institute of Cardiovascular Science, University College London, London, UK
| | - Adam Brown
- Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia
| | - Habib Samady
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea. .,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA, 30322, USA.
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Díez-Delhoyo F, Gutiérrez-Ibañes E, Fernández-Avilés F. Functional disorders in non-culprit coronary arteries and their implications in patients with acute myocardial infarction. Trends Cardiovasc Med 2019; 30:346-352. [PMID: 31547950 DOI: 10.1016/j.tcm.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/17/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
Abstract
Approximately 30-50% of patients with ST-segment elevation acute myocardial infarction have multivessel disease. The physiology of the non-culprit artery (NCA) is complex and represents a challenge to physicians as, while these plaques are presumably stable, clinical data show that they frequently lead to major adverse cardiovascular events. In addition the presence of microvascular and endothelial dysfunction may have prognostic implications and interfere with current physiological indices for stenosis severity assessment. In this review we aim to summarize current methods to study the microcirculation, discuss the evidence available regarding the endothelium and the microvascular compartment of the NCA; the best strategies to perform a complete revascularization based on proven ischemia; real limitations associated to hyperemic stenosis indices; and the potential role of novel resting-indices in this specific acute context.
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Affiliation(s)
- Felipe Díez-Delhoyo
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
| | - Enrique Gutiérrez-Ibañes
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Department of Bioengineering and Aerospace Engineering, Universidad Carlos III, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañon, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
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Xaplanteris P, Fournier S, Keulards DCJ, Adjedj J, Ciccarelli G, Milkas A, Pellicano M, Van't Veer M, Barbato E, Pijls NHJ, De Bruyne B. Catheter-Based Measurements of Absolute Coronary Blood Flow and Microvascular Resistance: Feasibility, Safety, and Reproducibility in Humans. Circ Cardiovasc Interv 2019; 11:e006194. [PMID: 29870386 DOI: 10.1161/circinterventions.117.006194] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/29/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The principle of continuous thermodilution can be used to calculate absolute coronary blood flow and microvascular resistance (R). The aim of the study is to explore the safety, feasibility, and reproducibility of coronary blood flow and R measurements as measured by continuous thermodilution in humans. METHODS AND RESULTS Absolute coronary flow and R can be calculated by thermodilution by infusing saline at room temperature through a dedicated monorail catheter. The temperature of saline as it enters the vessel, the temperature of blood and saline mixed in the distal part of the vessel, and the distal coronary pressure were measured by a pressure/temperature sensor-tipped guidewire. The feasibility and safety of the method were tested in 135 patients who were referred for coronary angiography. No significant adverse events were observed; in 11 (8.1%) patients, bradycardia and concomitant atrioventricular block appeared transiently and were reversed immediately on interruption of the infusion. The reproducibility of measurements was tested in a subgroup of 80 patients (129 arteries). Duplicate measurements had a strong correlation both for coronary blood flow (ρ=0.841, P<0.001; intraclass correlation coefficient=0.89, P<0.001) and R (ρ=0.780, P<0.001; intraclass correlation coefficient=0.89, P<0.001). In Bland-Altman plots, there was no significant bias or asymmetry. CONCLUSIONS Absolute coronary blood flow (in L/min) and R (in mm Hg/L/min or Wood units) can be safely and reproducibly measured with continuous thermodilution. This approach constitutes a new opportunity for the study of the coronary microcirculation.
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Affiliation(s)
- Panagiotis Xaplanteris
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Stephane Fournier
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Daniëlle C J Keulards
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Julien Adjedj
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Giovanni Ciccarelli
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Anastasios Milkas
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Mariano Pellicano
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Marcel Van't Veer
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Emanuele Barbato
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Nico H J Pijls
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.)
| | - Bernard De Bruyne
- From the Cardiovascular Center Aalst, Belgium (P.X., S.F., J.A., G.C., A.M., M.P., E.B., B.D.B.); Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands (D.K., M.v.V., N.H.J.P.); Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands (D.K., M.v.V., N.H.J.P.); and Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (E.B.).
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Li QW, Liu XJ, Li JH, Zhang GQ, Chen SM, Huang CL, Qiu M, Li YL, Duan P, Weng YJ, Zhang XY, Huang CY. Applying WCACG modified process is beneficial on reduced door-to-balloon time of acute STEMI patients. Biomedicine (Taipei) 2019; 9:10. [PMID: 31124456 PMCID: PMC6533935 DOI: 10.1051/bmdcn/2019090210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/18/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Various systems have employed with the objective to reduce the time from emergency medical services contact to balloon inflammation for ST-elevation myocardial infraction (STEMI) patients. The WCACG message system was used to an alternative communication platform to improve confirmation of the diagnosis and movement to treatment, resulted in shorten the door-to-balloon (D-to-B) time for STEMI patients. Methods: We collected 366 STEMI patients admitted at the Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, Department of Cardiology, during the period from June 2013 to October 2015. The patients were divided into two groups one underwent the current GC processes and the other group was handled using WCACG system. We compared between two groups with several indicators including D-to-B time, duration of hospitalization, associated costs, and incidence of adverse cardiovascular events. Results: The results show that the new method with WCACG system significantly reduced the average D-to-B time (from 100.42 ± 25.14 mins to 79.81 ± 20.51 mins, P < 0.05) compared to the GC processes, and also reduced the duration, costs and undesirable cardiac incidence during hospitalization. Conclusions: The modified WCACG process is an applicable system to save pieces of time and efficiently integrate the opinions of experts in emergency.
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Affiliation(s)
- Qiao-Wen Li
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Xiao-Jian Liu
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Jin-Hua Li
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Guo-Qi Zhang
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Su-Min Chen
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Chao-Long Huang
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Min Qiu
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Yue-Liang Li
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Peng Duan
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Yi-Jiun Weng
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China - Graduate Institute of Basic Medical Science, China Medical University, Taichung 404, Taiwan
| | - Xiao-Yong Zhang
- Department of Cardiology, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Chih-Yang Huang
- Graduate Institute of Basic Medical Science, China Medical University, Taichung 404, Taiwan - Graduate Institute of Chinese Medical Science, China Medical University, Taichung 404, Taiwan - Department of Health and Nutrition Biotechnology, Asia University, Taichung 413, Taiwan
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Kim HK, Kim HB, Lee JM, Kim SS, Bae IH, Park DS, Park JK, Shim JW, Na JY, Lee MY, Kim JS, Sim DS, Hong YJ, Nam CW, Doh JH, Park J, Koo BK, Kim SU, Lim KS, Jeong MH. Influence of Local Myocardial Infarction on Endothelial Function, Neointimal Progression, and Inflammation in Target and Non-Target Vascular Territories in a Porcine Model of Acute Myocardial Infarction. J Korean Med Sci 2019; 34:e145. [PMID: 31099195 PMCID: PMC6522891 DOI: 10.3346/jkms.2019.34.e145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/02/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with acute myocardial infarction (AMI) have worse clinical outcomes than those with stable coronary artery disease despite revascularization. Non-culprit lesions of AMI also involve more adverse cardiovascular events. This study aimed to investigate the influence of AMI on endothelial function, neointimal progression, and inflammation in target and non-target vessels. METHODS In castrated male pigs, AMI was induced by balloon occlusion and reperfusion into the left anterior descending artery (LAD). Everolimus-eluting stents (EES) were implanted in the LAD and left circumflex (LCX) artery 2 days after AMI induction. In the control group, EES were implanted in the LAD and LCX in a similar fashion without AMI induction. Endothelial function was assessed using acetylcholine infusion before enrollment, after the AMI or sham operation, and at 1 month follow-up. A histological examination was conducted 1 month after stenting. RESULTS A total of 10 pigs implanted with 20 EES in the LAD and LCX were included. Significant paradoxical vasoconstriction was assessed after acetylcholine challenge in the AMI group compared with the control group. In the histologic analysis, the AMI group showed a larger neointimal area and larger area of stenosis than the control group after EES implantation. Peri-strut inflammation and fibrin formation were significant in the AMI group without differences in injury score. The non-target vessel of the AMI also showed similar findings to the target vessel compared with the control group. CONCLUSION In the pig model, AMI events induced endothelial dysfunction, inflammation, and neointimal progression in the target and non-target vessels.
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Affiliation(s)
- Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Han Byul Kim
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - In Ho Bae
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
- Korea Cardiovascular Stent Research Institute, Jangseong, Korea
- Cardiovascular Convergence Research Center of Chonnam National University Hospital Designated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Dae Sung Park
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
- Korea Cardiovascular Stent Research Institute, Jangseong, Korea
- Cardiovascular Convergence Research Center of Chonnam National University Hospital Designated by Korea Ministry of Health and Welfare, Gwangju, Korea
- Research Institute of Medical Sciences, Chonnam National University, Gwangju, Korea
| | | | - Jae Won Shim
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
- Korea Cardiovascular Stent Research Institute, Jangseong, Korea
- Cardiovascular Convergence Research Center of Chonnam National University Hospital Designated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Joo Young Na
- Biomedical Research Institute, Chonnam National University Hospital, Gwangju, Korea
| | - Min Young Lee
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Joong Sun Kim
- Herbal Medicine Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea
| | - Doo Sun Sim
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
- Cardiovascular Convergence Research Center of Chonnam National University Hospital Designated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Young Joon Hong
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
| | - Chang Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Joon Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
- Institute on Aging, Seoul National University, Seoul, Korea
| | - Sun Uk Kim
- Futuristic Animal Resource and Research Center, Korea Research Institute of Bioscience and Biotechnology, Ochang, Korea
| | - Kyung Seob Lim
- Futuristic Animal Resource and Research Center, Korea Research Institute of Bioscience and Biotechnology, Ochang, Korea.
| | - Myung Ho Jeong
- Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Korea
- Korea Cardiovascular Stent Research Institute, Jangseong, Korea
- Cardiovascular Convergence Research Center of Chonnam National University Hospital Designated by Korea Ministry of Health and Welfare, Gwangju, Korea.
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Influence of Microcirculatory Dysfunction on Angiography-Based Functional Assessment of Coronary Stenoses. JACC Cardiovasc Interv 2019; 11:741-753. [PMID: 29673505 DOI: 10.1016/j.jcin.2018.02.014] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The authors sought to evaluate the influence of coronary microcirculatory dysfunction (CMD) on the diagnostic performance of the quantitative flow ratio (QFR). BACKGROUND Functional angiographic assessment of coronary stenoses based on fluid dynamics, such as QFR, constitutes an attractive alternative to fractional flow reserve (FFR). However, it is unknown whether CMD affects the reliability of angiography-based functional indices. METHODS FFR and the index of microcirculatory resistance (IMR) were measured in 300 vessels (248 patients) as part of a multicenter international registry. QFR was calculated at a blinded core laboratory. Vessels were classified into 2 groups according to microcirculatory status: low IMR (<23 U), and high IMR (≥23 U, CMD). The impact of CMD on the diagnostic performance of QFR, as well as on incremental value of QFR over quantitative angiography, was assessed using FFR as reference. RESULTS Percent diameter stenosis (%DS) and FFR were similar in low- and high-IMR groups (%DS 51 ± 12% vs. 53 ± 11%; p = 0.16; FFR 0.80 ± 0.11 vs. 0.81 ± 0.11; p = 0.23, respectively). In the overall cohort, classification agreement (CA) between QFR and FFR and diagnostic efficiency of QFR (area under the receiver-operating characteristics curve [AUC]) were high (CA: 88%; AUC: 0.93 [95% confidence interval (CI): 0.90 to 0.96]). However, when assessed according to microcirculatory status, a significantly lower CA and AUC of QFR were found in the high-IMR group as compared with the low-IMR group (CA: 76% vs. 92%; p < 0.001; AUC: 0.88 [95% CI: 0.79 to 0.94] vs. 0.96 [95% CI: 0.92 to 0.98]; p < 0.05). Compared with angiographic assessment, QFR increased by 0.20 (p < 0.001) and by 0.16 (p < 0.001) the AUC of %DS in low- and high-IMR groups, respectively. Independent predictors of misclassification between QFR and FFR were high IMR and acute coronary syndrome. CONCLUSIONS CMD decreases the diagnostic performance of QFR. However, even in the presence of CMD, QFR remains superior to angiography alone in ascertaining functional stenosis severity.
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Blázquez R, Álvarez V, Antequera-Barroso JA, Báez-Díaz C, Blanco V, Maestre J, Moreno-Lobato B, López E, Marinaro F, Casado JG, Crisóstomo V, Sánchez-Margallo FM. Altered hematological, biochemical and immunological parameters as predictive biomarkers of severity in experimental myocardial infarction. Vet Immunol Immunopathol 2018; 205:49-57. [PMID: 30459001 DOI: 10.1016/j.vetimm.2018.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/09/2018] [Accepted: 10/19/2018] [Indexed: 11/30/2022]
Abstract
Preclinical studies in cardiovascular medicine are necessary to translate basic research to the clinic. The porcine model has been widely used to understand the biological mechanisms involved in cardiovascular disorders for which purpose different closed-chest models have been developed in the last years to mimic the pathophysiological events seen in human myocardial infarction. In this work, we studied hematological, biochemical and immunological parameters, as well as Magnetic resonance derived cardiac function measurements obtained from a swine myocardial infarction model. We identified some blood parameters which were significantly altered after myocardial infarction induction. More importantly, these parameters (gamma-glutamyl transferase, glutamic pyruvic transaminase, red blood cell counts, hemoglobin concentration, hematocrit, platelet count and plateletcrit) correlated positively with cardiac function, infarct size and/or cardiac enzymes (troponin I and creatine kinase-MB). Thus several blood-derived parameters have allowed us to predict the severity of myocardial infarction in a clinically relevant animal model. Therefore, here we provide a simple, affordable and reliable way that could prove useful in the follow up of myocardial infarction and in the evaluation of new therapeutic strategies in this animal model.
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Affiliation(s)
- Rebeca Blázquez
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain.
| | - Verónica Álvarez
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | | | - Claudia Báez-Díaz
- CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain; Endoluminal Therapy and Diagnosis Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Virginia Blanco
- CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain; Endoluminal Therapy and Diagnosis Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Juan Maestre
- CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain; Endoluminal Therapy and Diagnosis Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Beatriz Moreno-Lobato
- Animal Modelling Service, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Esther López
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Federica Marinaro
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Javier G Casado
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain.
| | - Verónica Crisóstomo
- CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain; Endoluminal Therapy and Diagnosis Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain.
| | - Francisco Miguel Sánchez-Margallo
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, 10071, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, 28029, Spain.
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de Waard GA, van Royen N. Coronary Physiology in the Nonculprit Vessel After Acute Myocardial Infarction: To Go With the Flow or Unexpected Resistance? JACC Cardiovasc Interv 2018; 11:1859-1861. [PMID: 30236359 DOI: 10.1016/j.jcin.2018.07.034] [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: 07/19/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Guus A de Waard
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands.
| | - Niels van Royen
- Department of Cardiology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Lee JM, Kim HK, Koo BK. Reply. JACC Cardiovasc Interv 2018; 11:1660-1661. [DOI: 10.1016/j.jcin.2018.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
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40
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Feldman MD, Gupta AK. Fractional Flow Reserve in Nonculprit Vessel During ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2018; 11:725-727. [DOI: 10.1016/j.jcin.2017.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 10/17/2022]
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41
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Lee JM, Kim HK, Lim KS, Park JK, Choi KH, Park J, Hwang D, Rhee TM, Yang JH, Shin ES, Nam CW, Doh JH, Hahn JY, Koo BK, Jeong MH. Influence of Local Myocardial Damage on Index of Microcirculatory Resistance and Fractional Flow Reserve in Target and Nontarget Vascular Territories in a Porcine Microvascular Injury Model. JACC Cardiovasc Interv 2018; 11:717-724. [PMID: 29605246 DOI: 10.1016/j.jcin.2017.11.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/21/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the influence of microvascular damage in one vessel territory on invasively measured physiological parameters in the other vessel, using a porcine microvascular damage model. BACKGROUND Although fractional flow reserve (FFR)-guided decision-making for the nonculprit stenosis in patients with acute myocardial infarction has been reported to be better than angiography-guided revascularization, there have been debates regarding the influence of microvascular dysfunction on measured FFR in nonculprit vessels. METHODS In Yorkshire swine, microvascular damage was induced with selective intracoronary injection of microspheres (100 μm × 105 each) into the left anterior descending artery (LAD). Coronary stenosis was created in both the LAD and the left circumflex artery (LCx) using balloon catheters. Coronary physiological changes were assessed with index of microcirculatory resistance (IMR) and FFR at baseline and at each subsequent injection of microsphere up to a fifth dose in both the LAD and LCx. Measurements were repeated 5 times at each stage, and a total of 424 measurements were made in 12 Yorkshire swine models. RESULTS The median area stenosis in LAD and LCx was 48.1% (interquartile range: 40.8% to 50.4%) and 47.9% (interquartile range: 31.1% to 62.9%), respectively. At baseline, FFR in the LAD was lower than that in the LCx (0.89 ± 0.01 and 0.94 ± 0.01; p < 0.001). There was no difference in the IMR (18.4 ± 5.8 U and 17.9 ± 1.2 U; p = 0.847). With repeated injections of microspheres, IMR in LAD was significantly increased, up to 77.7 ± 15.7 U (p < 0.001). Given the same stenosis, FFR in the LAD was also significantly increased, up to 0.98 ± 0.01 along with IMR increase (p < 0.001). Conversely, IMR and FFR were not changed in the LCx throughout repeated injury to the LAD territory (p = 0.105 and p = 0.286 for IMR and FFR, respectively). The increase in LAD IMR was mainly driven by the increase in hyperemic mean transit time (p < 0.001). CONCLUSIONS In Yorkshire swine models, local microvascular damage increased both FFR and IMR in a vessel supplying target myocardial territory. However, IMR and FFR were maintained in the other vessel. These physiological results in swine support the concept that FFR measurement might provide useful information for evaluating nonculprit lesions in clinical settings involving significant acute myocardial injury.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Kyung Seob Lim
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | | | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- National Maritime Medical Center, Changwon, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea.
| | - Myung Ho Jeong
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea.
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Gewirtz H. PET measurements of myocardial blood flow post myocardial infarction: Relationship to invasive and cardiac magnetic resonance studies and potential clinical applications. J Nucl Cardiol 2017; 24:1883-1892. [PMID: 28577226 DOI: 10.1007/s12350-017-0930-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023]
Abstract
This review focuses on clinical studies concerning assessment of coronary microvascular and conduit vessel function primarily in the context of acute and sub acute myocardial infarction (MI). The ability of quantitative PET measurements of myocardial blood flow (MBF) to delineate underlying pathophysiology and assist in clinical decision making in this setting is discussed. Likewise, considered are physiological metrics fractional flow reserve, coronary flow reserve, index of microvascular resistance (FFR, CFR, IMR) obtained from invasive studies performed in the cardiac catheterization laboratory, typically at the time of PCI for MI. The role both of invasive studies and cardiac magnetic resonance (CMR) imaging in assessing microvascular function, a key determinant of prognosis, is reviewed. The interface between quantitative PET MBF measurements and underlying pathophysiology, as demonstrated both by invasive and CMR methodology, is discussed in the context of optimal interpretation of the quantitative PET MBF exam and its potential clinical applications.
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Affiliation(s)
- Henry Gewirtz
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Yawkey 5E, 55 Fruit St, Boston, MA, 02114, USA.
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43
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de Waard G, Di Mario C, Lerman A, Serruys P, van Royen N. Instantaneous wave-free ratio to guide coronary revascularisation: physiological framework, validation and differences from fractional flow reserve. EUROINTERVENTION 2017; 13:450-458. [DOI: 10.4244/eij-d-16-00456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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44
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de Waard GA, Fahrni G, de Wit D, Kitabata H, Williams R, Patel N, Teunissen PF, van de Ven PM, Umman S, Knaapen P, Perera D, Akasaka T, Sezer M, Kharbanda RK, van Royen N. Hyperaemic microvascular resistance predicts clinical outcome and microvascular injury after myocardial infarction. Heart 2017; 104:127-134. [PMID: 28663361 DOI: 10.1136/heartjnl-2017-311431] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Early detection of microvascular dysfunction after acute myocardial infarction (AMI) could identify patients at high risk of adverse clinical outcome, who may benefit from adjunctive treatment. Our objective was to compare invasively measured coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR) for their predictive power of long-term clinical outcome and cardiac magnetic resonance (CMR)-defined microvascular injury (MVI). METHODS Simultaneous intracoronary Doppler flow velocity and pressure measurements acquired immediately after revascularisation for AMI from five centres were pooled. Clinical follow-up was completed for 176 patients (mean age 60±10 years; 140(80%) male; ST-elevation myocardial infarction (STEMI) 130(74%) and non-ST-segment elevation myocardial infarction 46(26%)) with median follow-up time of 3.2 years. In 110 patients with STEMI, additional CMR was performed. RESULTS The composite end point of death and hospitalisation for heart failure occurred in 17 patients (10%). Optimal cut-off values to predict the composite end point were 1.5 for CFR and 3.0 mm Hg cm-1•s for HMR. CFR <1.5 was predictive for the composite end point (HR 3.5;95% CI 1.1 to 10.8), but not for its individual components. HMR ≥3.0 mm Hg cm-1 s was predictive for the composite end point (HR 7.0;95% CI 1.5 to 33.7) as well as both individual components. HMR had significantly greater area under the receiver operating characteristic curve for MVI than CFR. HMR remained an independent predictor of adverse clinical outcome and MVI, whereas CFR did not. CONCLUSIONS HMR measured immediately following percutaneous coronary intervention for AMI with a cut-off value of 3.0 mm Hg cm-1 s, identifies patients with MVI who are at high risk of adverse clinical outcome. For this purpose, HMR is superior to CFR.
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Affiliation(s)
- Guus A de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Gregor Fahrni
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK
| | - Douwe de Wit
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Rupert Williams
- Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Niket Patel
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK
| | - Paul F Teunissen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Sabahattin Umman
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Paul Knaapen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Divaka Perera
- Cardiovascular Division, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Murat Sezer
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
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Mejía-Rentería H, van der Hoeven N, van de Hoef TP, Heemelaar J, Ryan N, Lerman A, van Royen N, Escaned J. Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests. Int J Cardiovasc Imaging 2017; 33:1041-1059. [PMID: 28501910 DOI: 10.1007/s10554-017-1136-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/08/2017] [Indexed: 01/10/2023]
Abstract
The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.
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Affiliation(s)
- Hernán Mejía-Rentería
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Tim P van de Hoef
- AMC Heart Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Nicola Ryan
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain
| | | | | | - Javier Escaned
- Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain.
- Universidad Complutense de Madrid (UCM), Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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Baranyai T, Giricz Z, Varga ZV, Koncsos G, Lukovic D, Makkos A, Sárközy M, Pávó N, Jakab A, Czimbalmos C, Vágó H, Ruzsa Z, Tóth L, Garamvölgyi R, Merkely B, Schulz R, Gyöngyösi M, Ferdinandy P. In vivo MRI and ex vivo histological assessment of the cardioprotection induced by ischemic preconditioning, postconditioning and remote conditioning in a closed-chest porcine model of reperfused acute myocardial infarction: importance of microvasculature. J Transl Med 2017; 15:67. [PMID: 28364777 PMCID: PMC5376486 DOI: 10.1186/s12967-017-1166-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/15/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Cardioprotective value of ischemic post- (IPostC), remote (RIC) conditioning in acute myocardial infarction (AMI) is unclear in clinical trials. To evaluate cardioprotection, most translational animal studies and clinical trials utilize necrotic tissue referred to the area at risk (AAR) by magnetic resonance imaging (MRI). However, determination of AAR by MRI' may not be accurate, since MRI-indices of microvascular damage, i.e., myocardial edema and microvascular obstruction (MVO), may be affected by cardioprotection independently from myocardial necrosis. Therefore, we assessed the effect of IPostC, RIC conditioning and ischemic preconditioning (IPreC; positive control) on myocardial necrosis, edema and MVO in a clinically relevant, closed-chest pig model of AMI. METHODS AND RESULTS Acute myocardial infarction was induced by a 90-min balloon occlusion of the left anterior descending coronary artery (LAD) in domestic juvenile female pigs. IPostC (6 × 30 s ischemia/reperfusion after 90-min occlusion) and RIC (4 × 5 min hind limb ischemia/reperfusion during 90-min LAD occlusion) did not reduce myocardial necrosis as assessed by late gadolinium enhancement 3 days after reperfusion and by ex vivo triphenyltetrazolium chloride staining 3 h after reperfusion, however, the positive control, IPreC (3 × 5 min ischemia/reperfusion before 90-min LAD occlusion) did. IPostC and RIC attenuated myocardial edema as measured by cardiac T2-weighted MRI 3 days after reperfusion, however, AAR measured by Evans blue staining was not different among groups, which confirms that myocardial edema is not a measure of AAR, IPostC and IPreC but not RIC decreased MVO. CONCLUSION We conclude that IPostC and RIC interventions may protect the coronary microvasculature even without reducing myocardial necrosis.
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Affiliation(s)
- Tamás Baranyai
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Zoltán Giricz
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V. Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Gábor Koncsos
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Dominika Lukovic
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - András Makkos
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Márta Sárközy
- Department of Biochemistry, University of Szeged, Szeged, Hungary
| | - Noémi Pávó
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - András Jakab
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Csilla Czimbalmos
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hajnalka Vágó
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Ruzsa
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Levente Tóth
- Institute of Diagnostic Imaging and Radiation Oncology, University of Kaposvár, Kaposvár, Hungary
- Department of Radiology, University of Pécs, Pecs, Hungary
| | - Rita Garamvölgyi
- Institute of Diagnostic Imaging and Radiation Oncology, University of Kaposvár, Kaposvár, Hungary
| | - Béla Merkely
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Rainer Schulz
- Institute of Physiology, Justus Liebig University, Giessen, Germany
| | - Mariann Gyöngyösi
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Department of Biochemistry, University of Szeged, Szeged, Hungary
- Pharmahungary Group, Szeged, Hungary
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47
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Klein LW, Lotfi A. Ambiguities in Selecting the Optimal Strategy for the Nonculprit Stenosis in STEMI. JACC Cardiovasc Interv 2017; 10:325-328. [PMID: 28231900 DOI: 10.1016/j.jcin.2016.12.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - Amir Lotfi
- Baystate Medical Center, Springfield, Massachusetts
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48
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Gould KL, Johnson NP. Coronary Blood Flow After Acute MI: Alternative Truths. JACC Cardiovasc Interv 2016; 9:614-7. [PMID: 27013162 DOI: 10.1016/j.jcin.2016.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 11/15/2022]
Affiliation(s)
- K Lance Gould
- Division of Cardiology, Department of Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Memorial Hermann Hospital, Houston, Texas.
| | - Nils P Johnson
- Division of Cardiology, Department of Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Memorial Hermann Hospital, Houston, Texas
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