Going Against the Flow
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 7 Linguagem: Inglês
10.1161/circinterventions.118.007010
ISSN1941-7632
Autores Tópico(s)Advanced MRI Techniques and Applications
ResumoHomeCirculation: Cardiovascular InterventionsVol. 11, No. 7Going Against the Flow Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBGoing Against the FlowAssessing Coronary Hemodynamics Combining Invasive and Noninvasive Physiology Ziad A. Ali, MD, DPhil and J. Jane Cao, MD, MPH Ziad A. AliZiad A. Ali Ziad A. Ali, MD, DPhil, Columbia University Medical Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019. Email E-mail Address: [email protected] Center for Interventional Vascular Therapy, New York Presbyterian Hospital/Columbia University Medical Center and Cardiovascular Research Foundation (Z.A.A.). Search for more papers by this author and J. Jane CaoJ. Jane Cao The Heart Center, St. Francis Hospital, Roslyn, NY (J.J.C.). Search for more papers by this author Originally published13 Jul 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007010Circulation: Cardiovascular Interventions. 2018;11:e007010This article is a commentary on the followingImpact of Elective Percutaneous Coronary Intervention on Global Absolute Coronary Flow and Flow Reserve Evaluated by Phase-Contrast Cine-Magnetic Resonance Imaging in Relation to Regional Invasive Physiological IndicesSee Article by Kanaji et alInvasive physiological assessment is an important tool for guiding the decision to revascularize coronary stenoses. A fractional flow reserve (FFR) value ≤0.80 and instantaneous wave-free ratio ≤0.89 suggests a strong likelihood of a stenosis-inducing myocardial ischemia.1–5 Randomized clinical trials have demonstrated a benefit for FFR-guided versus angiography-guided revascularization or guideline-directed medical therapy (GDMT) alone6–8 and noninferiority of FFR and instantaneous wave-free ratio for 1-year major adverse cardiovascular events in intermediate stenoses.4,5 Though these major trials have undoubtedly impacted clinical practice, including societal guidelines,9–11 significant questions remain to be addressed. Although FFR-guided therapy in addition to GDMT reduced the number of adverse events compared with GDMT alone, almost 75% of patients with clinically significant FFR values managed by GDMT did not experience major adverse events, and almost 50% did not require revascularization through 5 years of follow-up.12 In light of these data, and studies such as ORBITA which failed to show an increase in exercise capacity with percutaneous coronary intervention (PCI) compared with placebo,13 there remains a need to identify which patients benefit from revascularization. Although we work on the assumption that any benefit from PCI is based on a reduction in ischemia by improving perfusion, we struggle for an invasive physiological definition of ischemia and use pressure as a surrogate of our inability to easily measure coronary flow.14 To this regard, would the ability to measure coronary flow help select patients with the most to gain from PCI or are the available data showing safety of deferral,15 improved outcomes compared with angiography8 and GDMT,6 as well as the prognostic value of post-PCI physiological assessment,16 sufficient?Noninvasively, global coronary blood flow and coronary flow reserve can be assessed by positron emission tomography, cardiac magnetic resonance imaging (MRI), and computed tomography with computational FFR. Using phase contrast MRI, it is also possible to measure coronary sinus blood flow (CSF).17 As the vast majority of coronary arterial blood drains to the coronary sinus, flow measurements in this location are an alternative cardiac magentic resonance method to measure total myocardial blood flow. By assessing CSF at rest and during hyperemia, it is possible to determine CSF reserve, an index of global coronary perfusion reserve.18In this issue of the Circulation: Cardiovascular Interventions, Kanaji et al19 attempt to demonstrate the complex interplay of invasive and noninvasive coronary physiology in 50 patients with stable coronary artery disease. Regional and global coronary flows were compared before and after FFR-guided PCI in a single proximal coronary artery stenosis, including invasive assessment of coronary flow reserve by thermodilution and index of microcirculatory resistance (IMR). In addition to improved post-PCI FFR, the majority of patients showed corresponding increases in coronary flow reserve and decreases in IMR, thus representing improved regional coronary hemodynamics. At the global level, hyperemic CSF and CSF reserve increased, whereas resting CSF was largely unchanged suggesting an improved global hyperemic coronary flow after PCI. Interestingly, in a subset of patients (n=12), invasive post-PCI coronary flow reserve decreased and IMR increased, whereas noninvasive hyperemic CSF decreased and coronary flow resistance increased. Collectively, these changes suggest impairment in coronary hemodynamics at the global, regional, and microcirculatory levels despite an improvement in FFR. This paradoxical change was found to be more common in vessels with pre-PCI FFR value between 0.75 and 0.80 compared with lower FFR values. The authors speculated that the relatively higher FFR was representative of higher coronary flow distal to the stenosis and low microcirculatory resistance evidenced by higher baseline hyperemic CSF and lower coronary vascular resistance. They further hypothesized that this combination represents a fully compensated distal vascular bed and as such increasing flow further by PCI would not substantially increase coronary flow. Indeed, previous studies have shown that IMR does not change dependent on the degree of epicardial coronary artery stenosis20 and when it does increase after PCI it is associated with distal thromboembolism and post-PCI troponin elevation.21 Therefore, the question remains whether the paradoxical change observed in the present study was because of PCI-induced distal thromboembolism or microcirculatory injury. Moreover, whether the marginally increased numeric values comparing pre- and post-PCI IMR have any relevance in the setting of worsened prognosis in the FFR grey-zone of 0.75 to 0.80, particularly with proximal culprit lesions,22 is unclear.Although an increase in regional coronary and to some degree global coronary blood flow is expected upon revascularization of a single vessel proximal flow limiting lesion, the exact contribution of regional to global flow at rest and under hyperemia is a complex phenomenon under homeostatic regulation. In the present study, in subjects with a paradoxical change, invasive regional hyperemic flow decreased by 19%, and global hyperemic blood flow decreased by 18%, clearly more than expected assuming all other regional flow is unaltered. Although differences in the timing of measurement (invasive measurements were performed immediately post-PCI compared with noninvasive on average 12 days later) may contribute to this finding, the results remain perplexing. Indeed, the small sample size of 50 subjects with only 12 subjects having paradoxical observations raises the simple explanation of type I error. Of course, comparing many variables repeatedly, the interpretation of statistical significance should be made with caution.Although resting CSF is a reliable index of global coronary blood flow, the hyperemic CSF is complex in subjects with ischemia as it is subject to change independent of regional coronary flow. Adenosine can increase cardiac output as a result of peripheral vasodilation and tachycardia, whereas induced ischemia may compromise left ventricular systolic function and reduce cardiac output, both of which could have been assessed by cardiac MRI, substantiating the findings and allowing greater understanding of coronary hemodynamics in the current study. Phase contrast imaging is a well-validated technique by MRI in quantitating blood flow. The accuracy, however, is highly dependent on the imaging acquisition plane that has to be perpendicular to the direction of flow. To ensure reliable comparison at rest and during hyperemia, the exact acquisition planes have to be acquired. The dependence on body position and breath-hold pattern before and during adenosine infusion may be challenging in patients experiencing discomfort because of adenosine and is a limitation of MRI for these measurements, particularly in the context of a relatively small cross-sectional area of the coronary sinus. Nonetheless, once images are acquired the reproducibility of flow measurement is excellent.Clearly, as is often the case in science, this novel study has raised more questions than answers. We agree with the authors that the mechanisms of paradoxical response to PCI in some cases remain elusive. Nonetheless, the authors should be commended for studying the complex interaction of epicardial coronary function, coronary microcirculation, and global coronary flow using both invasive and noninvasive modalities. To date, improving FFR has become the physiological goal of PCI in stable coronary artery disease.16 When this fails, we are quick to blame the microcirculation23; however, our ability to assess and interrogate this enormous vascular bed has remained elusive. The integration of invasive and noninvasive coronary physiology testing, allowing demonstration of enhancement in myocardial perfusion and function, is a major step towards this goal.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circinterventionsThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Ziad A. Ali, MD, DPhil, Columbia University Medical Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019. Email [email protected]eduReferences1. De Bruyne B, Baudhuin T, Melin JA, Pijls NH, Sys SU, Bol A, Paulus WJ, Heyndrickx GR, Wijns W. Coronary flow reserve calculated from pressure measurements in humans. 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Why is fractional flow reserve after percutaneous coronary intervention not always 1.0?JACC Cardiovasc Interv. 2016; 9:1032–1035. doi: 10.1016/j.jcin.2016.04.001.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesImpact of Elective Percutaneous Coronary Intervention on Global Absolute Coronary Flow and Flow Reserve Evaluated by Phase-Contrast Cine-Magnetic Resonance Imaging in Relation to Regional Invasive Physiological IndicesYoshihisa Kanaji, et al. Circulation: Cardiovascular Interventions. 2018;11 July 2018Vol 11, Issue 7 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007010PMID: 30006337 Originally publishedJuly 13, 2018 Keywordshemodynamicscoronary stenosispercutaneous coronary interventionEditorialsangiographyPDF download Advertisement
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