36

Physiologic Lesion Assessment 1989-2001

From the Education and Training Programme at the European Heart House

How to Apply Coronary Physiology in the Catheterization Laboratory
Recorded April 6-8, 2000 at the European Heart House, in Sophia Antipolis, France and introduced by N. Pijls, F.E.S.C. (NL) and B. de Bruyne (BE).
Topics:
- Background principles of physiologic measurements in the catheterization laboratory (coronary pressure, flow, IVUS)
- Practical set-up and implementation of these techniques in the cath lab
- Different equipment used
- Interpretation of measurements and pitfalls
- Alternative methods

Fellows Course Slide Sets

Physiologic Lesion Assessment, by B. De Bruyne

Review Article
Evaluation of the culprit plaque and the physiological significance of coronary atherosclerotic narrowings
Kern MJ, et al.
Circulation 2001;103:3142-9
http://www.circulationaha.org/cgi/content/full/103/25/3142
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11425782

Assessment of the functional significance of coronary lesions using a monorail catheter
Briguori C || Colombo A
J Invasive Cardiol 2001;13:279-86
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11287712

Fractional flow reserve compared with intravascular ultrasound guidance for optimizing stent deployment
Fearon WF, et al.
Circulation 2001;104:1917-22
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11602494

Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial
Bech GJ, et al.
Circulation 2001;103:2928-34
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11413082

Incremental doses of intracoronary adenosine for the assessment of coronary velocity reserve for clinical decision making
Di Segni E, et al.
Catheter Cardiovasc Interv 2001;54:34-40
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11553945

Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease
Bech GJ, et al.
Heart 2001;86:547-52
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11602550

Coronary thermodilution to assess flow reserve: experimental validation
De Bruyne B, et al.
Circulation 2001;104:2003-6
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11673336

Abnormal epicardial coronary resistance in patients with diffuse atherosclerosis but "Normal" coronary angiography
De Bruyne B, et al.
Circulation 2001;104:2401-6
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11705815

Abnormal coronary flow velocity reserve after coronary intervention is associated with cardiac marker elevation
Herrmann J, et al.
Circulation 2001;103:2339-45
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11352881

Fractional flow reserve in patients with prior myocardial infarction
De Bruyne B, et al.
Circulation 2001;104:157-62
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11447079

Pressure-derived fractional flow reserve to assess serial epicardial stenoses: theoretical basis and animal validation
De Bruyne B et al.
Circulation 2000;101:1840-7
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=0010769286
The interaction between 2 stenoses is such that FFR of each lesion separately cannot be calculated by the equation for isolated stenoses (P(d)/P(a) during hyperemia) applied to each separately but can be predicted by more complete equations taking into account P(a), P(m), P(d), and P(w).

Practice and potential pitfalls of coronary pressure measurement
Pijls NH et al.
Catheter Cardiovasc Interv 2000;49:1-16
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=0010627357
In this review, the practical set-up of coronary pressure measurement in the catheterization laboratory is discussed step-by-step, special attention is given to potential pitfalls and how to avoid them, and the interpretation of coronary pressure measurement in a variety of pathologic conditions is clarified.

Coronary Pressure Measurement to Assess the Hemodynamic Significance of Serial Stenoses Within One Coronary Artery. Validation in Humans
Pijls NH || Koolen JJ
Circulation. 2000; 102: 2371
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=0011067791
Coronary pressure measurements made by a pressure wire at maximum hyperemia provide a simple, practical method for assessing the individual hemodynamic significance of multiple stenoses within the same artery

Assessment of myocardial reperfusion by intravenous myocardial contrast echocardiography and coronary flow reserve after primary percutaneous transluminal coronary angioplasty [correction of angiography] in patients with acute myocardial infarction [published erratum appears in Circulation 2000 Jul 25;102(4):482]
Lepper W et al.
Circulation 2000;101:2368-74
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=0010821812
Intravenous MCE can be used to define perfusion defects after AMI. Assessment of microcirculation by MCE corresponds to evaluation by CFR. Serial intravenous MCE has the potential to identify patients likely to have improved left ventricular function after AMI.

Intravascular ultrasound criteria for the assessment of the functional significance of intermediate coronary artery stenoses and comparison with fractional flow reserve
Briguori C || Colombo A
Am J Cardiology 2001;87:136-141
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=0011152827
The combined evaluation of both percent area stenosis and MLD made the IVUS examination more specific (sensitivity 100%, specificity 76%). In 53 intermediate coronary lesions found by angiography, IVUS area stenosis >70%, MLD 10 mm reliably identified functionally critical intermediate coronary stenoses.

Review
Intermediate coronary artery stenosis: evidence-based decisions in interventions to avoid the oculostenotic reflex
Patil CV and Rafael Beyar R
International Journal of Cardiovascular Interventions 2000;3: 195
Patil et al review the difficult and grey area of the treatment of intermediate coronary artery stenosis, looking at how we use objective criteria for our decisions and how we may avoid our natural tendency for the oculostenotic reflex. Tools for physiologic assessment of lesion significance in the cath lab are helpful, user-friendly, and can be widely used for decision making. Yet the lack of large-based, well-controlled clinical trials is still a barrier to a better, clinically based definition of the need for revascularization.

Coronary revascularization directed by results of coronary Doppler flow measurements
Nicholas J, et al.
Cathet Cardiovasc Diagn 1994;31:153-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8149431

Part XII: Assessment of serial lesions in the proximal right coronary artery following intracoronary thrombolysis
Moore JA, et al.
Cathet Cardiovasc Diagn 1994;33:349-55.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=7889557

Impact of preintervention intravascular ultrasound imaging on transcatheter treatment strategies in coronary artery disease
Mintz GS, et al.
Am J Cardiol 1994;73:423-30.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8141081

Correlation of pharmacological 99mTc-sestamibi myocardial perfusion imaging with poststenotic coronary flow reserve in patients with angiographically intermediate coronary artery stenoses
Miller DD, et al.
Circulation 1994;89:2150-60.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8181140

Alterations of coronary flow velocity distal to coronary dissections before and after intracoronary stent placement
Kern MJ, et al.
Cathet Cardiovasc Diagn 1994;31:309-15.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8055573

Translesional pressure-flow velocity assessment in patients: Part I
Kern MJ, et al.
Cathet Cardiovasc Diagn 1994;31:49-60.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8118859

Fundamentals of translesional pressure-flow velocity measurements. Part II
Kern MJ, et al.
Cathet Cardiovasc Diagn 1994;31:137-43.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8149427

Continuous coronary flow velocity monitoring during coronary interventions: velocity trend patterns associated with adverse events
Kern MJ, et al.
Am Heart J 1994;128:426-34.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8074001

Doppler guide wire-derived coronary flow reserve distal to intermediate stenoses used in clinical decision making regarding interventional therapy
Deychak YA, et al.
Am Heart J 1994;128:178-81.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8017272

Rationale and application of coronary transstenotic pressure gradient measurements
De Bruyne B, et al.
Cathet Cardiovasc Diagn 1994;33:250-61.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=7874721

Measurement of volumetric coronary blood flow by simultaneous intravascular two-dimensional and Doppler ultrasound: validation in an animal model
Chou TM, et al.
Am Heart J 1994;128:237-43.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8037088

Can an intracoronary Doppler wire accurately measure changes in coronary blood flow velocity?
Vanyi J, et al.
Cathet Cardiovasc Diagn 1993;29:240-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8402851

Doppler-tipped guide wire assessment of retrograde coronary artery flow distal to a total occlusion and its reversal after laser recanalization
Thompson MA, et al.
Am Heart J 1993;125:526-30.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8427151

Assessment of coronary conductance and resistance vessel reactivity in response to nitroglycerin, ergonovine and adenosine: in vivo studies with simultaneous intravascular two-dimensional and Doppler ultrasound
Sudhir K, et al.
J Am Coll Cardiol 1993;21:1261-8.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8459086

Variations in acoustical beam properties of intracoronary Doppler catheters
Roth T, et al.
Cathet Cardiovasc Diagn 1993;30:257-63.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8269501

Analysis of coronary blood flow velocity dynamics in angiographically normal and stenosed arteries before and after endolumen enlargement by angioplasty
Ofili EO, et al.
J Am Coll Cardiol 1993;21:308-16.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8425991

Validation of volumetric flow measurements by means of a Doppler-tipped coronary angioplasty guide wire
Labovitz AJ, et al.
Am Heart J 1993;126:1456-61.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8249803

Improved methods for intracoronary Doppler flow velocity
Kern MJ.
Am J Cardiol 1993;72:1456-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8256745

Application of intracoronary flow velocity for detection and management of ostial saphenous vein graft lesions
Kern MJ, et al.
Cathet Cardiovasc Diagn 1993;30:5-10.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8402866

Use of the Doppler guide wire for intraluminal diagnosis to facilitate coronary intervention
Heuser RR, et al.
Am Heart J 1993;126:213-8.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8322667

Assessing the hemodynamic significance of coronary artery stenoses: analysis of translesional pressure-flow velocity relations in patients
Donohue TJ, et al.
J Am Coll Cardiol 1993;22:449-58.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8335814

Limitations of the zero crossing detector in the analysis of intracoronary Doppler: a comparison with fast Fourier transform analysis of basal, hyperemic, and transstenotic blood flow velocity measurements in patients with coronary artery disease
Di Mario C, et al.
Cathet Cardiovasc Diagn 1993;28:56-64.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8416334

Intracoronary blood flow velocity and transstenotic pressure gradient using sensor-tip pressure and Doppler guidewires: a new technology for the assessment of stenosis severity in the catheterization laboratory
Di Mario C, et al.
Cathet Cardiovasc Diagn 1993;28:311-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=8462080

Determination of the hemodynamic significance of coronary artery stenoses of intermediate severity
Segal J, et al.
Am Heart J 1992;124:1073-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=1529882

Alterations of phasic coronary artery flow velocity in humans during percutaneous coronary angioplasty
Segal J, et al.
J Am Coll Cardiol 1992;20:276-86.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=1386088

Validation of a Doppler guide wire for intravascular measurement of coronary artery flow velocity
Doucette JW, et al.
Circulation 1992;85:1899-911.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=1572046

Utility of Doppler color flow imaging for identification of femoral arterial complications of cardiac catheterization
Sheikh KH, et al.
Am Heart J 1989;117:623-8.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=2521974

Assessment of severity of coronary stenoses using a Doppler catheter. Validation of a method based on the continuity equation
Johnson EL, et al.
Circulation 1989;80:625-35.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=2527644