Angiography-derived index of microcirculatory resistance as a novel, pressure-wire-free tool to assess coronary microcirculation in ST elevation myocardial infarction

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Abstract

Immediate assessment of coronary microcirculation during treatment of ST elevation myocardial infarction (STEMI) may facilitate patient stratification for targeted treatment algorithms. Use of pressure-wire to measure the index of microcirculatory resistance (IMR) is possible but has inevitable practical restrictions. We aimed to develop and validate angiography-derived index of microcirculatory resistance (IMR _angio) as a novel and pressure-wire-free index to facilitate assessment of the coronary microcirculation. 45 STEMI patients treated with primary percutaneous coronary intervention (pPCI) were enrolled. Immediately before stenting and at completion of pPCI, IMR was measured within the infarct related artery (IRA). At the same time points, 2 angiographic views were acquired during hyperaemia to measure quantitative flow ratio (QFR) from which IMR _angio was derived. In a subset of 15 patients both IMR and IMR _angio were also measured in the non-IRA. Patients underwent cardiovascular magnetic resonance imaging (CMR) at 48 h for assessment of microvascular obstruction (MVO). IMR _angio and IMR were significantly correlated (ρ: 0.85, p < 0.001). Both IMR and IMR _angio were higher in the IRA rather than in the non-IRA (p = 0.01 and p = 0.006, respectively) and were higher in patients with evidence of clinically significant MVO (> 1.55% of left ventricular mass) (p = 0.03 and p = 0.005, respectively). Post-pPCI IMR _angio presented and area under the curve (AUC) of 0.96 (CI95% 0.92–1.00, p < 0.001) for prediction of post-pPCI IMR > 40U and of 0.81 (CI95% 0.65–0.97, p < 0.001) for MVO > 1.55%. IMR _angio is a promising tool for the assessment of coronary microcirculation. Assessment of IMR without the use of a pressure-wire may enable more rapid, convenient and cost-effective assessment of coronary microvascular function.

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Most cited references 18

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Diagnostic Accuracy of Fast Computational Approaches to Derive Fractional Flow Reserve From Diagnostic Coronary Angiography: The International Multicenter FAVOR Pilot Study.

Jelmer Westra, Matteo Tebaldi, Holger M. Nef … (2016)

The aim of this prospective multicenter study was to identify the optimal approach for simple and fast fractional flow reserve (FFR) computation from radiographic coronary angiography, called quantitative flow ratio (QFR).

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Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Jelmer Westra, Birgitte Andersen, Gianluca Campo … (2018)

Background Quantitative flow ratio (QFR) is a novel modality for physiological lesion assessment based on 3‐dimensional vessel reconstructions and contrast flow velocity estimates. We evaluated the value of online QFR during routine invasive coronary angiography for procedural feasibility, diagnostic performance, and agreement with pressure‐wire–derived fractional flow reserve (FFR) as a gold standard in an international multicenter study. Methods and Results FAVOR II E‐J (Functional Assessment by Various Flow Reconstructions II Europe‐Japan) was a prospective, observational, investigator‐initiated study. Patients with stable angina pectoris were enrolled in 11 international centers. FFR and online QFR computation were performed in all eligible lesions. An independent core lab performed 2‐dimensional quantitative coronary angiography (2D‐QCA) analysis of all lesions assessed with QFR and FFR. The primary comparison was sensitivity and specificity of QFR compared with 2D‐QCA using FFR as a reference standard. A total of 329 patients were enrolled. Paired assessment of FFR, QFR, and 2D‐QCA was available for 317 lesions. Mean FFR, QFR, and percent diameter stenosis were 0.83±0.09, 0.82±10, and 45±10%, respectively. FFR was ≤0.80 in 104 (33%) lesions. Sensitivity and specificity by QFR was significantly higher than by 2D‐QCA (sensitivity, 86.5% (78.4–92.4) versus 44.2% (34.5–54.3); P<0.001; specificity, 86.9% (81.6–91.1) versus 76.5% (70.3–82.0); P=0.002). Area under the receiver curve was significantly higher for QFR compared with 2D‐QCA (area under the receiver curve, 0.92 [0.89–0.96] versus 0.64 [0.57–0.70]; P<0.001). Median time to QFR was significantly lower than median time to FFR (time to QFR, 5.0 minutes [interquartile range, –6.1] versus time to FFR, 7.0 minutes [interquartile range, 5.0–10.0]; P<0.001). Conclusions Online computation of QFR in the catheterization laboratory is clinically feasible and is superior to angiographic assessment for evaluation of intermediary coronary artery stenosis using FFR as a reference standard. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02959814.

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Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials

Suzanne de Waha, Manesh R Patel, Christopher Granger … (2017)

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Author and article information

Contributors

Adrian P. Banning: adrian.banning@ouh.nhs.uk

Journal

Journal ID (nlm-ta): Int J Cardiovasc Imaging

Journal ID (iso-abbrev): Int J Cardiovasc Imaging

Title: The International Journal of Cardiovascular Imaging

Publisher: Springer Netherlands (Dordrecht )

ISSN (Print): 1569-5794

ISSN (Electronic): 1875-8312

Publication date (Electronic): 14 May 2020

Publication date PMC-release: 14 May 2020

Publication date (Print): 2020

Volume: 36

Issue: 8

Pages: 1395-1406

Affiliations

[1 ]GRID grid.410556.3, ISNI 0000 0001 0440 1440, Oxford Heart Centre, NIHR Biomedical Research Centre, , Oxford University Hospitals, ; Headley Way, Oxford, OX39DU UK

[2 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, Oxford Centre for Clinical Magnetic Resonance Research (OCMR), , University of Oxford, ; Oxford, UK

[3 ]GRID grid.415235.4, ISNI 0000 0000 8585 5745, MedStar Washington Hospital Center, ; Washington, DC USA

Article

Publisher ID: 1831

DOI: 10.1007/s10554-020-01831-7

PMC ID: 7381481

PubMed ID: 32409977

SO-VID: f9d964af-c185-4045-be4d-6a0a4825c13e

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Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 20 January 2020

Date accepted : 28 March 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000274, British Heart Foundation;

Award ID: CH/16/1/32013

Award Recipient : Keith M. Channon

Funded by: BHF Centre of Research Excellence, Oxford (GB)

Award ID: RG/13/1/30181

Award Recipient : Keith M. Channon

Funded by: FundRef http://dx.doi.org/10.13039/501100013373, NIHR Oxford Biomedical Research Centre;

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: index of microcirculatory resistance,microvascular obstruction,quantitative flow ratio,microvascular dysfunction,stemi

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: index of microcirculatory resistance, microvascular obstruction, quantitative flow ratio, microvascular dysfunction, stemi

Angiography-derived index of microcirculatory resistance as a novel, pressure-wire-free tool to assess coronary microcirculation in ST elevation myocardial infarction

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Karger: Cardiovascular System

Most cited references 18

Diagnostic Accuracy of Fast Computational Approaches to Derive Fractional Flow Reserve From Diagnostic Coronary Angiography: The International Multicenter FAVOR Pilot Study.

Diagnostic Performance of In‐Procedure Angiography‐Derived Quantitative Flow Reserve Compared to Pressure‐Derived Fractional Flow Reserve: The FAVOR II Europe‐Japan Study

Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials

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