Validation of coronary flow reserve measurements by thermodilution in clinical practice.

BACKGROUND: Coronary flow reserve (CFR) and fractional flow reserve (FFR) provide complementary information on the coronary circulation. Using a pressure wire, it is possible to calculate CFR by thermodilution (CFR(thermo)), so that FFR and CFR can be measured with a single guide wire. The present multicentric study was performed to compare the feasibility of CFR(thermo)obtained with an improved algorithm and a standardized injection technique and its agreement with Doppler-derived CFR (CFR(Doppler)). METHODS AND RESULTS: In 86 patients with coronary artery disease recruited during 1 week in eight centres FFR, CFR(thermo)and CFR(Doppler)were measured. FFR could be obtained in all patients (100%). An optimal CFR(Doppler)could be obtained in 69% of the patients. CFR(thermo)could be obtained in 97% of the patients. A significant correlation was found between CFR(Doppler)and CFR(thermo)(r=0.79, P<0.0001) but CFR(thermo)tended to be higher than CFR(Doppler). CONCLUSIONS: In a setting close to 'real world' practice, this multicentric study confirms the feasibility and reliability of thermodilution-derived CFR. In addition, the safety and the swiftness of assessing FFR and CFR with one single guide wire makes the latter a unique clinical tool for the evaluation of the coronary circulation.     

冠状动脉微血管病患者的三支冠状动脉血流储备的差异

目的 :观察冠状动脉 (冠脉 )造影正常而有冠脉微血管病基础者的三支冠脉血流储备 (Coronaryflowreserve ,CFR)之间是否有差异。方法 :临床上有不典型胸闷或胸痛的患者 4 5例 ,冠脉造影及左室射血分数正常 ,按有无冠脉微血管病基础分为甲、乙两组。甲组为冠脉微血管病组 ,共 2 9例 ,男 19例 ,女 10例 ,年龄 37～ 78(5 8±9.9)岁 ,其中心电图有左室肥厚或劳损表现的高血压患者 11例 ,糖尿病 3例 ,肥厚型心肌病 2例 ,长期吸烟者 10例 ,高血脂 8例 ;乙组为无冠脉微血管病组 ,共 16例 ,男 11例 ,女 5例 ,年龄 38～ 5 8(5 1± 8.6 )岁。冠脉造影过程中随机测定冠脉CFR值 (甲组 6 2支 ,左冠脉前降支 2 4支 ,冠脉左旋支 17支 ,右冠脉 2 1支 ;乙组 36支 ,左冠脉前降支13支 ,冠脉左旋支 8支 ,右冠脉 14支 )。结果 :甲组 6 2支冠脉的平均CFR为 2 .32± 0 .6 1,乙组 3.15± 0 .5 5 ,P <0 .0 1。甲组三支冠脉之间的CFR差异有统计学意义 ,P <0 .0 1;乙组三支冠脉的CFR差别无统计学意义P >0 .0 5。甲组前降支的CFR远低于右冠脉与回旋支 (2 .0 4± 0 .5 2∶2 .5 9± 0 .6 5 ,2 .39± 0 .5 5 ,均 P<0 .0 5 ) ;回旋支较右冠脉的CFR低 ,但差异无统计学意义 (2 .39± 0 .5 5∶2 .5 9± 0 .6 5 ,P >0 .0 5 )。结论 :冠脉微血     

Clinical value of digital radiographic coronary quantification: comparison with visual assessment and coronary flow reserve.

The value of quantitative assessment of coronary artery dimensions at the site of the most critical coronary stenosis was assessed by comparison with the correspondent reactive hyperaemia as measured by digital subtraction angiography and with the functional results. Thirty-two coronary lesions were analysed and flow reserve data were obtained in an additional 11 vascular distributions without coronary obstruction in 19 patients. Minimal diameter less than 1.25 mm and minimal area less than 1.5 mm2 at the site of the stenosis best separated vascular distributions with inadequate hyperaemic response from those with sufficient reactive hyperaemia (chi 2 = 19.57; P less than 0.0001). Identification of lesion severity based on videodensitometric percentage area stenosis greater than 70% or percentage diameter stenosis greater than 50% yielded similar but poorer results (respectively chi 2 = 14.53; P less than 0.001 and chi 2 = 10.29; P less than 0.005). Additionally, when visually determined percentage stenosis was compared to the quantitatively assessed value, only a fair correlation was observed (r = 0.74), with visual overestimation of lesion severity by an average of 11.1 +/- 9.8% (mean +/- SD). Reactive hyperaemia in vessels with coronary obstruction could be described from minimal coronary dimensions by a quadratic equation but did not correlate closely in this patient population (r = 0.54 with minimal diameter and r = 0.58 with minimal area).(ABSTRACT TRUNCATED AT 250 WORDS)     

Validation of noninvasive assessment of coronary flow velocity reserve in the right coronary artery. A comparison of transthoracic echocardiographic results with intracoronary Doppler flow wire measurements.

AIMS: Assessment of coronary flow velocity reserve (CFR) noninvasively using transthoracic Doppler echocardiography (TDE) is validated for the left anterior descending artery only. We evaluated the feasibility and reproducibility to assess CFR using TDE in the right coronary artery, and compared the results with intracoronary Doppler flow wire (DFW) measurements. METHODS AND RESULTS: Introduction of a modified apical 2-chamber view allows visualization of the posterior descending branch of the right coronary artery (RPD). 42 consecutive patients (31 men, mean age 61+/-10) with suspected coronary artery disease scheduled for coronary angiography underwent CFR assessment using TDE in fundamental imaging mode; the results were compared with DFW measurements. CFR could be taken noninvasively in 81% (34/42); in case of right dominant- or balanced coronary circulation type success rate was significantly higher (87%; 33/38) than in case of left dominant coronary circulation (25%; 1/4). Correlation between echocardiographically and intracoronary derived CFR results was significant (r=0.85, P<0.0001), as well as reproducibility (r=0.94, P<0.0001) and interobserver variability (r=0.78, P<0.0001). CONCLUSION: Coronary flow reserve assessed in the peripheral RCA by TDE concurs very closely with intracoronary Doppler flow wire CFR results. This new approach allows feasible, accurate and reproducible measurement of CFR in the RCA.     

阿托伐他汀对冠状动脉血流缓慢患者冠状动脉血流储备的影响

目的 探讨冠状动脉血流缓慢患者冠状动脉血流储备(CFR)的改变以及阿托伐他汀对这类患者CFR的影响.方法 入选有胸痛症状但冠状动脉造影结构正常的冠状动脉血流缓慢患者91例,分为治疗组(51例)和无治疗组(40例).治疗组给予阿托伐他汀20 mg治疗8周.另选26例冠状动脉造影正常且运动试验阴性的无心脏疾患者为正常对照组.治疗前后测定治疗组和无治疗组的血脂以及利用腺苷负荷超声记录左前降支远端血流频谱,并评价CFR.结果 (1)冠状动脉血流缓慢者接受阿托伐他汀8周治疗后总胆固醇(TC)和低密度脂蛋白胆固醇(LDL-C)较无治疗组及正常对照组明显减低[TC:(3.83±0.80)mmol/L比(5.30±1.18)mmol/L和(5.32±1.17)mmol/L,均P＜0.05:LDL=C:(2.26±0.64)mmol/L比(3.28±0.85)mmol/L和(3.30±0.82)mmol/L,均P＜0.05].(2)给予阿托伐他汀前,治疗组与无治疗组CFR(分别为2.32±0.30和2.25±0.33)均低于正常对照组(3.15±0.34,P＜0.05);8周后,治疗组冠状动脉血流速度(CFV)[(26.06±3.22)cm/s]较无治疗组[(29.02±3.36)cm/s]及治疗前静息状态[(28.43±3.40)cm/s]低(均P＜0.05),最大冠状动脉扩张状态CFV高于无治疗组和对照组[分别为(77.63±8.96)、(65.17±7.22)和(64.58±6.26)cm/s,P＜0.05],CFR低于治疗前和无治疗组(分别为3.07±0.29、2.28±0.35和2.32±0.30,P＜0.05),且与正常对照组差异均无统计学意义.结论 冠状动脉血流缓慢患者CFR明显减低,短期阿托伐他汀在调脂的同时可以有效改善其CFR.     

经导管急性微血管栓塞对冠状动脉血流和冠状动脉血流储备的影响

目的　建立经导管的急性微血管栓塞动物模型 ,研究不同微栓塞水平冠状动脉血流(CBF)和冠状动脉血流储备 (CFR)的变化。方法　 10头小型猪 (2 1～ 2 5kg) ,不开胸经导管由前降支重复注入微栓塞球 (4 5 μm) ,使用多普勒导丝、压力导丝和腔内超声导管测量前降支中段平均流速、压力和腔内面积 ,CBF =平均流速×面积。冠状动脉内注射腺苷 18μg达到最大充血状态 ,CFR =充血CBF 基础CBF。在微栓塞前、注入 5万、10万、12万、14万和 15万微栓塞球时分别测量基础状态和充血状态的血流动力学指标。结果　注入 5万微球时基础CBF(rCBF)升高 ,较微栓塞前差异有显著性[(0 30± 0 0 9)ml·s- 1 vs (0 2 6± 0 10 )ml·s- 1 ,P <0 0 5 ],随着微球量的增加rCBF降低。CFR在微栓塞后降低 ,不同微栓塞水平的CFR与微栓塞前比较差异均有显著性。结论　经导管急性微血管栓塞中 ,随着微栓塞球量增加 ,rCBF呈现先增加后下降的双期改变 ;微栓塞后CFR下降 ,CFR在一定微栓塞程度时又有增加。     

冠状动脉造影正常的胸痛患者冠状动脉血流储备功能研究

目的 :评价冠状动脉血流储备 (CFR)功能的测定对阐明冠状动脉造影正常患者的胸痛机制的临床作用。方法 :4 0例冠状动脉造影正常的胸痛患者分为非心脏病组、X综合征组及高血压组 ,采用TIMI计帧法测定注射罂粟碱前后相关冠状动脉血流帧数的变化 ,并计算CFR。结果 :X综合征组用药前后血流速度均慢于非心脏病组 (P <0 .0 5 ,P <0 .0 1) ,高血压组静息血流速度快于非心脏病组 (P <0 .0 5 )。非心脏病组的CFR范围为2 .0～ 2 .8,X综合征组及高血压组的CFR低于非心脏病组 (P <0 .0 1)。结论 :TIMI计帧法可用于CFR的测定 ,X综合征及高血压患者CFR降低 ,原因可能与冠状动脉小血管的充血反应能力下降和 (或 )基础冠状动脉血流的增加有关     

Cardiac magnetic resonance perfusion imaging for the functional assessment of coronary artery disease: a comparison with coronary angiography and fractional flow reserve.

AIMS: Cardiac magnetic resonance perfusion imaging (CMRI) is a promising technique for non-invasive measurement of myocardial perfusion reserve. Fractional flow reserve (FFR) is an established invasive method for functional assessment of coronary artery disease (CAD). To prospectively assess the diagnostic value of CMRI for the detection of haemodynamically significant coronary lesions, compared with coronary angiography (CA) and FFR. METHODS AND RESULTS: Forty-three patients with suspected or known CAD underwent CA, CMRI, and FFR measurement. First pass magnetic resonance perfusion examination was performed during hyperaemia (140 microg/kg/min adenosine over 6 min) and at rest. One hundred and twenty-nine perfusion territories were assessed by semi-quantitative evaluation of signal intensity-time curves using the myocardial perfusion reserve index (MPRI) [upslope(stress(corrected))/upslope(rest(corrected))]. Perfusion territories were categorized as normal (coronary stenosis < or = 50%), intermediate (stenosis > 50% and FFR > 0.75), or severe (stenosis > 50% and FFR < or = 0.75 or total occlusion). MPRI values (+/-SD) were significantly different between the three categories [normal, 2.2 +/- 0.5 vs. intermediate, 1.8 +/- 0.5 (P = 0.005) and intermediate vs. severe, 1.2 +/- 0.3 (P < 0.001)]. An MPRI cut-off value of 1.5 (derived from receiver operating characteristics analysis) distinguished haemodynamically relevant (severe) from non-relevant (normal and intermediate) stenoses with a sensitivity of 88% (CI 74-100%) and a specificity of 90% (CI 84-96%). CONCLUSION: In contrast to earlier studies that compared CMRI with morphological examination (CA) alone, the present study compared CMRI with CA plus a standard invasive functional assessment (FFR) and demonstrated that CMRI is able to distinguish haemodynamically relevant from non-relevant coronary lesions with a high sensitivity and specificity and may therefore contribute to clinical decision-making.     

Single administration of cerivastatin, an HMG-CoA reductase inhibitor, improves the coronary flow velocity reserve: a transthoracic Doppler echocardiography study

HMG-CoA reductase inhibitors (statins) have been shown to improve the endothelial function by lowering lipids. Recent studies also suggest a direct impact of statins on the vascular wall. We assessed the rapid effect of cerivastatin on the coronary flow velocity reserve (CFVR) using transthoracic Doppler echocardiography (TTDE). The coronary flow velocity from the distal left anterior descending artery was measured in 16 healthy subjects (all male, age 24–38 years) using a 5-MHz transducer, on the day before, just before, and 3 h after administering 0.3 mg of cerivastatin. Hyperemia was achieved by the intravenous administration of adenosine, and the CFVR was calculated as the radio of the mean diastolic hyperemic coronary flow velocity to the basal flow velocity. The serum lipid profile and high-sensitivity C-reactive protein (hsCRP) were measured. The CFVR following the single administration of cerivastatin increased from 2.93 ± 0.58 to 3.91 ± 0.86, P = 0.003, and was significantly higher than the CFVR measured at the same time on the previous day (3.91 ± 0.86 vs 3.37 ± 0.48, P = 0.009). Neither the serum lipid profile nor hsCRP exhibited a remarkable change after cerivastatin administration. We concluded that a single-dose administration of cerivastatin, an HMG-CoA reductase inhibitor, improves the coronary flow velocity reserve without modifying the serum lipid profile.     

Low density lipoprotein cholesterol level inversely correlated with coronary flow velocity reserve in patients with Type 2 Diabetes

Objectives To evaluate the association of coronary artery endothelial function and plasma levels of low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) in patients with Type 2 Diabetes Mellitus (DM). Methods We investigated 90 participants from our institution between October 2007 to March 2010: non-DM (n = 60) and DM (n = 30). As an indicator of coronary endothelial dysfunction, we used non-invasive Doppler echocardiography to quantify coronary flow velocity reserve (CFVR) in the distal part of the left descending artery after rest and after intravenous adenosine administration. Results Plasma level of LDL-C was significantly higher in patients with DM than in non-DM (3.21±0.64 vs. 2.86±0.72 mmo/L, P < 0.05), but HDL-C level did not differ between the groups (1.01 ± 0.17 vs. 1.05 ± 0.19 mmo/L). Furthermore, the CFVR value was lower in DM patients than non-diabetics (2.45 ± 0.62 vs. 2.98 ± 0.68, P < 0.001). Plasma levels of LDL-C were negatively correlated with CFVR in all subjects (r = -0.35, P < 0.001; 95% confidence interval (CI): -0.52 - -0.15) and in the non-DM (r = -0.29, P < 0.05; 95% CI:-0.51 - -0.05), with an even stronger negative correlation in the DM group (r = -0.42, P < 0.05; 95% CI:-0.68 - -0.06). Age (β = 0.019, s = 0.007, sβ = -0435, 95% CI: -0.033 - -0.055, P = 0.008), LDL-C (β = -0.217, s = 0.105,sβ= -0.282, 95% CI: -0.428 - -0.005, P = 0.045) remained independently correlated with CFVR in the DM group. However, we found no correlation between HDL-C level and CFVR in any group. Conclusions Diabetes may contribute to coronary artery disease (CAD) by inducing dysfunction of the coronary artery endothelium. Increased LDL-C level may adversely impair coronary endothelial function in DM. HDL-C may lose its endothelial-protective effects, in part as a result of pathological conditions, especially under abnormal glucose metabolism.     

高血压患者冠脉血流储备的变化及福辛普利治疗的影响

目的:观察高血压病患者冠状动脉血流储备(coronary flow reserve,CFR)的变化及福辛普利治疗对高血压病患者CFR的影响。方法:选择28例高血压病患者(高血压病组)及28例健康人(对照组),检测福辛普利治疗前的血压,空腹及餐后2小时的血糖(FBG及P2hBG)、血脂、血清内皮素(ET—1)水平以及CFR的状况,并与对照组进行比较,并将治疗前、后的各项指标进行比较。结果:高血压病患者福辛普利治疗前、后血糖与血脂水平与对照组比较没有显著性差异(P>0.05);高血压病患者的收缩压(SBP)、舒张压(DBP)及ET-1水平均较对照组高(P<0.05),福辛普利治疗6月后患者的SBP、DBP、ET-1水平较治疗前明显下降(P<0.05);高血压病患者CFR低于对照组(P<0.05),福辛普利治疗6月后CFR较治疗前明显上升(P<0.05)。结论:福辛普利治疗能有效降低高血压病患者的血压,改善患者的内皮功能从而改善患者的CFR。     

福辛普利对X综合征患者冠脉血流储备的影响

目的:应用彩色多普勒超声仪检测冠状动脉血流储备(coronary flow reserve,CFR),观察福辛普利对X综合征患者CFR的影响。方法:选取26例X综合征患者,比较福辛普利(5mg或10mg)治疗前后患者血压、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、甘油三酯(TG)、内皮素(ET-1)、静急状态时患者冠状动脉的基础血流速度(bFV)、潘生丁注射后的最大血流速度(mFV)及冠状动脉血流储备(CFR)的变化。结果:福辛普利治疗6个月后,X综合征患者的 SBP、DBP、TC、LDL-C、TG水平轻度下降(P>0.05),ET-1水平显著下降,从(103.5±9.7)pg/ml到(77.5±12.0)pg/ml(P<0.05);患者的bFV改变不明显(P>0.05),而mFV从治疗前的(57.2±8.4)cm/s上升到(72.1±7.6)cm/s(P<0.05),CFR从治疗前的2.52±0.56上升到3.32±0.44(P<0.01)。结论:应用福辛普利治疗X综合征患者可有效改善患者的内皮功能和CFR。     

临界性高血压患者冠状动脉血流储备功能的研究

目的 :了解无症状临界性高血压患者是否有冠状动脉功能异常。方法 :经食管超声心动描记术研究 2 0例正常人 (正常对照组 )及 17例无症状临界性高血压患者 (临界性高血压组 )的冠状动脉血流储备 (CFR)。以潘生丁静脉注射后和静息时舒张期的最大血流速度比率 (D/R PDV)和收缩期最大血流速度比率 (D/R PSV )作为CFR指标。结果 :1两组受检者静息时的 PDV无显著性差异〔(43± 10 ) m m/s∶ (46± 8) mm /s,P >0 .0 5〕;2静脉注射潘生丁后临界性高血压组的 D/R PDV、D/R PSV较正常对照组明显减少 ,两组之间有显著性差异 (D/RPDV:2 .2 5± 0 .36∶ 2 .86± 0 .42 ,D/R PSV:2 .0 0± 0 .2 6∶ 2 .5 6± 0 .41,P<0 .0 5 )。结论 :无症状临界性高血压患者 CFR能力降低。