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Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses : A Multicenter Study Using Intracoronary Pressure and Flow

Ahmad, Yousif ; Vendrik, Jeroen ; Eftekhari, Ashkan ; Howard, James P. ; Cook, Christopher ; Rajkumar, Christopher ; Malik, Iqbal ; Mikhail, Ghada ; Ruparelia, Neil and Hadjiloizou, Nearchos , et al. (2019) In Circulation. Cardiovascular Interventions 12(12).
Abstract

BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with... (More)

BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2). RESULTS: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74. CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
aortic valve stenosis, diastole, hyperemia, microcirculation, myocardium
in
Circulation. Cardiovascular Interventions
volume
12
issue
12
article number
e008263
publisher
American Heart Association
external identifiers
  • pmid:31752515
  • scopus:85075494229
ISSN
1941-7632
DOI
10.1161/CIRCINTERVENTIONS.119.008263
language
English
LU publication?
yes
id
7d239867-1368-4d7a-bd5c-97fd986acca7
date added to LUP
2019-12-04 14:08:32
date last changed
2024-04-02 22:28:19
@article{7d239867-1368-4d7a-bd5c-97fd986acca7,
  abstract     = {{<p>BACKGROUND: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. METHODS: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2). RESULTS: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s-1 versus post-TAVI 3.04±1.6 mm Hg·cm·s-1 [P=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [P=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74. CONCLUSIONS: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values &lt;0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.</p>}},
  author       = {{Ahmad, Yousif and Vendrik, Jeroen and Eftekhari, Ashkan and Howard, James P. and Cook, Christopher and Rajkumar, Christopher and Malik, Iqbal and Mikhail, Ghada and Ruparelia, Neil and Hadjiloizou, Nearchos and Nijjer, Sukhjinder and Al-Lamee, Rasha and Petraco, Ricardo and Warisawa, Takayuki and Wijntjens, Gilbert W.M. and Koch, Karel T. and van de Hoef, Tim and de Waard, Guus and Echavarria-Pinto, Mauro and Frame, Angela and Sutaria, Nilesh and Kanaganayagam, Gajen and Ariff, Ben and Anderson, Jon and Chukwuemeka, Andrew and Fertleman, Michael and Koul, Sasha and Iglesias, Juan F. and Francis, Darrel and Mayet, Jamil and Serruys, Patrick and Davies, Justin and Escaned, Javier and van Royen, Niels and Götberg, Matthias and Juhl Terkelsen, Christian and Høj Christiansen, Evald and Piek, Jan J. and Baan, Jan and Sen, Sayan}},
  issn         = {{1941-7632}},
  keywords     = {{aortic valve stenosis; diastole; hyperemia; microcirculation; myocardium}},
  language     = {{eng}},
  number       = {{12}},
  publisher    = {{American Heart Association}},
  series       = {{Circulation. Cardiovascular Interventions}},
  title        = {{Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses : A Multicenter Study Using Intracoronary Pressure and Flow}},
  url          = {{http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008263}},
  doi          = {{10.1161/CIRCINTERVENTIONS.119.008263}},
  volume       = {{12}},
  year         = {{2019}},
}