Circulation, Vol 90, 1215-1224, Copyright © 1994 by American Heart Association
C Di Mario, R Krams, R Gil and PW Serruys
BACKGROUND: Coronary flow reserve (CFR), the functional index of stenosis
severity more frequently used in the catheterization laboratory, is greatly
affected by the hemodynamic conditions at the time of measurement and
cannot be applied in the immediate assessment of the outcome of coronary
interventions. The aim of the present study was to establish the
feasibility and reproducibility of the assessment of the slope of the
instantaneous diastolic relation between coronary flow velocity and aortic
pressure during maximal hyperemia (IHDVPS) using a spectral analysis of the
intracoronary Doppler signal, to assess the sensitivity and specificity of
this index in the detection of flow-limiting coronary stenoses in
comparison with CFR, and to study the possibility of determining the
zero-flow pressure from the intercept of the velocity-pressure relation on
the pressure axis during a controlled cardiac arrest. METHODS AND RESULTS:
The instantaneous peak coronary flow velocity measured after intracoronary
papaverine with a Doppler guidewire was plotted against the simultaneously
measured aortic pressure, and the slope of the velocity-pressure relation
in the phase of progressive diastolic velocity decrease was calculated
during four consecutive beats. In nine normal arteries, a controlled
diastolic cardiac arrest was induced by an intracoronary bolus injection of
3 mg adenosine. The IHDVPS could be assessed in 79 of 95 patients (83%),
with a moderate intraobserver variability (0.4 +/- 11% after independent
selection of different beats during maximal hyperemia). The IHDVPS showed
no significant correlation with heart rate, mean diastolic aortic pressure,
type of vessel studied, and cross- sectional area at the site of the
velocity recording. The IHDVPS was significantly lower in arteries with
> or = 30% diameter stenosis than in normal or near-normal arteries
(0.71 +/- 0.48 versus 1.73 +/- 0.80 cm.s-1.mm Hg-1, P < .0000002). In
the stenosis group, both IHDVPS and CFR were significantly correlated with
the minimal luminal cross- sectional area (r = .46, P < .05 and r = .62,
P < .002, respectively). The study of the velocity-pressure relation
during long diastolic pauses showed a curvilinear relation between velocity
and pressure in the lower pressure range, with an upward concavity to the
velocity axis and no intercept with the pressure axis in most cases.
CONCLUSIONS: The IHDVPS can distinguish between arteries with and without
coronary stenoses and has a significant inverse correlation with the
severity of the stenosis. Under the stable hemodynamic conditions of this
study, the IHDVPS and CFR had similar sensitivities and specificities in
distinguishing normal and stenotic vessels and demonstrated similar
correlation with minimal luminal cross-sectional area. The curvilinearity
of the velocity-pressure relation during long diastolic pauses, possibly
due to a significant reduction of luminal cross- sectional area at low
pressures, complicates the use of the flow velocity-pressure relation for
the assessment of the zero-flow pressure.
ARTICLES
Slope of the instantaneous hyperemic diastolic coronary flow velocity- pressure relation. A new index for assessment of the physiological significance of coronary stenosis in humans
Intracoronary Imaging Laboratory, Erasmus University, Rotterdam, Netherlands.
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