The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)


Comprehensive physiological evaluation of epicardial and microvascular coronary domains using vascular conductance and zero flow pressure

EuroIntervention 2019;14:e1593-e1600 published online April 2018. DOI: 10.4244/EIJ-D-18-00021

1. Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands; 2. Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain; 3. Department of Cardiology, Imperial College London, London, United Kingdom; 4. Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands; 5. Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands; 6. Department of Cardiology, Amphia Hospital, Breda, the Netherlands; 7. Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands

Aims: Assessment of the coronary circulation has been based largely on pressure ratios (epicardial) and resistance (micro-vessels). Simultaneous assessment of epicardial (CEPI) and microvascular conductance (CMICRO) provides an intuitive approach using the same units for both coronary domains and expressing the actual deliverability of blood. The aim of this study was to develop a novel integral method for assessing the functional severity of epicardial and microvascular disease.

Methods and results: We performed intracoronary pressure and Doppler flow velocity measurements in 403 vessels in 261 patients with stable coronary artery disease. Hyperaemic mid-to-late diastolic pressure and flow velocity (PV) relationships were calculated. The slope of the aortic PV indicates the overall conductance and the slope of the distal PV relationship represents CMICRO. The intercept with the x-axis represents zero-flow pressure (Pzf). CEPI was derived from microvascular and overall conductance. Median CEPI was higher compared to CMICRO (4.2 [2.1-8.0] versus 1.3 [1.0-1.7] cm/s/mmHg, p<0.001). CMICRO was independent of stenosis severity (1.3 [1.0-1.7] in FFR ≤0.80 versus 1.4 [1.0-1.8] in FFR >0.8, p=0.797). ROC curves (using FFR and HSR concordant vessels as standard) demonstrated an excellent ability of CEPI to characterise significant stenoses (AUC 0.93). When CEPI<CMICRO, a decrease in flow velocity and coronary pressure (optimal cut-off value 0.97, AUC 0.90) was demonstrated.

Conclusions: A comprehensive assessment of separate CEPI and CMICRO was feasible. CEPI has a remarkable diagnostic efficiency to detect a clinically relevant stenosis. When CEPI<CMICRO, distal flow and pressure decrease steeply, indicating myocardial ischaemia. CMICRO can be used to explore the severity of microvascular disease.

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