Coronary Angiographic and Intracoronary Flow Patterns … · Coronary Angiographic and Intracoronary Flow Patterns ... as a reference standard for myocardial viability. • This study

Angioplasty Summit 2005

Ajou University Medical Center

SeungSeung--Jea Tahk MD., PhD.Jea Tahk MD., PhD.AjouAjou University Medical CenterUniversity Medical Center

SuwonSuwon, Korea, Korea

Angioplasty Summit 2005Angioplasty Summit 2005

Coronary Angiographic and Coronary Angiographic and IntracoronaryIntracoronary Flow Patterns Flow Patterns for the Evaluation of Myocardial Viability in AMIfor the Evaluation of Myocardial Viability in AMIA Comparison with Positron Emission TomographyA Comparison with Positron Emission Tomography



Background

•• Establishing angiographic Establishing angiographic epicardialepicardial flow after AMI is not flow after AMI is not always synonymous with tissuealways synonymous with tissue--level myocardial perfusion, level myocardial perfusion, which is important determinant of left ventricular function which is important determinant of left ventricular function change and prognosis after acute myocardial infarction.change and prognosis after acute myocardial infarction.



Background

•• Coronary angiographic and physiologic indices such as..Coronary angiographic and physiologic indices such as..–– TIMI myocardial perfusion gradeTIMI myocardial perfusion grade–– Deceleration time of diastolic flow velocityDeceleration time of diastolic flow velocity–– MicrovascularMicrovascular resistance indexresistance index–– Coronary flow velocity reserveCoronary flow velocity reserve–– Coronary wedge pressureCoronary wedge pressure

have been known as parameters which represent myocardial vihave been known as parameters which represent myocardial viability after ability after AMI.AMI.

•• 1818FF--FDG regional uptake on positron emission tomography has been useFDG regional uptake on positron emission tomography has been used d as a reference standard for myocardial viability.as a reference standard for myocardial viability.

•• This study was designed to evaluate the efficacy of angiographicThis study was designed to evaluate the efficacy of angiographic and and physiologic indices for the evaluation of myocardial viability physiologic indices for the evaluation of myocardial viability by comparison by comparison with PET in AMI patients who received PCI. with PET in AMI patients who received PCI.



Study Population

Inclusion CriteriaInclusion Criteria•• First onset of acute STEMIFirst onset of acute STEMI•• >75% in diameter >75% in diameter stenosisstenosis, eligible, eligible for for stentingstenting. . •• Residual diameter Residual diameter stenosisstenosis<30% after <30% after stentingstenting•• Informed consent to perform coronary Informed consent to perform coronary stentingstenting, , intracoronaryintracoronary

physiologic study, and PET imaging within 1 week after onset.physiologic study, and PET imaging within 1 week after onset.

Exclusion CriteriaExclusion Criteria•• CardiogenicCardiogenic shockshock•• Left main diseaseLeft main disease•• Atrial fibrillation, SVT or VT, 2Atrial fibrillation, SVT or VT, 2ndnd or 3or 3rdrd degree AV blockdegree AV block



Study Population

•• 26 consecutive patients satisfying inclusion criteria were studi26 consecutive patients satisfying inclusion criteria were studied.ed.

1.541.54±±0.370.37RWMSIRWMSI50 50 ±± 1111LVEF (%)LVEF (%)21 21 ±± 4141Time to reperfusion (hr)Time to reperfusion (hr)7 (26.9%)7 (26.9%)InferiorInferior1 ( 3.8%)1 ( 3.8%)PosteriorPosterior18(69.2%)18(69.2%)AnteriorAnterior

Infarct related arteryInfarct related artery22(84.6%)22(84.6%)Gender (Male, %)Gender (Male, %)

56 56 ±± 1313Age (years)Age (years)



Angiographic and Coronary Physiologic Assessment

Coronary Angiographic EvaluationCoronary Angiographic Evaluation•• Quantitative Coronary AngiographyQuantitative Coronary Angiography•• TIMI FlowTIMI Flow•• TIMI Myocardial Perfusion GradesTIMI Myocardial Perfusion Grades•• Collateral Flow GradesCollateral Flow Grades

Coronary Flow Parameters Coronary Flow Parameters •• Coronary Flow Reserve (CFR) = Coronary Flow Reserve (CFR) = hAPVhAPV / / bAPVbAPV•• Microvascular Resistance Index (MVRI) = Mean Microvascular Resistance Index (MVRI) = Mean PcorPcor / APV/ APV•• Deceleration Time of Diastolic Flow Velocity (DDT)Deceleration Time of Diastolic Flow Velocity (DDT)•• Coronary wedge pressure (Coronary wedge pressure (PcwPcw))



Methods

Coronary wedge pressure Coronary wedge pressure

Conventional Balloon Catheter (OWT/Monorail) orConventional Balloon Catheter (OWT/Monorail) orStent Balloon CatheterStent Balloon CatheterPressure Wire (RADI)Pressure Wire (RADI)

IntracoronaryIntracoronary flow measurementsflow measurements

Doppler Guide WireDoppler Guide WireFloWire™ (Endosonic)FloWire XT (JOMETRICS)FloWire XT (JOMETRICS)

FlowMap®® System

Intracoronary Adenosine 24-48µg



PET ImagingPET Imaging

J Nucl Cardiol 1999;649BonowBonow RO et al. Circulation 1991;83:26RO et al. Circulation 1991;83:26

Discovery ST, Combined PET and CT Scan, GE medical system, USADiscovery ST, Combined PET and CT Scan, GE medical system, USAMyocardial viability threshold: 50% or more uptake of 18F-FDG



Case 1 Coronary Angiography

Pre PCI Post PCI TIMI 2 TMPG 0 OHK IS 7111474

Acute Anterior STEMI, M/52, Time to reperfusion: 6 hrs, LVEF: 33%



Case 1 Coronary Wedge Pressure

OHK IS 7111474

Pa

Pcw

Pcw/Pa



Case 1 Intracoronary Flow Measurement

bDDT: 60 ms MVRI: 4.45 mmHg•cm-1•sec-1

hDDT: 60 ms CFR: 1.4

OHK IS 7111474



Case 1 FDG PET Imaging

OHK IS 7111474



Case 1 Echocardiography

Post PCI

OHK IS 7111474

2 Months FU

LVEF (%) 37 40LVEDV (ml) 95 111LVESV (ml) 61 69RWMSI 1.88 1.76




Park KD 7225812

Acute Anterior MI, M/57, Time to reperfusion: 3 hrs, LVEF: 49%

Pre PCI Post PCI TIMI 2 TMPG 1




Park KD 7225812

Pa

Pcw

Pcw/Pa




Park KD 7225812






Park KD 7225812




Park KD 7225812

Post PCI 5 Months FU





Park KW 708697

Acute Anterior MI, M/61, Time to reperfusion: 5 hrs, LVEF: 44%

Pre PCI Post PCI TIMI 3 TMPG 3


Ajou University Medical CenterPark KW 708697


Pa

Pcw

Pcw/Pa




Park KW 708697






Park KW 708697




Park KW 708697

Post PCI 4 Months FU




Angiographic Findings

0 ( 0.0%)0 ( 0.0%)Grade 3Grade 3

16(61.5%)16(61.5%)Grade 0Grade 06 (21.3%)6 (21.3%)Grade 1Grade 14 (15.4%)4 (15.4%)Grade 2Grade 2

Collateral FlowCollateral Flow

3.46 3.46 ±± 0.430.43Reference Vessel Size (mm)Reference Vessel Size (mm)9 9 ±± 55DS (%)DS (%)

PostPost--PCI (Stent)PCI (Stent)3.14 3.14 ±± 0.380.38MLD (mm)MLD (mm)

92 92 ±± 1010DS (%)DS (%)0.30 0.30 ±± 0.330.33MLD (mm)MLD (mm)

PrePre--PCIPCI



Post PCI TIMI and TMP Grades

0

5

10

15

20

25

0/1 2 3

Post PCI TIMI

No

0

5

10

15

0/1 2 3

Post PCI TMPG

No

5(19.2)

21(80.8)

7(26.9) 7(26.9)

12(46.2)



Physiologic and PET Findings

0.30 0.30 ±± 0.100.10PcwPcw/Pa/Pa

49.9 49.9 ±± 14.514.5%FDG Uptake (%)%FDG Uptake (%)

29.5 29.5 ±± 10.810.8PcwPcw (mmHg)(mmHg)

1.80 1.80 ±± 0.660.66CFRCFR

2.90 2.90 ±± 1.531.53hMVRIhMVRI (mmHg.cm(mmHg.cm-1.sec.sec-1))

685.6 685.6 ±± 340.0340.0hDDThDDT (ms)(ms)

644.7 644.7 ±± 360.2360.2bDDTbDDT (ms)(ms)

Total Patients(26)Total Patients(26)



Viability on PET %FDG Uptake and Angiographic Parameters

0

10

20

30

40

50

60

70

0/1 2 3

0

10

20

30

40

50

60

70

0/1 2 3

37.3±8.4

52.9±14.1

37.7±9.045.7±11.2

59.5±12.6FDG % FDG %

P=0.028 P=0.002

Post PCI TIMI Post PCI TMPG



MVRI

876543210

FDG

(%)

90

80

70

60

50

40

30

20

100

post-stent CFR

4.03.02.01.00.0

FDG

(%)

90

80

70

60

50

40

30

20

100

r= 0.681r= 0.681P<0.001P<0.001

r= r= --0.4140.414p=0.045p=0.045

Viability on PET %FDG Uptake and Physiologic Parameters



bDDT(ms)

160012008004000

FDG

(%)

90

80

70

60

50

40

30

20

100

hDDT(ms)

2000160012008004000

FDG

(%)

90

80

70

60

50

40

30

20

100

r= 0.607r= 0.607p=0.002p=0.002

r= 0.653r= 0.653p=0.001p=0.001




Pcw(mmHg)

706050403020100

FDG

(%)

908070605040302010

0

Pcw/Pa

.7.6.5.4.3.2.10.0

FDG

(%)

90

80

70

60

50

40

30

20

100

r= r= --0.4720.472p=0.020p=0.020

r= r= --0.4670.467p=0.021p=0.021




Patients without Collaterals Patients with Collaterals


Pcw(mmHg)

403020100FD

G(%

)

70

60

50

40

30

20

10

0

Pcw(mmHg)

706050403020100

FDG

(%)

90

80

70

60

50

40

30

20

100

r= 0.075r= 0.075p=0.861p=0.861

r= r= --0.5370.537p=0.032p=0.032



Viability on PET Clinical Characteristics

__________________________________________________________

Viable(11) Non Viable(15) p value__________________________________________________________

Age 56 ± 15 56 ± 12 0.929Gender (Male, %) 9(81.8%) 13(86.7%) 1.000Hypertension 4(36.4%) 8(53.3%) 0.453Diabetes 3(27.3%) 4(26.7%) 1.000Smoking 7(63.6%) 11(73.3%) 0.683Dyslipidemia 1(9.1%) 2(13.3%) 1.000

CK 1801 ± 1742 4311 ± 3815 0.081CK-MB 204 ± 190 321 ± 151 0.126

LVEF(%) 55 ± 10 47 ± 11 0.078RWMSI 1.30 ± 0.18 1.69 ± 0.38 0.002%FDG Uptake 63.8 ± 9.0 39.8 ± 7.7 <0.001

__________________________________________________________Myocardial viability threshold: 50% or more uptake of 18F-FDG



Viability on PET Angiographic Characteristics

________________________________________________________

Viable(11) Non Viable(15) P value________________________________________________________

IRA 0.484LAD 7(63.6%) 11(73.3%)RCA 1(9.1%) 0(0.0%)LCx 3(27.3%) 4(26.7%)

Pre-PCIMLD (mm) 0.49 ± 0.35 0.17 ± 0.26 0.016DS (%) 86.2 ± 10.2 95.1 ± 7.5 0.017

Post-PCIMLD (mm) 3.20 ± 0.35 3.10 ± 0.41 0.528DS (%) 9.7 ± 4.7 9.2 ± 4.7 0.785

Ref. VD (mm) 3.56 ± 0.31 3.39 ± 0.48 0.323

________________________________________________________Myocardial viability threshold: 50% or more uptake of 18F-FDG



Viability on PET Physiologic Parameters

________________________________________________________

Viable (11) Non-Viable (15) p Value________________________________________________________

bDDT 854 ± 366 495 ± 280 0.012

hDDT 865 ± 334 557 ± 292 0.025

hMVRI 2.14 ± 0.72 3.60 ± 1.68 0.009

CFR 2.30 ± 0.62 1.45 ± 1.41 0.001

Pcw 23.3 ± 5.12 32.6 ± 11.6 0.042

Pcw/Pa 0.25 ± 0.05 0.33 ± 0.12 0.088________________________________________________________

Myocardial viability threshold: 50% or more uptake of 18F-FDG



Agreement between Angiographic/Physiologic Parameters and Viability on PET

0.4170.41766.766.777.877.870.870.8PcwPcw (26)(26)

0.5890.58971.471.490.090.079.279.2MVRI (2.64)MVRI (2.64)

0.5000.50071.471.480.080.075.075.0hDDThDDT (560)(560)

0.6670.66778.678.690.090.083.383.3CFR (1.5)CFR (1.5)

0.6570.65785.785.780.080.083.383.3bDDTbDDT (637)(637)

0.2800.28053.353.377.877.862.562.5PcwPcw/Pa (0.31)/Pa (0.31)

0.7760.77686.786.790.990.988.588.5TMPG(0TMPG(0--2/3)2/3)

0.2970.29733.333.3100.0100.061.561.5TIMI(0TIMI(0--2/3)2/3)

κκ valuevalueSpecificitySpecificitySensitivitySensitivityAgreementAgreementParametersParameters

( ) best cut-off value from receiver operating curve analysis



Conclusions

•• In AMI patients who received PCI, onIn AMI patients who received PCI, on--site site coronary angiographic coronary angiographic and physiologic indices including, and physiologic indices including, –– TIMI myocardial perfusion gradeTIMI myocardial perfusion grade–– Deceleration time of diastolic flow velocityDeceleration time of diastolic flow velocity–– MicrovascularMicrovascular resistance indexresistance index–– Coronary flow velocity reserveCoronary flow velocity reserve–– Coronary wedge pressure Coronary wedge pressure

showed significant correlations with myocardial viability onshowed significant correlations with myocardial viability on 1818FF--FDG PET imaging, and should be considered as important FDG PET imaging, and should be considered as important prognostic factors.prognostic factors.

•• Simply assess myocardial viability and prognosis with a little Simply assess myocardial viability and prognosis with a little longer final angiography after primary PCI longer final angiography after primary PCI ……



Agreement between Angiographic Parameters and Viability on PET

<0.001<0.001Post PCIPost PCITMPGTMPG

13131100--22

22101033

15151111

Post PCIPost PCITIMITIMI

15151111

1111111133

550000--220.0530.053

pp--valuevalueNonNon--ViableViableViableViable



CFR

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV BCV 1.5 1.5 Sensitivity : 90.0%Sensitivity : 90.0%Specificity : 78.6%Specificity : 78.6%AUC : 0.879AUC : 0.879

(0.681(0.681--0.974)0.974)

MVRI

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV 2.64BCV 2.64Sensitivity : 90.0%Sensitivity : 90.0%Specificity : 71.4%Specificity : 71.4%AUC : 0.786AUC : 0.786

(0.572(0.572--0.924)0.924)

Agreement between Physiologic Parameters and Viability on PETReceiver Operating Curve Analysis



bDDT

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV 637 msBCV 637 msSensitivity : 80.0%Sensitivity : 80.0%Specificity : 85.7%Specificity : 85.7%AUC : 0.789AUC : 0.789

(0.567(0.567--0.926)0.926)

hDDT

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV 560 msBCV 560 msSensitivity : 80.0%Sensitivity : 80.0%Specificity : 71.4%Specificity : 71.4%AUC : 0.761AUC : 0.761

(0.544(0.544--0.909)0.909)




Pcw

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV 26 mmHgBCV 26 mmHgSensitivity : 87.5%Sensitivity : 87.5%Specificity : 68.7%Specificity : 68.7%AUC : 0.777AUC : 0.777

(0.563(0.563--0.919)0.919)

Pcw/Pa

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sen

sitiv

ity

BCV BCV 0.310.31Sensitivity : 87.5%Sensitivity : 87.5%Specificity : 56.2%Specificity : 56.2%AUC : 0.750AUC : 0.750

(0.533(0.533--0.902)0.902)




ConclusionsConclusions

•• In AMI patients who received PCI, onIn AMI patients who received PCI, on--site site coronary angiographic and coronary angiographic and physiologic indices including, physiologic indices including, –– TIMI myocardial perfusion gradeTIMI myocardial perfusion grade–– Deceleration time of diastolic flow velocityDeceleration time of diastolic flow velocity–– MicrovascularMicrovascular resistance indexresistance index–– Coronary flow velocity reserveCoronary flow velocity reserve–– Coronary wedge pressure Coronary wedge pressure

showed significant correlations with myocardial viability onshowed significant correlations with myocardial viability on 1818FF--FDG FDG PET imaging, and should be considered as important prognostic PET imaging, and should be considered as important prognostic factors.factors.

•• Simply assess myocardial viability and prognosis with a little lSimply assess myocardial viability and prognosis with a little longer onger final angiography after primary PCI !final angiography after primary PCI !



0

10

20

30

40

50

60

CFR>1.5 CFR ≤≤1.51.5

57±14

43±10

p=0.009FDG(%)

0

10

20

30

40

50

60

MVRI>2.64 MVRI ≤≤2.642.64

57±14

42±9

p=0.008FDG(%)

Degree of FDG-UptakePhysiologic Parameters



0

10

20

30

40

50

60

70

bDDT>637 ms bDDT ≤≤637 ms637 ms

62±11

42±11

p=0.001FDG(%)

0

10

20

30

40

50

60

57±14

42±11

p=0.014FDG(%)

hDDT>560 ms hDDT ≤≤560 ms560 ms




0

10

20

30

40

50

60

Pcw >26 mmHgPcw ≤≤26 mmHg26 mmHg

56±15

44±13

p=0.052FDG(%)

0

10

20

30

40

50

60

52±1646±14

p=0.297

Pcw/Pa >0.31Pcw/Pa ≤≤0.310.31

FDG(%)




PET Imaging

•• Discovery ST, Combined PET and CT Scan, GE medical system, USA Discovery ST, Combined PET and CT Scan, GE medical system, USA

•• PET imaging was performed 1 week after PCI by routine protocol.PET imaging was performed 1 week after PCI by routine protocol.

•• 50 g of oral glucose(50% Dextrose solution 100cc) are given 1 ho50 g of oral glucose(50% Dextrose solution 100cc) are given 1 hour before FDG(ur before FDG(1818FF--Fluorodeoxyglucose) injection.Fluorodeoxyglucose) injection.

•• 30 minutes after FDG 370 MBq(10 30 minutes after FDG 370 MBq(10 mCimCi) injection PET/CT images obtained.) injection PET/CT images obtained.

•• Perfusion and FDG images are analyzed by quantitative activity pPerfusion and FDG images are analyzed by quantitative activity profile analysis similar to rofile analysis similar to that used in SPECT image processing.that used in SPECT image processing.

•• %FDG was obtained from dividing the summed %FDG perfusion scores%FDG was obtained from dividing the summed %FDG perfusion scores in the risk area in the risk area by the number of segments of infarct territory.by the number of segments of infarct territory.



0.0530.053

0 (0)0 (0)0 (0)0 (0)0~10~1Post PCIPost PCI

TIMITIMI 5 (33.3)5 (33.3)0 (0)0 (0)22

11 (66.7)11 (66.7)11 (100)11 (100)33

15151111

Pre PCIPre PCITIMITIMI

15151111

2 (13.3)2 (13.3)3 (27.3)3 (27.3)33

2 (13.3)2 (13.3)5 (45.4)5 (45.4)22 0.0620.062

11 (73.4)11 (73.4)3 (27.3)3 (27.3)0~10~1

PP--valuevalueNonNon--ViableViableViableViable

Viability on PET TIMI Epicardial Flow



Viability on PET TIMI Myocardial Perfusion Grades

<0.001<0.001

7 (46.7)7 (46.7)0 (0)0 (0)0~10~1Post PCIPost PCI

TMPGTMPG 6 (40.0)6 (40.0)1 (9.1)1 (9.1)22

2 (13.3)2 (13.3)10 (90.9)10 (90.9)33

7777

Pre PCIPre PCITMPGTMPG

15151111

0 (0)0 (0)2 (28.6)2 (28.6)33

0 (0)0 (0)1 (14.3)1 (14.3)22 0.1480.148

7 (100)7 (100)4 (57.1)4 (57.1)0~10~1

PP--valuevalueNonNon--ViableViableViableViable

Documents

Coronary Angiographic and Intracoronary Flow Patterns … · Coronary Angiographic and Intracoronary Flow Patterns ... as a reference standard for myocardial viability. • This study