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Potential Protective Effect of High CoronaryWedge Pressure on Left Ventricular Function

After Coronary OcclusionBernard de Bruyne, MD, Bernhard Meier, MD, Leo Finci, MD,

Philip Urban, MD, and Wilhelm Rutishauser, MD

To assess the potential of coronary collateral circulation to protect myocardium after occlusion ofa coronary vessel, the mean coronary wedge pressure, the angiographic grade of collateral channels,and the left ventricular function were studied in 47 consecutive patients with mechanical recanali-zation of totally occluded coronary arteries. Coronary wedge pressure measurements were obtained39 51 days (range, 2 hours to 361 days) after the presumed time of occlusion. The patients weredivided into two groups: 31 with a coronary wedge pressure more than 30 mm Hg (group 1) and 16with a coronary wedge pressure of or less than 30 mm Hg (group 2). Patients in group 1 had asignificantly higher mean global left ventricular ejection fraction than those in group 2 (63 9% vs.49+±7%, p<0.001). Regional left ventricular function (artery-related area change) was alsosuperior in group 1 compared with group 2 (47±11% vs. 36+10%, p<0.01). Global leftventricular function was significantly correlated to coronary wedge pressure (r= 0.51, p<0.001) butnot to the angiographic presence of collaterals. The data suggest that a high coronary wedgepressure is associated with improved left ventricular function after coronary artery occlusion andthat coronary wedge pressure more accurately reflects the physiological role of collaterals than theirangiographic presence. (Circulation 1988;78:566-572)

T he functional importance of collateral coro-nary circulation in patients with coronaryartery disease remains controversial. Col-

laterals are angiographically demonstrable only ifsevere coronary artery disease is present.' Severalinvestigators have failed to demonstrate a long-termbeneficial effect of collaterals on left ventricularfunction.1-5 Other studies suggest that in patientswith severe coronary artery stenoses or occludedcoronary arteries, collaterals may have a protectiverole concerning myocardial function.6-16 However,most of the available clinical data originate frompostmortem or angiographic studies.

Experimentally, the coronary collateral circula-tion has been studied mainly in the dog heart.Because collaterals are more developed in dogsthan in healthy humans, the results can not neces-sarily be extrapolated to the human coronary circu-lation. The hemodynamics of coronary collateralshave been studied directly in humans during aorto-coronary bypass surgery,17 and, more recently, the

From the Cardiology Center, University Hospital, Geneva,Switzerland.Address for correspondence: B. Meier, MD, Cardiology Cen-

ter, University Hospital, 1211 Geneva 4, Switzerland.Received November 20, 1987; revision accepted April 28,

1988.

pressure distally to coronary lesions was measuredduring percutaneous angioplasty18-22 and the rela-tion of the coronary wedge pressure (pressure in thedistal part of the occluded artery) to spontaneouslyvisible and recruitable collaterals has been estab-lished.22 To evaluate the protective role of thecoronary collateral circulation, we studied the rela-tion between the mean coronary wedge pressuremeasured during percutaneous transluminal coro-nary angioplasty and the left ventricular function inpatients with occlusion of a major coronary vessel.

Patients and MethodsPatients

Coronary wedge pressure measurements weredone in 53 of 108 consecutive patients with attemptedrecanalization of a total coronary occlusion. Fourpatients with a previous myocardial infarction in aregion other than that supplied by the attemptedvessel were excluded. Two additional patients wereexcluded because of unsatisfactory quality of theleft ventriculogram. The remaining 47 patients con-stituted the study population. Among them, 13patients underwent mechanical recanalization dur-ing the acute phase of a myocardial infarction. Theremaining 34 underwent an elective procedure for a

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de Bruyne et al Coronary Wedge Pressure and LV Function 567

chronic total occlusion. The date of occlusion wassupposed to be the moment of the acute infarction.In patients without clinically documented acutemyocardial infarction, the most marked change inanginal symptoms was considered as the occlusiondate. Thirty-seven patients had clinically docu-mented myocardial infarction. In four additionalpatients, a clear moment of unstable angina wasnoted. In six patients, no such acute coronary eventwas found, and the date of occlusion remainedundetermined. Twenty patients with normal coro-nary arteries and normal left ventricular functionserved as a control group for angiographic evalua-tion of the regional left ventricular function.

Angiography and AngioplastyPercutaneous transluminal coronary angioplasty

was done by the femoral approach as previouslydescribed.23 Steerable dilatation catheters (Schnei-der Shiley, Zurich, Switzerland) were used in allcases. The balloon sizes ranged from 2.5 to 3.4 mm,and their internal luminal diameters ranged from0.39 to 0.55 mm.The diagnostic angiograms were performed 11 ± 23

days (range, 1-140 days) before angioplasty for thepatients with elective procedures (n = 34); eightpatients had recanalization of the occluded arterysimultaneously with the diagnostic angiogram, 20within 7 days after the diagnostic angiogram, andsix patients had delayed angioplasty at 10, 18, 29,32, 54, or 140 days.The extent of the collateral circulation on the

initial angiogram was assessed by two indepen-dent observers according to the classification ofRentrop et a124: 0, no visible filling of any collateralchannels; 1 +, collateral filling of branches of theoccluded vessel without any dye reaching theepicardial segment of the occluded vessel; 2+,partial collateral filling of the epicardial segment ofthe occluded vessel; and 3+, complete collateralfilling of the occluded vessel. All patients receivedeither intravenous, intracoronary, or sublingualnitrates before angioplasty.

Coronary Wedge PressureCoronary wedge pressure was defined as the

mean distal coronary pressure measured at the tipof the dilatation catheter while the balloon wasinflated in the stenosis with a pressure of two bars.Correct position of the balloon was documented oncinefilm. The pressure was measured via the liquidcolumn of nonionic contrast medium in the centrallumen of the balloon catheter by a Statham P23Gstrain gauge (Statham Instruments, Oxnard, Cali-fornia) and recorded on a photographic recorder(Model DR 16, Electronics for Medicine, WhitePlains, New York). The mean pressure was roundedoff to the next value dividable by 5 as soon as it hadleveled off. This took from 15 to 30 seconds depend-ing on the type of catheter used. Before eachprocedure, the pressure recording system was cal-

30` RIGHT ANTERIOR OBLIQUE PROJECTION

600 LEFT ANTERIOR

FIGURE 1. Diagram defining the nine myocardial regionsconsidered [i.e., five for the 300 right anterior oblique(RAO) projection andfourfor the 600 left anterior oblique(LAO) projection]. First, the respective centers ofgravity(Gd, Gs) and midaortic points of the end-diastolic andend-systolic RAO silhouettes are determined to define thezero reference line of each silhouette. Then, radii origi-nating from the center of gravity are drawn at 300, 900,150°, 2100, 2700, and 3000 from the zero reference line.These radii define the five labeled regions of the RAOsilhouettes: anterobasal (1), anterolateral (2), apical (3),diaphragmatic (4), and posterobasal (5). The same isdone for the LAO projection with the angles 600, 1200,180°, 240°, and 300°. This yields the four regions: poste-rior (6), posterolateral (7), distal septal (8), and proximalseptal (9).

ibrated to zero level at three fifths of the antero-posterior chest diameter above the table at the levelof the fourth intercostal space. A simultaneoustracing from guiding and dilatation catheters wasobtained just before advancing the latter into thecoronary tree. This allowed for checks for equical-ibration and leaks in the pressure lines.

Global and Regional Left Ventricular FunctionThe global and regional left ventricular ejection

fractions were evaluated from biplane ventriculo-

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568 Circulation Vol 78, No 3, September 1988

TABLE 1. Clinical and Angiographic Characteristics of 47 PatientsCWP >30 mm Hg CWP <30 mm Hg

(n=31) (n= 16) p

Age 56 + 8 52 10 NSMan:woman ratio 29:2 14:2 NSNumber of diseased vessels 1 25 (81%) 13 (81%) NS

2 5 (16%) 2 (12%) NS3 1 (3%) 1 (6%) NS

Occluded vessels LAD 17 (55%) 8 (50%) NSRCA 7 (23%) 5 (31%) NSLCx 7 (23%) 3 (19%) NS

Time since occlusion (days)* 36 42 45 90 NSTime from onset of symptoms to

occlusion (weeks)* 13 ± 11 5 8 <0.05

*Available in 41 of 47 patients. CWP, coronary wedge pressure; LAD, left anterior descending coronary artery:RCA, right coronary artery; LCx, left circumflex coronary artery; NS, not significant.

grams, performed before diagnostic coronary angio-grams or immediately before angioplasty. Filmingwas performed at 50 frames/sec during a powerinjection of 40-48 ml nonionic contrast mediumthrough a pigtail catheter over a period of 4 sec-onds. Left ventricular ejection fractions were deter-mined from end-diastolic and end-systolic contourswith the area-length method.25 Premature contrac-tions and the two following cycles were excludedfrom analysis. Left ventricular wall segments weredetermined as described in Figure 1. Regional leftventricular function was assessed for each segmentby computerized planimetry as follows: segmentalarea change (%) =(segmental end-diastolic area -segmental end-systolic area/segmental end-diastolicarea) x 100. The following relation between theoccluded arteries and the myocardial segment wasassumed: for the left anterior descending coronaryartery, the anterobasal, anterolateral, apical, distal

st80-p < 0.0001 0.001 0.001 NS

607

0~~~~~~~~~~~~~~~

t 70 T T,

50

40-'C'''D30 ...X n = 31 16: 17 .8. 7 .5 3.

CWP> 30 mmHg l :-:-iCWP <30 mmHgFIGURE 2. Bar charts of mean global left ventricularejection fraction for high (>30 mm Hg) and low (.30 mmHg) coronary wedge pressure (CWP). LAD, left anteriordescending coronary artery; LCX, left circumflex coronaryartery; RCA, right coronary artery; NS, not significant.

septal, and proximal septal segments; for the rightcoronary artery, the diaphragmatic, posterobasal,and posterolateral segment; and for the left circum-flex coronary artery, the posterior, posterolateral,and posterobasal segments.

StatisticsAll values are reported as mean ± SD. Differ-

ences in the distribution of age, sex, occludedvessel, and number of diseased vessels betweengroups were evaluated by V2 technique. Anunpaired t test was used to evaluate continuousvariables such as coronary wedge pressure, leftventricular ejection fraction, left ventricular end-diastolic pressure, artery-related area changes,delay between occlusion and angiography, delaybetween occlusion and coronary wedge pressuremeasurements, and duration of anginal symptoms.The correlation between coronary wedge pressureand left ventricular ejection fraction was evaluated

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FIGURE 3. Plot of relation between global left ventricu-lar ejection fraction and coronary wedge pressure.

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de Bruyne et al Coronary Wedge Pressure and LV Function 569

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Degree of visible collaterals 30.A . L 30--1IIGURE 4. Flot oj relation between coronary wedge

pressure and angiographic degree of collateralization.NS=not significant.

by a least-squares regression. Significance wasaccepted at the 5% probability level.

ResultsThe patients were separated into two groups

according to the level of coronary wedge pressure:group 1 consisted of 31 patients with a coronarywedge pressure in the occluded artery more than 30mm Hg (range, 35-65 mm Hg; mean, 45 ± 9 mm Hg)and group 2 consisted of 16 patients whose coro-nary wedge pressure in the occluded artery was 30mm Hg or less (range, 10-30 mm Hg; mean, 23 ±7mm Hg). The cutoff was done according to previ-ously published data.22 The baseline characteristicsof the two groups are summarized in Table 1. Therewas a similar distribution of sex, extent of coronaryartery disease, vessel distribution, and intervalbetween baseline ventriculography and measure-ment of the coronary wedge pressure. The percent-age of patients with acute myocardial infarction was

p70

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0-2 NS0-3 NS1-2 NS

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Degree of visible collaterals

FIGURE 5. Plot of global left ventricular ejection frac-tion for different angiographic degrees of collateraliza-tion. NS, not significant.

smaller in group 1 (23%, or seven of 31) than ingroup 2 (43%, or seven of 16), but the differencewas not statistically significant. Left ventricularend-diastolic pressure was lower in group 1 (12 ± 5vs. 15 ± 5 mm Hg in group 2). Again, the differencewas not statistically significant. The duration ofanginal symptoms until the presumed date of occlu-sion was significantly longer in group 1 (13±11weeks) than in group 2 (5 ± 8 weeks) (p<0.05).

Global Left Ventricular FunctionFigure 2 shows that the mean value of the global

left ventricular ejection fraction was significantlyhigher in group 1 (63 ± 9%) than in group 2 (49 ± 7%)(p<O.OOl). This difference remained significant whenonly the 34 patients with elective procedures were

NS NSmm1

FIGURE 6. Bar charts of occludedartery related regional left ventricularfunctionfor high (>30 mm Hg) and low(.30 mm Hg) coronary wedge pressureandfor normal controls. LAD, left ante-rior descending coronary artery; RCA,right coronary artery; LCX, left circum-flex coronary artery; CWP, coronarywedge pressure; NS, not significant.20

Normal CWP > 30 mmHg E:-:CWP . 30 mmHgcontrols

.

1L---- lt;L,

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570 Circulation Vol 78, No 3, September 1988

considered (62+10% vs. 48 ±6%; p<0.005). Theglobal left ventricular ejection fraction was alsohigher in group I than in group 2 when comparingpatients stratified to the vessel occluded (Figure 2).This difference, however, was not significant in thesubgroup with recanalization of the left circumflexcoronary artery. This may be attributed to the smallsize of this group. There was a significant correla-tion between the coronary wedge pressure and theglobal left ventricular ejection fraction: r=0.51,p<0.001 (Figure 3). Furthermore, with a cutoffvalue of the coronary wedge pressure at 30 mm Hg,it was possible to separate the patients with anormal global left ventricular function (ejectionfraction, -55%) from those with an impairedglobal left ventricular function. Although therewas a relation between the coronary wedge pres-sure and the angiographically determined extent ofcollateral circulation (Figure 4), the latter did notsignificantly correlate with the global left ventri-cular ejection fraction (Figure 5).

Regional Ejection FractionWall motion of the myocardial area related to the

occluded artery was better preserved albeit notnormal in group 1 with high compared with group 2with low coronary wedge pressure (Figure 6). Thedifference remained significant with separate analy-ses of the left anterior descending coronary arteryand the right coronary artery. The difference wasnot significant in the left circumflex group, probablybecause of the small number of patients.

DiscussionDespite anecdotal reports supporting the salutary

potential of coronary collateral circulation,26,27 itsbeneficial effect on left ventricular function inpatients with coronary heart disease has been ques-tioned by several investigators.1-5

Studies limited to occluded arteries support apositive correlation between the presence of coro-nary collaterals and preserved left ventricularfunction. 12,16.22 Recently, Saito et a113 found thatamong patients with successful thrombolysis, thosewith good collaterals showed more improvement inleft ventricular function (acute vs. late measure-ments) than those without. This improvement wasnot related to the delay between onset of symptomsand beginning of intracoronary lysis. In thesepatients, collaterals prevented complete infarctiondespite coronary occlusion during several hours.Two other studies emphasize the importance ofresidual flow attributed to subtotal occlusion orgood collaterals in the first hours of acute myocar-dial infarction.14,15The conclusions of these studies were, in gen-

eral, supported by angiographic evaluation of theextent of collaterals. Current angiographic equip-ment reveals only vessels with luminal diametersof at least 100 gm. Whether good angiographicvisualization represents good flow in a given ves-

sel remains an open issue. Angiography may notbe the best method to demonstrate the protectiveeffect of collaterals in patients.Coronary Wedge PressureA more physiological approach was provided by

hemodynamic evaluation of coronary collateral flowobtained in humans during aortocoronary bypasssurgery. 17 As previously validated in animal studies,28coronary pressure distally to an occlusion has beenconsidered to constitute an indicator of collateralfunction. More recently, four studies have reportedthe measurement of this pressure during percutaneouscoronary angioplasty.18-22 Coronary wedge pressurewas found to reflect fairly weHl the angiographicallyestimated degree of collateralization.22 We have shownthat the coronary wedge pressure not only reflectsalready visible collaterals but also recruitable collat-erals not visible on diagnostic angiograms.22 Further-more, an increased restenosis rate was reported to beassociated with both angiographically well-developedcollateral2' and a high coronary wedge pressure.29

In the present study, we have considered thedistal coronary pressure determined during percu-taneous balloon revascularization of totally occludedcoronary arteries as a functional indicator of collat-eral circulation. When performing pressure record-ings, the balloon catheter was not flushed withsaline. The coronary wedge pressure was measuredwith a column of contrast medium resulting in anonphasic (damped) pressure tracing correspondingto the mean distal pressure. Even investigatorsrecording more phasic pressures were prompted touse only the mean pressure for comparison betweenthe different groups because of important dampingof high-frequency components by the fluid-filledsystems and the small lumen of the cathetersused. 18,20

Besides coronary flow, there may be other signif-icant determinants of coronary wedge pressure. Inprevious studies,22 the coronary wedge pressurewas assessed at 15 and 60 seconds of coronaryocclusion during three consecutive balloon infla-tions and compared with the left ventricular end-diastolic pressure measured simultaneously with ahigh-fidelity manometer-tipped catheter introducedthrough the opposite femoral artery. There was nodifference in coronary wedge pressure assessed atthe beginning and at the end of a 60-second inflationcycle, whereas the left ventricular end-diastolicpressure increased. Moreover, in this series ofpatients, we found no difference in left ventricularend-diastolic pressure between groups 1 and 2, butthese values were not obtained simultaneously withcoronary wedge pressure measurements.The results indicate that the higher the perfusion

pressure provided by the collaterals, the better thesystolic wall motion of the occluded artery relatedsegment is preserved. Global left ventricular ejec-tion fraction was found to be higher in patients witha high coronary wedge pressure than in those with a

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de Bruyne et al Coronary Wedge Pressure and LV Function 571

low coronary wedge pressure. The differencebetween group 1 with high and group 2 with lowcoronary wedge pressure was more pronounced inpatients with occlusion of the left anterior descend-ing coronary artery than in patients with occlusionof the right coronary artery or the left circumflexcoronary artery. The small number of patients withocclusion of the right coronary artery or the leftcircumflex coronary artery may at least partiallyexplain the lesser extent of the positive effect of ahigh coronary wedge pressure. Furthermore, theleft anterior descending distribution in our analysisevaluates five regions of interest versus three regionsin the right and left circumflex coronary arterydistribution, respectively.Our data support the hypothesis that more than 30

mm Hg of coronary wedge pressure preserves somebut not all contractile function in the myocardial areadependent on an occluded artery. In contrast, wefound no significant correlation between left ventri-cular function and the angiographically determineddegree of coronary collateral circulation. This leadsus to conclude that coronary wedge pressure is amore accurate indicator of the protective role ofcoronary collaterals after coronary occlusion.

Limitations of StudyThe major limitation of such a study is the delay

between the occlusion of the vessel and the assess-ment of the coronary wedge pressure. It is probablethat the perfusion pressure derived from collater-als in the first minutes and hours after occlusion isthe most important determinant for myocardialprotection during acute myocardial infarction.Because the collateral flow is likely to increasewith time after coronary artery occlusion,30 it isprobable that some patients allocated to the groupwith high coronary wedge pressure did indeedhave a low coronary wedge pressure during thefirst hours of occlusion. This would only reinforceour conclusions.

All our patients were studied after administrationof either intravenous or sublingual nitrates, whichhave been shown to reduce collateral resistance inthe fibrillating heart.17 Their effect on collateralinflow in beating hearts as measured by the coro-nary wedge pressure has not been clarified.

ConclusionOur data suggest a relation between angiographi-

cally determined coronary collaterals and coronarywedge pressure. The results indicate that a highcoronary wedge pressure is associated with less-impaired left ventricular function after coronaryartery occlusion. Coronary wedge pressure seemsto be a better determinant of the protective role ofthe collaterals than does angiographic assessment.

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KEY WORDS * coronary wedge pressure * collaterals .

coronary occlusion * regional ventricular function

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B de Bruyne, B Meier, L Finci, P Urban and W Rutishauserafter coronary occlusion.

Potential protective effect of high coronary wedge pressure on left ventricular function

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1988 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/01.CIR.78.3.566

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