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Value of Index of Microvascular Resistance (IMR) in Microvascular
Integrity
Value of Index of Microvascular Value of Index of Microvascular Resistance (IMR) in Microvascular Resistance (IMR) in Microvascular
IntegrityIntegrity
Seung-Woon Rha, Korea University Guro Hospital,Myeong-Ho Yoon, Ajou University Hospital
Imaging & Physiology Summit 2009 Nov 20, 2009
Microvascular IntegrityMicrovascular Integrity
TMP gradeTMP gradeTMP grade
PcwPcw
• CFR• DDT, SAPV
• MVRI
•• CFRCFR•• DDT, SAPVDDT, SAPV
•• MVRIMVRI
To date, a simple and invasive method for assessing the integrity of coronary
microcirculation and myocardial viability in patients with AMI immediately after
primary angioplasty is lacking.
To date, a simple and invasive method for assessing the integrity of coronary
microcirculation and myocardial viability in patients with AMI immediately after
primary angioplasty is lacking.
Assessment of MicrovasculatureAssessment of Microvasculature
1. Noninvasive imaging
; Contrast Echo, MRI, RI scan, PET…
2. ECG; ST segment resolution
3. Coronary Angiography
;TIMI myocardial perfusion grade
4. Physiologic Studies
1) Coronary flow reserve,
2) other Doppler parameters
3) Index of Microcirculatory Resistance (IMR)
Microvascular resistanceMicrovascular resistance
PaPa
Collateral flow Collateral flow and pressureand pressure
PvPvPdPd
Microvascular circulationMicrovascular circulation-- Cell necrosisCell necrosis-- Cell edemaCell edema-- WBC, thrombotic materialsWBC, thrombotic materials
and platelets packingand platelets packing-- Spasm Spasm …………
Microvascular IntegrityMicrovascular Integrity
TmnTmnRR
MethodsMethods
Intracoronary Pressure WireIntracoronary Pressure Wire(Radi Medical System, Uppsala, Sweden)(Radi Medical System, Uppsala, Sweden)Pa (mean Ao pr.), Pd (mean distal coronary pr.)Pa (mean Ao pr.), Pd (mean distal coronary pr.)TTmnmn (mean transit time)(mean transit time)Pcw (coronary wedge pressure), PcwPcw (coronary wedge pressure), Pcw--Pa ratio (Pcw/Pa)Pa ratio (Pcw/Pa)Thermodilution CFR = hyperemic TThermodilution CFR = hyperemic Tmnmn / basal T/ basal Tmnmn
FFR = hyperemic Pd / hyperemic PaFFR = hyperemic Pd / hyperemic PaIMR = Pd IMR = Pd hyperemic Thyperemic Tmnmn
Measurement of coronary pressure parametersMeasurement of coronary pressure parametersMeasurement of coronary pressure parameters
Intracoronary Doppler MeasurementsIntracoronary Doppler Measurements
Measurement of CFRMeasurement of CFR
Intracoronary Doppler MeasurementsIntracoronary Doppler Measurements
Measurement of DDTMeasurement of DDT
2 sec
240
0
120
cm/s
Intracoronary Pressure MeasurementsIntracoronary Pressure Measurements
ThrombusThrombus
Equalization : G/C pressure with the sensor
Equalization : Equalization : G/C pressure G/C pressure with the sensorwith the sensor
bPdbPd
bPabPa
PcwPcwhPdhPd
hPahPa
hPd/hPa = FFRhPd/hPa = FFRhPd/hPa = FFR
bTmnbTmnhTmnhTmn
bTmn/hTmn = CFRthermo
bTbTmnmn/hT/hTmnmn = = CFRCFRthermothermo
Pd hTmn = IMRPdPd hThTmnmn = = IMRIMR
SalineSalineSalineSalineSalineSaline
AdenosineAdenosine
IMRIMR
Resistance = ∆ Pressure / Flow
1 / Tmn ≅ Flow
IMR = (Pd – Pv) / (1 / Tmn)
IMR = Pd Tmn
at maximal hyperemia…
Resistance = ∆ Pressure / Flow
1 / Tmn ≅ Flow
IMR = (Pd – Pv) / (1 / Tmn)
IMR = Pd Tmn
at maximal hyperemia…
Derivation of Index of Microcirculatory Resistance (IMR)Derivation of Index of Microcirculatory Resistance (IMR)Derivation of Index of Microcirculatory Resistance (IMR)
Adapted from: Pijls and De Bruyne, Coronary PressureKluwer Academic Publishers, 2000
• Clearly defined normal value• Not affected by resting hemodynamics
• Easy to perform
FFR vs. CFRFFR vs. CFR
IMRIMR
Derivation of Index of Microcirculatory Resistance (IMR)Derivation of Index of Microcirculatory Resistance (IMR)Derivation of Index of Microcirculatory Resistance (IMR)
0 50 100 150 200 250 300Absolute flow (ml/min)Absolute flow (ml/min)
1 / T
mn
1 / T
mn
0
1.0
2.0
3.0
IMRIMR
0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8
TMR (mmHg/ml/min)TMR (mmHg/ml/min)
80
70
60
50
40
30
20
10
0
IMR
(mm
Hg·
s)IM
R (m
mH
g·s)
Correlation between IMR and TMR at 24 different combinations of myocardial resistance and epicardial stenosis severity
Correlation between IMR and TMR at 24 different combinations of Correlation between IMR and TMR at 24 different combinations of myocardial resistance and epicardial stenosis severitymyocardial resistance and epicardial stenosis severity
Aarnoudse, Fearon et al. Catheter Cardiovasc Interv. 2004;62(1):56-63.
Reproducibility of IMRReproducibility of IMR
Cor
rela
tion
with
bas
e lin
eC
orre
latio
n w
ith b
ase
line
IMRIMR CFRCFR FFRFFR
1.0
0.8
0.6
0.4
0.2
0.0
Martin et al. Circulation 2006;113;2054-2061
Mean correlation coefficients of IMR, CFR, FFR values comparing baseline measurements with each hemodynamic intervention
Mean correlation coefficients of IMR, CFR, FFR values comparing Mean correlation coefficients of IMR, CFR, FFR values comparing baseline measurements with each hemodynamic interventionbaseline measurements with each hemodynamic intervention
repeat baseline / RV pacing at 110 bpm nitroprusside infusion / dobutamine infusion
repeat baseline / RV pacing at 110 bpm repeat baseline / RV pacing at 110 bpm nitroprusside infusion / dobutamine infusionnitroprusside infusion / dobutamine infusion
Microvascular Integrity in AMIMicrovascular Integrity in AMI
The preservation of the microvascular functions (microvascular integrity) is an important determinants of improvement of the left ventricular function and clinical outcomes after PCI in AMI.
The indices of microvascular integrity were related with clinical outcomes of AMI patients.
Coronary flow reserve, Phasic coronary flow velocity pattern, Microvascular resistance index
: Index of microvascular resistance (IMR) Coronary capillary wedge pressure
Microvascular IntegrityMicrovascular Integrity
Gibson et al. Circulation 2000;101;125-130
Epicardial TIMI 3 flow
9
0
Mor
talit
y (%
)
Epicardial TIMI 2/1/0 flow
TMPG 3 TMPG 0/1/2
9
0
Mor
talit
y (%
)
TMPG 3 TMPG 0/1/2
p = 0.04
4 way p = 0.008
0.7%
4.7%
7.4%
4.7%
6.8%
3.5%
n = 455 n = 294
Relationship of both TIMI grade and TMP grade to 30-day mortalityRelationship of both TIMI grade and TMP grade to 30Relationship of both TIMI grade and TMP grade to 30--day mortalityday mortality
Microvascular IntegrityMicrovascular Integrity
After successful primary PCI for AMI, CFRperformed before discharge was correlated with 201Tl SPECT redistribution patterns and late LV contractility recovery.
F. Beygui et al., J Am Coll Cardiol 2002;40:877
Phasic Coronary flow velocity parameters or patterns is useful in predicting recovery of regional LV function.
Deceleration time of diastolic flow velocity (DDT) > 600msSystolic average peak velocity (SAPV) > 6.5 cm/sec
Akasaka et al. Circulation 1999;100:339
Microvascular IntegrityMicrovascular Integrity
The parameter that correlates best with residual myocardial viability is coronary wedge pressure (Pcw) and this may be a useful index for predicting patient prognosis.
Shimada et al. Heart 2003;89:71–76
In AMI, collateral flow index (CFIp) seems to increase with the severity of microvascular dysfunction. Because higher CFIp was associated with poorer functional recovery, it provides a simple and useful estimate of clinical outcomes in AMI.
Yamamoto et al. J Am Coll Cardiol 2001;38:1383-9
Correlation between IMR and Peak CKCorrelation between IMR and Peak CK
0
1000
2000
3000
4000
5000
6000
7000
0 25 50 75 100 125 150 175
IMR
CK
R=0.54
P <0.001*
R p
CFR .26 0.22
TFG .13 0.50cTFC .09 0.65TMPG .027 0.89ST res .16 0.42
Shah et al. AHA 2006
Peak CK and IMRPeak CK and IMR
0
1000
2000
3000
4000
IMR <35 IMR>35
Peak
CK
P <0.001
1209 ±966
3387 ±1531
Shah et al. AHA 2006
FollowFollow--Up Ejection Fraction and IMRUp Ejection Fraction and IMR
0
10
20
30
40
50
60
70
IMR < 35 IMR > 35
Ejec
tion
Frac
tion
(%)
P = 0.01
57.5 ±12
46.1 ±8
Shah et al. AHA 2006
FollowFollow--Up Echo Wall Motion Score and IMRUp Echo Wall Motion Score and IMR
18.6
27.5
0
5
10
15
20
25
30
IMR < 35 IMR > 35
Wal
l Mot
ion
Scor
e
P = 0.01
Shah et al. AHA 2006
IMR and Microvascular DamagesIMR and Microvascular Damages
TwentyTwenty--nine patients with STEMI treated with primary nine patients with STEMI treated with primary stenting.stenting.
IMR above the median level of 32 had greater peak CK IMR above the median level of 32 had greater peak CK (3128(3128±±1634 vs. 12011634 vs. 1201±±911 IU, p=0.002)911 IU, p=0.002)
IMRIMRrr pp
Peak CKPeak CK 0.540.54 0.0040.004Neutrophil %Neutrophil % 0.520.52 0.010.01
TMPGTMPG --0.420.42 0.030.03CFRCFR --0.430.43 0.030.03cTFCcTFC 0.540.54 0.0040.004
Fearon W et al. J Am Coll Cardiol 2008;51:560–5
ThreeThree--Month Wall MotionMonth Wall MotionScore With Low Versus High IMRScore With Low Versus High IMR
Fearon W et al. J Am Coll Cardiol 2008;51:560–5
Relation Between Change in WMS and Relation Between Change in WMS and IMRIMR
Fearon W et al. J Am Coll Cardiol 2008;51:560–5
Correlation between the IMR & percent Correlation between the IMR & percent change in Achange in A--WMSWMS
recovery of LV wall motion (–)
recovery of LV wall motion (+)
CutCut--off value of the IMR for predicting LV off value of the IMR for predicting LV wall motion recoverywall motion recovery
Sensitivity 73%Sensitivity 73%Specificity 100%Specificity 100%
Accuracy 89%Accuracy 89%
IMR and Changes of WMSIMR and Changes of WMS
Comparison of percent change in A-WMS in patientspresenting with an IMR ≤ 33 U and those presenting with
an IMR > 33 U
Comparison of percent change in AComparison of percent change in A--WMS in patientsWMS in patientspresenting with an IMR presenting with an IMR ≤≤ 33 U and those presenting with33 U and those presenting with
an IMR > 33 Uan IMR > 33 U
Correlation between the IMR and RegionalCorrelation between the IMR and RegionalFDG uptake imaged by PETFDG uptake imaged by PET
recovery of LV wall motion (–)recovery of LV wall motion (+)
FDG uptake with an IMR FDG uptake with an IMR ≤≤ 33 U and those 33 U and those presenting with an IMR > 33 Upresenting with an IMR > 33 U
Case 1 : CAGCase 1 : CAG
M/64 STEMI (ant.), onset to balloon time - 120 minM/64 STEMI (ant.), onset to balloon time - 120 min
Pre PCIPre PCI Post PCIPost PCI
Case 1 : IMRCase 1 : IMR
IMR : 11.7 U, CFRthermo : 2.0IMR : 11.7 U, CFRthermo : 2.0M/64 STEMI (ant.)M/64 STEMI (ant.)
Case 1 : FDG PETCase 1 : FDG PET
Myocardial Viability : FDG PET Myocardial Viability : FDG PET Myocardial Viability : FDG PET
FDG Uptake = 70.7%FDG Uptake = 70.7%
Case 1 : EchocardiogramCase 1 : Echocardiogram
After primary PCIAfter primary PCI
66‐‐mo followmo follow‐‐upup
Percent change in APercent change in A‐‐WMS: 42.1%WMS: 42.1%
Case 2 : CAGCase 2 : CAG
M/60 STEMI (ant.), onset to balloon time - 600 minM/60 STEMI (ant.), onset to balloon time - 600 min
Pre PCIPre PCI Post PCIPost PCI
Case 2 : IMRCase 2 : IMR
IMR : 72.3 U, CFRthermo : 1.7 IMR : 72.3 U, CFRthermo : 1.7 M/60 STEMI (ant.)M/60 STEMI (ant.)
Case 2 : FDG PETCase 2 : FDG PET
FDG Uptake = 37.4% FDG Uptake = 37.4%
Myocardial Viability : FDG PET Myocardial Viability : FDG PET Myocardial Viability : FDG PET
Case 2 : EchocardiogramCase 2 : Echocardiogram
After primary PCIAfter primary PCI
66‐‐mo followmo follow‐‐upup
Percent change in APercent change in A‐‐WMS: WMS: ‐‐8.3%8.3%
Advantage of IMRAdvantage of IMR
Highly reproducible index which is not affected hemodynamic conditons
IMR has good correlation with absolute coronary blood flow and true microvascular reistance
Limitations of IMRLimitations of IMR
• Lack of optimal cutoff value about microvascular dysfunction
• Additional procedure for inducing hyperemia• No large randomized clinical data
ConclusionsConclusions
IMR, a novel index representing the microvascular integrity, is a reliable parameter for the invasive, on-site assessment of myocardial viability after
primary PCI in AMI.
IMR, a novel index representing the microvascular IMR, a novel index representing the microvascular integrity, is a reliable parameter for the invasive, integrity, is a reliable parameter for the invasive, onon--site assessment of myocardial viability after site assessment of myocardial viability after
primary PCI in AMI.primary PCI in AMI.
What do interventionists need in clinical practice?
1) Epicardial Vessel FFR
2) Microvasculature IMR!!
Research Fellow 2009Research Fellow 2009
Dr Ramasamy, Dr Poddar from India RN, Seo Young ParkKorean Research Fellow, Ji Young Park
Dr Wang from Tianjin, China
Thank You for Your Attention!! Thank You for Your Attention!!
Korea University Guro Hospital
Korea University Guro Hospital