Assessment of the coronary microcirculation in the cardiac catheterisation laboratory

Abstract

The coronary microcirculation is a key determinant of blood supply to the myocardium and outweighs the epicardial arteries in its abundance and distribution. Recent studies have shown the clinical benefit of assessing the microcirculation, and this practice has now been given a recommendation within the latest international guidelines and consensus statements. However, the uptake of assessing the microcirculation remains low. We continue to focus our efforts in diagnosing and managing epicardial coronary disease in the cardiac catheterisation laboratory and mostly ignore the microvasculature. This is in large part due to the lack of familiarity with available tools to perform these assessments. This review aims to summarise the various techniques available to invasively assess the coronary microcirculation in the catheterisation laboratory. The advantages, disadvantages, pitfalls and clinical implications of each method are discussed.

Keywords

Coronary microvascular disease / microvascular angina / index of microcirculatory resistance / coronary physiology

References

[1] Ford TJ,Good R.Stratified medical therapy using invasive coronary function testing in Angina: the CorMicA trial.J Am Coll Cardiol2018;72:2841-55

[2] Ng MK,Ho M.The index of microcirculatory resistance predicts myocardial infarction related to percutaneous coronary intervention.Circ Cardiovasc Interv2012;5:515-22

[3] Fearon WF,Yong AS.Prognostic value of the Index of Microcirculatory Resistance measured after primary percutaneous coronary intervention.Circulation2013;127:2436-41 PMCID:PMC5429864

[4] Fearon WF,Ng M.Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction.J Am Coll Cardiol2008;51:560-5

[5] Knuuti J,Saraste A.2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.Eur Heart J2020;41:407-77

[6] Kunadian V,Camici PG.An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European society of cardiology working group on coronary pathophysiology & microcirculation endorsed by coronary vasomotor disorders international study group.EuroIntervention2021;16:1049-69

[7] Pustjens TFS,Damman P.Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): a position paper from the Dutch ACS working group.Neth Heart J2020;28:116-30 PMCID:PMC7052103

[8] Schelbert HR.Anatomy and physiology of coronary blood flow.J Nucl Cardiol2010;17:545-54 PMCID:PMC2906723

[9] Feher A.Quantitative assessment of coronary microvascular function: dynamic single-photon emission computed tomography, positron emission tomography, ultrasound, computed tomography, and magnetic resonance imaging.Circ Cardiovasc Imaging2017;10:e006427 PMCID:PMC5678979

[10] Pries AR,Bugiardini R.Coronary vascular regulation, remodelling, and collateralization: mechanisms and clinical implications on behalf of the working group on coronary pathophysiology and microcirculation.Eur Heart J2015;36:3134-46

[11] Pries AR.Coronary microcirculatory pathophysiology: can we afford it to remain a black box?.Eur Heart J2017;38:478-88 PMCID:PMC5381591

[12] Sorop O,Chandler S.Experimental animal models of coronary microvascular dysfunction.Cardiovasc Res2020;116:756-70 PMCID:PMC7061277

[13] Sugisawa J,Takeuchi M.Beneficial effects of exercise training on physical performance in patients with vasospastic angina.Int J Cardiol2021;328:14-21

[14] Nishi T,Ciccarelli G.Prognostic value of coronary microvascular function measured immediately after percutaneous coronary intervention in stable coronary artery disease: an international multicenter study.Circ Cardiovasc Interv2019;12:e007889

[15] Kern MJ,Bech JW.Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology.Circulation2006;114:1321-41

[16] Layland J,McEntegart M.Vasodilatory capacity of the coronary microcirculation is preserved in selected patients with non-ST-segment-elevation myocardial infarction.Circ Cardiovasc Interv2013;6:231-6

[17] van de Hoef TP,Damman P.Impaired coronary autoregulation is associated with long-term fatal events in patients with stable coronary artery disease.Circ Cardiovasc Interv2013;6:329-35

[18] Meuwissen M,Siebes M.Role of variability in microvascular resistance on fractional flow reserve and coronary blood flow velocity reserve in intermediate coronary lesions.Circulation2001;103:184-7

[19] de Waard GA,de Wit D.Hyperaemic microvascular resistance predicts clinical outcome and microvascular injury after myocardial infarction.Heart2018;104:127-34

[20] Rivero F,Gomez-Lara J.Coronary microvascular dysfunction assessed by continuous intracoronary thermodilution: a comparative study with index of microvascular resistance.Int J Cardiol2021;333:1-7

[21] de Waard GA,van Lavieren MA.Invasive minimal microvascular resistance is a new index to assess microcirculatory function independent of obstructive coronary artery disease.J Am Heart Assoc.2016;5:e004482 PMCID:PMC5210399

[22] Konijnenberg LSF,Duncker DJ.Pathophysiology and diagnosis of coronary microvascular dysfunction in ST-elevation myocardial infarction.Cardiovasc Res2020;116:787-805 PMCID:PMC7061278

[23] Patel N,Dall'Armellina E.Zero-flow pressure measured immediately after primary percutaneous coronary intervention for st-segment elevation myocardial infarction provides the best invasive index for predicting the extent of myocardial infarction at 6 months: an OxAMI study (Oxford Acute Myocardial Infarction).JACC Cardiovasc Interv2015;8:1410-21

[24] Gibson CM,Daley WL.TIMI frame count: a quantitative method of assessing coronary artery flow.Circulation1996;93:879-88

[25] 't Hof AW, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group.Circulation1998;97:2302-6

[26] De Maria GL,Shanmuganathan M.Angiography-derived index of microcirculatory resistance as a novel, pressure-wire-free tool to assess coronary microcirculation in ST elevation myocardial infarction.Int J Cardiovasc Imaging2020;36:1395-406 PMCID:PMC7381481

[27] Ahn JM,Johnson NP.Fractional flow reserve and pressure-bounded coronary flow reserve to predict outcomes in coronary artery disease.Eur Heart J2017;38:1980-9

[28] Vicente J,Croisille P.Comparison of the angiographic myocardial blush grade with delayed-enhanced cardiac magnetic resonance for the assessment of microvascular obstruction in acute myocardial infarctions.Catheter Cardiovasc Interv2009;74:1000-7

[29] Ng MK,Fearon WF.Invasive assessment of the coronary microcirculation: superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance compared with coronary flow reserve.Circulation2006;113:2054-61

[30] Fearon WF.Invasive assessment of the coronary microvasculature: the index of microcirculatory resistance.Circ Cardiovasc Interv2017;10:e005361

[31] Ford TJ,Sidik N.1-year outcomes of angina management guided by invasive coronary function testing (CorMicA).JACC Cardiovasc Interv2020;13:33-45

[32] De Maria GL,Wolfrum M.Index of microcirculatory resistance as a tool to characterize microvascular obstruction and to predict infarct size regression in patients with STEMI undergoing primary PCI.JACC Cardiovasc Imaging2019;12:837-48

[33] Payne AR,Doolin O.Microvascular resistance predicts myocardial salvage and infarct characteristics in ST-elevation myocardial infarction.J Am Heart Assoc2012;1:e002246 PMCID:PMC3487342

[34] Fahrni G,De Maria GL.Index of microcirculatory resistance at the time of primary percutaneous coronary intervention predicts early cardiac complications: insights from the OxAMI (Oxford study in acute myocardial infarction) cohort.J Am Heart Assoc.2017;6:e005409 PMCID:PMC5721736

[35] De Maria GL,Patel N.How does coronary stent implantation impact on the status of the microcirculation during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction?.Eur Heart J2015;36:3165-77 PMCID:PMC4664836

[36] De Maria GL,Borlotti A.Index of microcirculatory resistance-guided therapy with pressure-controlled intermittent coronary sinus occlusion improves coronary microvascular function and reduces infarct size in patients with ST-elevation myocardial infarction: the oxford acute myocardial infarction - pressure-controlled intermittent coronary sinus occlusion study (OxAMI-PICSO study).EuroIntervention2018;14:e352-9

[37] McCartney PJ,Maznyczka AM.Effect of low-dose intracoronary alteplase during primary percutaneous coronary intervention on microvascular obstruction in patients with acute myocardial infarction: a randomized clinical trial.JAMA2019;321:56-68 PMCID:PMC6583564

[38] Sezer M,Aslanger E.Effect of intracoronary streptokinase administered immediately after primary percutaneous coronary intervention on long-term left ventricular infarct size, volumes, and function.J Am Coll Cardiol2009;54:1065-71

[39] Gutierrez-Barrios A,Diaz-Retamino E.Invasive assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy: the index of microvascular resistance.Cardiovasc Revasc Med2015;16:426-8

[40] Rivero F,Garcia-Guimaraes M.Time-related microcirculatory dysfunction in patients with takotsubo cardiomyopathy.JAMA Cardiol2017;2:699-700 PMCID:PMC5815019

[41] Yang HM,Luikart H.Invasive assessment of coronary physiology predicts late mortality after heart transplantation.Circulation2016;133:1945-50

[42] Marcus ML.Coronary flow reserve in patients with normal coronary angiograms.J Am Coll Cardiol1985;6:1254-6

[43] Sakamoto N,Owada T.A reduction of coronary flow reserve is associated with chronic kidney disease and long-term cardio-cerebrovascular events in patients with non-obstructive coronary artery disease and vasospasm.Fukushima J Med Sci2012;58:136-43

[44] Yilmaz Y,Yonal O.Coronary flow reserve is impaired in patients with nonalcoholic fatty liver disease: association with liver fibrosis.Atherosclerosis2010;211:182-6

[45] Garcia D,Durand LG.Impairment of coronary flow reserve in aortic stenosis.J Appl Physiol (1985)2009;106:113-21

[46] Gaibazzi N,Suma S.Coronary flow velocity reserve reduction is associated with cardiovascular, cancer, and noncancer, noncardiovascular mortality.J Am Soc Echocardiogr2020;33:594-603

[47] Lee SH,Park J.Prognostic implications of resistive reserve ratio in patients with coronary artery disease.J Am Heart Assoc2020;9:e015846 PMCID:PMC7428535

[48] van't Veer M,Rutten MC.Continuous infusion thermodilution for assessment of coronary flow: theoretical background and in vitro validation.Med Eng Phys2009;31:688-94

[49] Wijnbergen I,Lammers J,Pijls NH.Absolute coronary blood flow measurement and microvascular resistance in ST-elevation myocardial infarction in the acute and subacute phase.Cardiovasc Revasc Med2016;17:81-7

[50] Xaplanteris P,Keulards DCJ.Catheter-based measurements of absolute coronary blood flow and microvascular resistance: feasibility, safety, and reproducibility in humans.Circ Cardiovasc Interv2018;11:e006194

[51] Gallinoro E,Colaiori I.Thermodilution-derived volumetric resting coronary blood flow measurement in humans.EuroIntervention2021;

[52] Konst RE,Pellegrini D.Absolute coronary blood flow measured by continuous thermodilution in patients with ischemia and nonobstructive disease.J Am Coll Cardiol2021;77:728-41

[53] Fournier S,van 't Veer M.Normal values of thermodilution-derived absolute coronary blood flow and microvascular resistance in humans.EuroIntervention2020;

[54] Fearon WF,Balsam LB.Comparison of coronary thermodilution and Doppler velocity for assessing coronary flow reserve.Circulation2003;108:2198-200

[55] Everaars H,Driessen RS.Doppler flow velocity and thermodilution to assess coronary flow reserve: a head-to-head comparison with [(15)O]H2O PET.JACC Cardiovasc Interv2018;11:2044-54

[56] Gaster AL,Thayssen P,Haghfelt TH.Reproducibility of intravascular ultrasound and intracoronary Doppler measurements.Catheter Cardiovasc Interv2001;53:449-58

[57] Maznyczka AM,Berry C.Reference invasive tests of microvascular injury in myocardial infarction.Heart2018;104:90-2 PMCID:PMC5861382

[58] Verhoeff BJ,Spaan JA,Siebes M.Minimal effect of collateral flow on coronary microvascular resistance in the presence of intermediate and noncritical coronary stenoses.Am J Physiol Heart Circ Physiol2012;303:H422-8

[59] Williams RP,De Silva K.Doppler versus thermodilution-derived coronary microvascular resistance to predict coronary microvascular dysfunction in patients with acute myocardial infarction or stable angina pectoris.Am J Cardiol2018;121:1-8 PMCID:PMC5746201

[60] Hassell M,van Lavieren MA.Microvascular dysfunction following ST-elevation myocardial infarction and its recovery over time.EuroIntervention2017;13:e578-84

[61] Teunissen PF,Hollander MR.Doppler-derived intracoronary physiology indices predict the occurrence of microvascular injury and microvascular perfusion deficits after angiographically successful primary percutaneous coronary intervention.Circ Cardiovasc Interv2015;8:e001786

[62] Kitabata H,Kubo T.Coronary microvascular resistance index immediately after primary percutaneous coronary intervention as a predictor of the transmural extent of infarction in patients with ST-segment elevation anterior acute myocardial infarction.JACC Cardiovasc Imaging2009;2:263-72

[63] Kitabata H,Ishibashi K.Prognostic value of microvascular resistance index immediately after primary percutaneous coronary intervention on left ventricular remodeling in patients with reperfused anterior acute ST-segment elevation myocardial infarction.JACC Cardiovasc Interv2013;6:1046-54

[64] Doucette JW,Payne HM.Validation of a Doppler guide wire for intravascular measurement of coronary artery flow velocity.Circulation1992;85:1899-911

[65] Kern MJ.The challenges of measuring coronary flow reserve: comparisons of doppler and thermodilution to [(15)O]H2O PET perfusion.JACC Cardiovasc Interv2018;11:2055-7

[66] Barbato E,Aengevaeren WR.Validation of coronary flow reserve measurements by thermodilution in clinical practice.Eur Heart J2004;25:219-23

[67] Chamuleau SA,de Cock CC.Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease.J Am Coll Cardiol2002;39:852-8

[68] Pepine CJ,Sharaf BL.Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study.J Am Coll Cardiol2010;55:2825-32 PMCID:PMC2898523

[69] Hoeven Nvd,Waard Gd.TCT-523 Instantaneous Hyperemic Diastolic Velocity Pressure Slope for comprehensive physiological evaluation of epicardial and microvascular status.J Am Coll Cardiol2016;68:B211

[70] Ganz P.Assessment of structural disease in the coronary microvasculature.Circulation2009;120:1555-7

[71] Escaned J,Garcia-Pavia P.Assessment of microcirculatory remodeling with intracoronary flow velocity and pressure measurements: validation with endomyocardial sampling in cardiac allografts.Circulation2009;120:1561-8

[72] Feigl EO.Coronary physiology.Physiol Rev1983;63:1-205

[73] Mancini GB,DeBoe SF.The diastolic hyperemic flow versus pressure relation. a new index of coronary stenosis severity and flow reserve.Circulation1989;80:941-50

[74] Yong AS,Fearon WF.Calculation of the index of microcirculatory resistance without coronary wedge pressure measurement in the presence of epicardial stenosis.JACC Cardiovasc Interv2013;6:53-8