Post on 12-May-2018
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
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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
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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.
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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.
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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
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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)
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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))
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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
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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
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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%
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Case 1 Coronary Wedge Pressure
OHK IS 7111474
Pa
Pcw
Pcw/Pa
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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
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Case 1 FDG PET Imaging
OHK IS 7111474
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Case 1 Echocardiography
Post PCI
OHK IS 7111474
2 Months FU
LVEF (%) 37 40LVEDV (ml) 95 111LVESV (ml) 61 69RWMSI 1.88 1.76
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Case 2 Coronary Angiography
Park KD 7225812
Acute Anterior MI, M/57, Time to reperfusion: 3 hrs, LVEF: 49%
Pre PCI Post PCI TIMI 2 TMPG 1
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Case 2 Coronary Wedge Pressure
Park KD 7225812
Pa
Pcw
Pcw/Pa
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Case 2 Intracoronary Flow Measurement
Park KD 7225812
bDDT: 434 ms MVRI: 4.86 mmHg•cm-1•sec-1
hDDT: 495 ms CFR: 1.2
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Case 2 FDG PET Imaging
Park KD 7225812
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Case 2 Echocardiography
Park KD 7225812
Post PCI 5 Months FU
LVEF (%) 50 42LVEDV (ml) 86 90LVESV (ml) 40 53RWMSI 1.38 1.44
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Case 3 Coronary Angiography
Park KW 708697
Acute Anterior MI, M/61, Time to reperfusion: 5 hrs, LVEF: 44%
Pre PCI Post PCI TIMI 3 TMPG 3
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Case 3 Coronary Wedge Pressure
Pa
Pcw
Pcw/Pa
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Case 3 Intracoronary Flow Measurement
Park KW 708697
bDDT: 733 ms MVRI: 3.56 mmHg•cm-1•sec-1
hDDT: 766 ms CFR: 2.3
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Case 3 FDG PET Imaging
Park KW 708697
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Case 3 Echocardiography
Park KW 708697
Post PCI 4 Months FU
LVEF (%) 47 60LVEDV (ml) 86 87LVESV (ml) 48 38RWMSI 1.26 1.13
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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
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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)
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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)
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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
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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
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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
Viability on PET %FDG Uptake and Physiologic Parameters
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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
Viability on PET %FDG Uptake and Physiologic Parameters
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Patients without Collaterals Patients with Collaterals
Viability on PET %FDG Uptake and Physiologic Parameters
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
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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
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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
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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
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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
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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 ……
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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
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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
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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)
Agreement between Physiologic Parameters and Viability on PETReceiver Operating Curve Analysis
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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)
Agreement between Physiologic Parameters and Viability on PETReceiver Operating Curve Analysis
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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 !
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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
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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
Degree of FDG-UptakePhysiologic Parameters
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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(%)
Degree of FDG-UptakePhysiologic Parameters
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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.
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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
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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