Comparison of myocardial contrast echocardiography and coronary angiography for assessing the acute protective effects of collateral recruitment during occlusion of the left anterior descending coronary artery at the time of elective angioplasty

doi:10.1016/S0002-9149(97)00134-3

The American Journal of Cardiology

Volume 79, Issue 10, 15 May 1997, Pages 1329-1333

https://doi.org/10.1016/S0002-9149(97)00134-3 Get rights and content

Abstract

To assess the immediate change in collateral flow distribution within the occluded myocardium and the acute protective effects on myocardial ischemia after coronary occlusion, myocardial contrast echocardiography (MCE) was performed in 15 patients with normal left ventricular function undergoing elective coronary angioplasty of the left anterior descending artery, and the results were compared with those obtained from coronary angiography (CA). The sonicated or nonsonicated contrast material was injected into the right coronary artery before and during coronary occlusion and collaterals were graded on a 4-point scale (none = 0 to good = 3). Development of subjective anginal symptoms, ST-segment shift and wall motion abnormality during coronary occlusion were graded on a 4-point scale (none = 0 to severe = 3). Both MCE and CA detected a significant development in collateral flow during coronary occlusion. There was no significant correlation between MCE and CA collateral grades before or during coronary occlusion. The collateral flow assessed with MCE was inversely but significantly correlated with development of subjective anginal symptoms (r_s = −0.70, p < 0.01), ST-segment shift (r_s = −0.78, p < 0.005) or wall motion abnormality (r_s = −0.91, p < 0.001) during coronary occlusion. In contrast, the angiographic collateral flow was not correlated with development of anginal symptoms (r_s = −0.46, p = 0.10), ST-segment shift (r_s = −0.41, p = 0.14), or wall motion abnormality (r_s = −0.26, p = 0.35). The present study suggested that the acute protective effects of coronary collaterals during coronary occlusion were closely associated with myocardial perfusion rather than the angiographic epicardial collateral vessel filling, and thus MCE was useful in assessing the acute protective effects of coronary collaterals during coronary occlusion.

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Cited by (19)

Quantitative Assessment of Microcollateral Recruitment During Coronary Occlusion Using Real-time Intravenous Myocardial Contrast Echocardiography
2008, Journal of the American Society of Echocardiography
Citation Excerpt :
Furthermore, anatomic and morphometric methods, such as postmortem casts, dyes, and colored or radiolabeled microspheres, have been used to identify coronary collateral microvascular anatomy; however, these assessments cannot be performed repetitively in short periods of time. We have already reported that the acute protective effects of coronary collaterals during acute coronary occlusion are significantly correlated with myocardial perfusion assessed using MCE, rather than the angiographic epicardial collateral vessel filling.4 Many studies have reported the advantages and superiority of MCE to coronary angiography.8,9
Residual collateral-derived myocardial blood flow (MBF) (A × β) is important to protect against myocardial ischemia after acute coronary occlusion.
Recruitment of microcollateral was assessed in 22 dogs with left circumflex coronary artery occlusion by analysis of MBF and regional wall thickening (WT) using real-time myocardial contrast echocardiography.
Video intensity and WT at the center of risk area were significantly lower than those at the border of risk area. The video intensity, A value, β value, and MBF correlated well with WT after left circumflex coronary artery occlusion. The WT of the area with above 25% of normal MBF was preserved and was higher than that at below 25%. However, the deterioration of WT was not distinguished according to A value.
Real-time myocardial contrast echocardiography is a useful noninvasive method to evaluate collateral-derived MBF, which can be a reliable index of protection against myocardial ischemia.
Myocardial contrast echocardiography assessment of acute changes in collateral perfusion of contralateral coronary artery with coronary flow reserve after coronary angioplasty
2005, Journal of the American Society of Echocardiography
Coronary flow velocity reserve (CFVR) is used to evaluate the severity of epicardial and intramyocardial coronary artery disease. Collateral flow to an adjacent compromised myocardial territory may influence the CFVR of a specific artery.
To assess the impact of collateral flow on CFVR, we measured CFVR and assessed perfusion area (PA) with myocardial contrast echocardiography in the right coronary arteries of 18 patients with total/subtotal occlusion of the left anterior descending coronary artery before and after angioplasty. A total of 10 patients had well-developed collaterals emerging from the right coronary artery (group I) and 8 patients did not (group II). Using a Doppler-tipped guidewire, we measured CFVR, which is defined as the ratio of papaverine-induced hyperemic average peak velocity of coronary flow to baseline.
Before angioplasty of the left anterior descending coronary artery, CFVR was significantly reduced in group I compared with group II (2.35 ± 0.47 vs 3.26 ± 0.54, P < .01). Baseline average peak velocity in group I before angioplasty was significantly greater than that after angioplasty (23.7 ± 11.6 vs 19.2 ± 9.7 cm/s, P < .05). After angioplasty, CFVR immediately increased in group I to 3.46 ± 0.54 (P < .001). The increase in CFVR was well correlated with the decrement in PA after angioplasty (r = 0.883, P < .001).
The CFVR of an artery that supplies extensive collaterals is limited because of an elevation in the baseline resting flow velocity. This restriction in CFVR improves proportionally with decreases in PA that occurs after angioplasty of the ipsilateral coronary artery. These data suggest that PA, in addition to coronary artery structure, influences CFVR.
Intraoperative ischemia and long-term events after minimally invasive coronary surgery
2004, Annals of Thoracic Surgery
Citation Excerpt :
Another limitation is that troponin enzymes were not systematically available at the time of the study. Myocardial contrast echocardiography is more accurate than coronary angiography in the detection of collateral circulation [19] and could have added insights into the mechanism of protection against ischemia. Also, the metabolic effects of coronary occlusion were not assessed in the present study.
Concern has been raised about the effects of prolonged left anterior descending (LAD) artery occlusion during minimally invasive direct coronary artery bypass graft surgery (MIDCABG). We sought to assess the impact of myocardial dysfunction during MIDCABG on long-term outcome and the protective role of collateral circulation on myocardial ischemia.
Myocardial function was evaluated in 92 patients by intraoperative transesophageal echocardiography during MIDCABG.
Wall motion score index increased during LAD occlusion (p < 0.00l) and reverted after LAD reopening (p < 0.001 versus occlusion and p = not significant versus baseline). The change in wall motion score index (occlusion versus baseline) was higher in patients with multivessel disease (p < 0.05) and in patients with LAD Thrombolysis in Myocardial Infarction study classification flow grade 2 or less without collateral circulation (p < 0.05). Myocardial stunning was documented in 12 patients (13%). The 5-year adverse event rate (including death, myocardial infarction, and revascularization) was 12%. By multivariate Cox regression analysis, multivessel disease, but not perioperative ischemia or stunning, was the only predictor of event-free survival.
During MIDCABG anterior wall dysfunction is transient, with prompt recovery after completion of the anastamosis in most cases; myocardial stunning can be documented in a minority of patients. Flow either antegrade or retrograde in the LAD territory plays a protective role against the development of ischemia. Multivessel disease, but not perioperative ischemia or stunning, predicts long-term event-free survival.
Fate of collateral circulation after successful coronary angioplasty of total occlusion assessed by coronary angiography and myocardial contrast echocardiography
2002, Journal of the American Society of Echocardiography
Citation Excerpt :
Therefore, previous studies only assessed epicardial collateral vessel filling rather than myocardial perfusion through the collateral circulation in the occluded bed. MCE is a suitable imaging technique for the assessment of myocardial perfusion through collateral flow by the selective intracoronary injection of a sonicated contrast medium into a donor coronary artery.26-35 Previous studies have demonstrated the functional significance of collateral flow detection by MCE in both the experimental and clinical setting.
A well-developed collateral circulation is frequently observed in patients with total coronary occlusion. However, the fate of the collateral circulation after successful percutaneous transluminal coronary angioplasty (PTCA) has not been fully characterized. The purpose of this study was to compare the efficacy of coronary angiography and myocardial contrast echocardiography (MCE) in the evaluation of the collateral circulation after PTCA and to assess the temporal changes of the collateral circulation after successful PTCA of a totally occluded artery by using these 2 diagnostic methods. The study group was comprised of 20 consecutive patients (16 male, mean age 54 years) who underwent elective PTCA for total coronary occlusion. Coronary angiography was performed before, immediately after, and 24 hours after PTCA. MCE was also performed before, immediately after, and 24 hours after PTCA, by the intracoronary injection of sonicated radiographic contrast medium. According to the angiographic findings, the collateral circulation was graded on a scale of 0 to 3 as follows: 0 = no visible filling; 1 = collateral filling of side branches; 2 = partial collateral filling of the epicardial artery; 3 = complete filling of the epicardial artery. By MCE, myocardial perfusion by the collateral circulation was assessed by scoring the contrast pattern of collateral-dependent myocardial segments as follows: 0 = none; 0.5 = patchy or epicardial; 1 = homogeneous. The left anterior descending artery was occluded in 12 patients and the right coronary artery in 8 patients. Coronary angiographic collateral grades before PTCA were grade 2 in 5 patients and grade 3 in 15. PTCA with stenting was successfully performed in all patients without significant residual stenosis. Coronary angiography showed collateral circulation disappeared after PTCA in all patients. However, residual collateral perfusion was observed in 7 patients by MCE, performed immediately after PTCA (score 1 in 3 patients; score 0.5 in 4 patients). This residual collateral perfusion could be demonstrated even 24 hours after PTCA by MCE in 3 patients (all patients were 0.5 in myocardial perfusion score). In conclusion, successful PTCA with stenting of a totally occluded coronary artery leads to a disappearance of collateral vessels by coronary angiography in most of the patients. However, although angiographically not visible, coronary collateral circulation may persist even 24 hours after successful PTCA of a totally occluded artery demonstrated by MCE. (J Am Soc Echocardiogr 2002;15:389-95.)
Acute changes in systolic and diastolic events during clinical coronary angioplasty: A comparison of regional velocity, strain rate, and strain measurement
2002, Journal of the American Society of Echocardiography
Citation Excerpt :
The impact of collateral circulation on myocardial function and global left ventricular performance has already been well recognized.29,30 It has been also shown that collaterals protect “at-risk” areas during coronary angioplasty of the related artery.35 Thus, they can alter the response of a myocardial segment to acute ischemia.
Ultrasound-derived natural strain rate and strain are new Doppler myocardial imaging (DMI) parameters, which can measure local deformation independently of overall heart motion and thus could better characterize local contractility than DMI velocities alone. This study was undertaken to evaluate the relative benefits of regional velocity, strain rate, and strain measurements in detecting the range of acute changes in regional myocardial function in the “at-risk” zone during coronary angioplasty. Sixty-one patients (aged 63 ± 12, 18 women) with stable angina pectoris were studied before, at the end of, and during recovery from a 60-second percutaneous transluminal coronary angioplasty (PTCA) balloon occlusion. High frame rate (147 fps) color DMI regional velocity data were derived from basal posterior (parasternal view) and mid, apical septal (apical view) “at-risk” segments as well as from the corresponding segments in healthy subjects and analyzed offline for velocity (VEL), strain rate (SR), and strain (ϵ) measurements. Coronary occlusion resulted in the reduction in VEL_SYS, SR_SYS, and ϵ_SYS values for both radial (RCA/CX occlusion) and longitudinal data (LAD occlusion) in all segments analyzed. Velocity parameters alone failed to distinguish between baseline and occlusive measurements in the “at-risk” segments with visually abnormal baseline function. SR_SYS and ϵ_SYS had a higher diagnostic accuracy (sensitivity 75%, 80% and specificity 80%, 82%, respectively) than VEL_SYS velocity alone (sensitivity 68%, specificity 65%,) for identifying acute ischemia in either baseline normal and abnormal segments. DMI-derived indexes can identify and quantify the spectrum of acute systolic and diastolic ischemic changes induced during clinical PTCA. The quantitation of regional deformation rather than motion would appear to be more appropriate in detecting and quantifying acute ischemic changes in myocardial function, especially in segments with pre-existing abnormal function. (J Am Soc Echocardiogr 2002;15:1-12.)
Characterization of contraction and perfusion in the lateral border zone between normal and ischemic myocardium following coronary occlusion by myocardial contrast echocardiography
2001, American Journal of Cardiology

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Comparison of myocardial contrast echocardiography and coronary angiography for assessing the acute protective effects of collateral recruitment during occlusion of the left anterior descending coronary artery at the time of elective angioplasty

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

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

Circulation

Limitation of myocardial ischemia by collateral circulation during sudden controlled coronary artery occlusion in human subjects: a prospective study

Circulation

Influence of coronary collateral vessels on myocardial infarct size in humans: results of phase I Thrombolysis in Myocardial Infarction (ITMI) trial

Circulation

Functional significance of collateral blood flow in patients with recent acute myocardial infarction: a study using myocardial contrast echocardiography

Circulation

Immediate appearance of coronary collaterals during ergonovine-induced arterial spasm

Chest