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Observational Study
. 2020 May 5;9(9):e015669.
doi: 10.1161/JAHA.119.015669. Epub 2020 Apr 22.

Recovery of Absolute Coronary Blood Flow and Microvascular Resistance After Chronic Total Occlusion Percutaneous Coronary Intervention: An Exploratory Study

Daniëlle C J Keulards  1 , Grigoris V Karamasis  2   3 , Osama Alsanjari  2   3 , Jesse P A Demandt  1 , Marcel Van't Veer  1   4 , Jo M Zelis  1 , Simon A Dello  1 , Mohamed El Farissi  1 , Klio Konstantinou  2   3 , Kare H Tang  2 , Paul A Kelly  2 , Thomas R Keeble  2   3 , Nico H J Pijls  1   4 , John R Davies  2   3 , Koen Teeuwen  1
Affiliations
Observational Study

Recovery of Absolute Coronary Blood Flow and Microvascular Resistance After Chronic Total Occlusion Percutaneous Coronary Intervention: An Exploratory Study

Daniëlle C J Keulards et al. J Am Heart Assoc. .

Abstract

Background This study aimed to investigate longitudinal physiological changes in the recanalized coronary chronic total occlusion (CTO) vessel and its dependent myocardium after successful percutaneous coronary intervention (PCI). Methods and Results In this pilot study, 25 patients scheduled for elective CTO PCI with viable myocardium and angiographically visible collaterals were included. Absolute coronary blood flow and absolute microvascular resistance were measured invasively using continuous thermodilution. Measurements were performed immediately after successful CTO PCI and at short-term follow-up. In a subgroup of patients, physiological measurements were performed at the predominant donor vessel before CTO PCI, immediately afterwards, and at follow-up. Absolute coronary blood flow in the recanalized CTO artery increased from 148±53 mL/min immediately after PCI to 221±77 mL/min at follow-up (P<0.001). In agreement, absolute resistance in the myocardial territory perfused by the CTO artery, decreased from 545±255 Wood units immediately after the procedure to 387±128 Wood units at follow-up (P=0.014). There were no significant changes in the absolute coronary blood flow and resistance in the predominant donor between baseline and follow-up. Positive remodeling of the distal CTO vessel with an increase in lumen diameter was observed. Conclusions After successful CTO PCI, blood flow in the recanalized artery and microvascular function of the dependent myocardium are not immediately normal but recover over time.

Keywords: chronic total coronary occlusion; coronary flow; coronary microvascular function; coronary microvascular resistance; coronary revascularization.

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Figures

Figure 1
Figure 1. Typical case example.
Complete assessment of 1 patient at baseline and at follow‐up. A and D, The CTO artery (right coronary artery) and the donor artery (left anterior descending) before PCI. The absolute flow in the donor vessel is 256 mL/min, with a resistance of 231WU. B, E, and G, Flow and resistance measured directly after PCI. C, F and H, At follow‐up the CTO vessel showed an increase in flow from 161 mL/min to 300 mL/min, and resistance of the dependent myocardium decreased from 370 to 243 WU. Flow in the donor artery decreased further. CTO indicates chronic total occlusion; FFR, fractional flow reserve; PCI, percutaneous coronary intervention; Q, absolute coronary flow during steady state maximum hyperemia; R, microvascular resistance; and WU, Wood units. Reprinted from Keulards et al17 with permission. Copyright ©2018, Europa Group.
Figure 2
Figure 2. Increase of flow and decrease of microvascular resistance over time in the CTO vessel.
Overview of all performed measurements in the CTO vessel. A, Absolute blood flow measured in the CTO vessel directly after PCI and at follow‐up. B, Microvascular resistance measured in the CTO vessel directly after PCI and at follow‐up. CTO indicates chronic total occlusion; and PCI, percutaneous coronary intervention.
Figure 3
Figure 3. Flow and resistance over time in the donor artery. Overview of all performed measurements in the donor vessel.
A, Absolute blood flow measured in the donor vessel before PCI, directly after PCI, and at follow‐up. B, Microvascular resistance measured in the donor vessel before PCI, directly after PCI and at follow‐up. PCI indicates percutaneous coronary intervention.
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