背景:冠状动脉造影和生存能力检测是诊断和治疗缺血性心肌病的基石。目前,没有单一的测试满足这两种需求。冠状波强度分析可询问对向心肌的收缩性和微血管生理学,因此有可能实现在单个程序中完全评估冠状动脉生理学和心肌生存力的目标。我们假设在冠状动脉造影期间测量的冠状动脉波强度分析可以预测生存能力,其准确性与晚钆增强的心脏磁共振成像相似。
方法:纳入左心室射血分数≤40%且广泛性冠心病患者。静息时在心脏导管插入期间评估冠状波强度分析,在腺苷诱导的充血期间,以及使用双压力多普勒传感冠状动脉导丝在低剂量多巴酚丁胺压力下。用心脏磁共振成像评估瘢痕负荷。在优化药物治疗±血运重建后,在基线和6个月随访时评估局部左心室功能,使用经胸超声心动图。主要结果是心肌活力,通过功能恢复的回顾性观察确定。
结果:40名参与者接受了基线生理检查,心脏磁共振成像,还有超声心动图,30例在6个月时进行了超声心动图检查;21/42个领土在随访超声心动图中存活。静息向后压缩波能量在可行区域明显高于非可行区域(-5240±3772对-1873±1605Wm-2s-1,P<0.001),在预测生存力方面,其准确性与心脏磁共振成像相当(曲线下面积为0.812vs.0.757,P=0.649);-2500Wm-2s-1的阈值敏感性为86%,特异性为76%.
结论:后向压缩波能量在预测生存能力方面的准确性与钆增强心脏磁共振成像相似。冠状动脉波强度分析有可能简化缺血性心肌病的管理,类似于血流储备分数对稳定型心绞痛管理的影响。
Coronary angiography and viability testing are the cornerstones of diagnosing and managing ischemic cardiomyopathy. At present, no single test serves both needs. Coronary wave intensity analysis interrogates both contractility and microvascular physiology of the subtended myocardium and therefore has the potential to fulfil the goal of completely assessing coronary physiology and myocardial viability in a single procedure. We hypothesized that coronary wave intensity analysis measured during coronary angiography would predict viability with a similar accuracy to late-gadolinium-enhanced cardiac magnetic resonance imaging.
Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. Coronary wave intensity analysis was assessed during cardiac catheterization at rest, during adenosine-induced hyperemia, and during low-dose dobutamine stress using a dual pressure-Doppler sensing coronary guidewire. Scar burden was assessed with cardiac magnetic resonance imaging. Regional left ventricular function was assessed at baseline and 6-month follow-up after optimization of medical-therapy±revascularization, using transthoracic echocardiography. The primary outcome was myocardial viability, determined by the retrospective observation of functional recovery.
Forty participants underwent baseline physiology, cardiac magnetic resonance imaging, and echocardiography, and 30 had echocardiography at 6 months; 21/42 territories were viable on follow-up echocardiography. Resting backward compression wave energy was significantly greater in viable than in nonviable territories (-5240±3772 versus -1873±1605 W m-2 s-1, P<0.001), and had comparable accuracy to cardiac magnetic resonance imaging for predicting viability (area under the curve 0.812 versus 0.757, P=0.649); a threshold of -2500 W m-2 s-1 had 86% sensitivity and 76% specificity.
Backward compression wave energy has accuracy similar to that of late-gadolinium-enhanced cardiac magnetic resonance imaging in the prediction of viability. Coronary wave intensity analysis has the potential to streamline the management of ischemic cardiomyopathy, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.