Prediction of troponin elevation by means of intracoronary electrocardiogram during percutaneous coronary intervention of coronary bifurcation lesions (from COronary SIde Branch Residual IschemiA and COllateralization Assessment Study; COSIBRIA & Co Study

Abstract

A b s t r a c t Background:The influence of periprocedural ischaemia on coronary artery bifurcation stenting (percutaneous coronary intervention [PCI]) remains uncertain. Aim:To determine the differences in rates of end procedural ischaemia after bifurcation lesion PCI detected with intracoronary electrocardiography (icECG).Methods: Unipolar icECGs were recorded before, during, and after stent placement and at the end of procedure in side branch (SB) and main branch (MB). Coronary wire was placed in all distal vessels with diameter > 1.5 mm to "map" the distal zones of ischaemia. The patient population consisted of patients with stable/unstable angina with troponin I evaluated before and after PCI. Results:We studied 147 patients (68% males) with mean age of 64 ± 9 years. One hundred and forty-two patients had icECG recordings at the end of PCI from all locations of the treated region; 36% of patients had MB ST segment elevation (STE) and 31% had icECG STE in the SB region (p = 0.378). The icECG had sensitivity of 82% and specificity of 81% to detect troponin I elevation, with positive predictive value of 81% and negative predictive value of 83%. The independent predictors of troponin increase (> 5 × N) were: sex (for female gender, OR = 0.130, CI 0.017-0.995, p = 0.049), previous myocardial infarction (OR = 33.23, CI 2.802-394.1, p = 0.005), and icECG STE in MB or SB or occlusion of secondary SB (OR = 7.877, CI 2.474-25.07, p < 0.001) and for any troponin elevation were double product -SBPxHR (OR = 0.999, CI 0.999-1.00, p = 0.022) and icECG STE in MB or SB or occlusion of secondary SB (OR = 9.762, CI 3.273-29.12, p < 0.001). Conclusions:Intracoronary electrocardiography is a highly sensitive and specific method for determination of ischaemic regions and prediction of elevated troponin I. 944 INTRODUCTIONCoronary bifurcation lesions remain a major therapeutic challenge with high early and late complication rates. It has been shown that angiographically high grade ostial side branch (SB) stenosis is not flow limiting and may not cause ischaemia. Our studies with delayed gadolinium enhancement magnetic resonance imaging before and after bifurcation percutaneous coronary intervention (PCI) demonstrated that occurrence of angiographic stenosis of more than 70% in diameter is associated with periprocedural myonecrosis in the region of SB [1]. Moreover, the post-procedural myocardial injury after uncomplicated PCI is not uncommon [2-4] with a frequency of 5% to 30%. Although this is thought to have no clinical significance, clinical trials demonstrated an increased risk of adverse cardiac events in patients with periprocedural myonecrosis [5].The unipolar intracoronary electrocardiogram (icECG) recording from angioplasty guidewire represents local epicardial ECG and has been shown to be more sensitive and more reliable in detecting regional myocardial ischaemia during balloon inflation than standard ECG [6][7][8][9][10]. The icECG detects earlier ischaemia and the changes are more prominent than surface ECG. The wire...

Prognostic and diagnostic accuracy of intracoronary electrocardiogram recorded during percutaneous coronary intervention: a meta-analysis

“…The difference of the definitions that significant ST-segment changes on IC-ECG in each study was not very great. The reference standards reported in the diagnostic studies were varied, including FFR,5 13 echocardiogram14 and troponin 12 15 16…”

“…Vassilev et al found out that the exact size of recording electrode is the last 3 cm of every workhorse guidewire. 16 And Uetani found that the waveforms of IC-ECG were different in the same position between conventional uninsulated guidewires and polymer-covered wires. 11 However, we could not perform sensitivity analysis for different guide wires, limited by the included studies, to verify the hypothesis that different types of guide wires would affect the diagnostic accuracy of IC-ECG.…”

“…But Vassilev found that when they pulled back the guidewire, the elevated ST-segment would suddenly normalise if the wire tip exited the border of ischaemic territory. 16 And they explored a method to detect and define the ischaemic territory. Further researches should consider how these details affect the diagnostic accuracy of IC-ECG in order to guide the PCI procedures better.…”

“…In some studies, the ST-segment elevation or resolution recorded by IC-ECG during or after PCI procedures have been shown to be sensitive and reliable for detecting myocardial viability, local myocardial ischaemia or microvascular obstruction. [5][6][7][8][9][10][11][12][13][14][15][16] But IC-ECG is neither widely used during PCI nor recommended in guidelines. This up-to-date meta-analysis of published studies was conducted to evaluate the prognostic and diagnostic accuracy of IC-ECG recorded during PCI.…”

“…Intracoronary ECG (IC-ECG) recording, with a guidewire functioning as a unipolar electrode, might be an alternative tool for guiding PCI. In some studies, the ST-segment elevation or resolution recorded by IC-ECG during or after PCI procedures have been shown to be sensitive and reliable for detecting myocardial viability, local myocardial ischaemia or microvascular obstruction 5–16. But IC-ECG is neither widely used during PCI nor recommended in guidelines.…”