Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis

Scarsini, Roberto; Pighi, Michele; Mainardi, Andrea; Portolan, Leonardo; Springhetti, Paolo; Mammone, Concetta; Mora, Francesco Della; Fanti, Diego; Tavella, Domenico; Gottin, Leonardo; Bergamini, Corinna; Benfari, Giovanni; Pesarini, Gabriele; Ribichini, Flavio

doi:10.1136/heartjnl-2022-321907

Cited by 5 publications

(1 citation statement)

References 24 publications

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“…Conversely, with the use of mean contrast transit time, the longer the segment of interest, the higher the mean contrast transit time and thus the higher the angiography-derived IMR. 29 The relevance of microvascular function assessment in the setting of SAS was recently highlighted by Scarsini et al 30 who showed that IMR is significantly higher in patients with low-flow low-gradient compared with patients with high-gradient SAS. Moreover, in low-flow low-gradient SAS, a recovery of left ventricular systolic function after TAVI occurred only in patients with preserved microvascular function but not in patients with microvascular dysfunction.…”

Section: Discussionmentioning

confidence: 99%

Integrated Assessment of Computational Coronary Physiology From a Single Angiographic View in Patients Undergoing TAVI

Fezzi,

Ding,

Scarsini

et al. 2023

Circ: Cardiovascular Interventions

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BACKGROUND: Angiography-derived computational physiology is an appealing alternative to pressure-wire coronary physiology assessment. However, little is known about its reliability in the setting of severe aortic stenosis. This study sought to provide an integrated assessment of epicardial and microvascular coronary circulation by means of single-view angiography-derived physiology in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). METHODS: Pre-TAVI angiographic projections of 198 stenotic coronary arteries (123 patients) were analyzed by means of Murray’s law-based quantitative flow ratio and angiography microvascular resistance. Wire-based reference measurements were available for comparison: fractional flow reserve (FFR) in all cases, instantaneous wave-free ratio in 148, and index of microvascular resistance in 42 arteries. RESULTS: No difference in terms of the number of ischemia-causing stenoses was detected between FFR ≤0.80 and Murray’s law-based quantitative flow ratio ≤0.80 (19.7% versus 19.2%; P =0.899), while this was significantly higher when instantaneous wave-free ratio ≤0.89 (44.6%; P =0.001) was used. The accuracy of Murray’s law-based quantitative flow ratio ≤0.80 in predicting pre-TAVI FFR ≤0.80 was significantly higher than the accuracy of instantaneous wave-free ratio ≤0.89 (93.4% versus 77.0%; P =0.001), driven by a higher positive predictive value (86.9% versus 50%). Similar findings were observed when considering post-TAVI FFR ≤0.80 as reference. In 82 cases with post-TAVI angiographic projections, Murray’s law-based quantitative flow ratio values remained stable, with a low rate of reclassification of stenosis significance (9.9%), similar to FFR and instantaneous wave-free ratio. Angiography microvascular resistance demonstrated a significant correlation (Rho=0.458; P =0.002) with index of microvascular resistance, showing an area under the curve of 0.887 (95% CI, 0.752–0.964) in predicting index of microvascular resistance ≥25. CONCLUSIONS: Angiography-derived physiology provides a valid, reliable, and systematic assessment of the coronary circulation in a complex scenario, such as severe aortic stenosis.

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Section: Discussionmentioning

confidence: 99%

Integrated Assessment of Computational Coronary Physiology From a Single Angiographic View in Patients Undergoing TAVI

Fezzi,

Ding,

Scarsini

et al. 2023

Circ: Cardiovascular Interventions

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Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation

Scarsini,

Portolan,

Della Mora

et al. 2023

Heart

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ObjectivesThis study aimed to evaluate the prognostic value of coronary microvascular dysfunction (CMD) at long term after transcatheter aortic valve implantation (TAVI) and to explore its relationship with extravalvular cardiac damage (EVCD). Moreover, we sought to test the correlation between angiography-derived index of microcirculatory resistance (IMRangio) and invasive IMR in patients with aortic stenosis (AS).MethodsThis was a retrospective analysis of the Verona Valvular Heart Disease Registry (Italy) including 250 patients (83 (80–86) years, 53% female) with severe AS who underwent TAVI between 2019 and 2021. IMRangiowas calculated offline using a computational flow model applied to coronary angiography obtained during the TAVI workup. CMD was defined as IMRangio≥30 units.The primary endpoint was the composite of cardiovascular death and rehospitalisation for heart failure (HF). Advanced EVCD was defined as pulmonary circulation impairment, severe tricuspid regurgitation or right ventricular dysfunction.The correlation between IMR and IMRangiowas prospectively assessed in 31 patients undergoing TAVI.ResultsThe primary endpoint occurred in 28 (11.2%) patients at a median follow-up of 22 (IQR 12–30) months. Patients with CMD met the primary endpoint more frequently than those without CMD (22.9% vs 2.8%, p<0.0001). Patients with CMD were more frequently characterised by advanced EVCD (33 (31.4%) vs 27 (18.6%), p=0.024). CMD was an independent predictor of adverse outcomes (adjusted HR 6.672 (2.251 to 19.778), p=0.001) and provided incremental prognostic value compared with conventional clinical and imaging variables. IMRangiodemonstrated fair correlation with IMR.ConclusionsCMD is an independent predictor of cardiovascular mortality and HF after TAVI.

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Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives

Springhetti,

Abdoun,

Clavel

2024

JCM

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Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient–prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.

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Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis

Cited by 5 publications

References 24 publications

Integrated Assessment of Computational Coronary Physiology From a Single Angiographic View in Patients Undergoing TAVI

Integrated Assessment of Computational Coronary Physiology From a Single Angiographic View in Patients Undergoing TAVI

Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation

Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives

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