(Circulation. 1999;100:2491.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Abnormal Coronary Flow Velocity Reserve After Coronary Artery Stenting in Patients
Role of Relative Coronary Reserve to Assess Potential Mechanisms
From the Department of Internal Medicine, Division of Cardiology, Saint Louis University Health Sciences Center, Mo, and Service D’Explorations Fonctionnelles (P.D., E.A., J.-L.D.-R.), Unite D’Hemodynamique et de Cardiologie Interventionnelle, Henri Mondor University Hospital, University of Paris XII, Creteil, France.
Correspondence to Morton J. Kern, MD, Director, J.G. Mudd Cardiac Catheterization Laboratory, Saint Louis University Health Sciences Center, 3635 Vista Avenue at Grand Blvd, St. Louis, MO 63110. E-mail kernm{at}slu.edu
Background—Absolute coronary flow velocity reserve (CVR) after stenting may remain abnormal as a result of several different mechanisms. Relative CVR (rCVR=CVRtarget/CVRreference) theoretically normalizes for global microcirculatory disturbances and facilitates interpretation of abnormal CVR.
Methods and Results—To characterize potential mechanisms of
poststent physiology, CVR was measured using a Doppler-tipped
angioplasty guidewire in 55 patients before and after angioplasty,
after stenting, and in an angiographically normal reference vessel. For
the group, the percent diameter stenosis decreased from
75±13% to 40±18% after angioplasty and to 10±9% (all
P<0.05) after stent placement. After angioplasty, CVR
increased from 1.63±0.71 to 1.89±0.55 (P<0.05) and
after stent placement, to 2.48±0.75 (P<0.05 versus
pre- and postangioplasty). After angioplasty, rCVR increased from
0.64±0.26 to 0.75±0.23 and after stent placement to 1.00±0.34. In 17
patients with CVRstent 
2.0, increased basal
coronary flow, rather than attenuated hyperemia, was
responsible in large part for the lower CVRstent compared
with patients having CVRstent >2.0. In 8 patients with
CVRstent <2.0, a normal rCVR supported global
microvascular disease. The subgroup of 9 patients with
CVRstent <2.0 and abnormal rCVR (16% of the studied
patients) may require a pressure-derived fractional flow reserve to
differentiate persistent obstruction from diffuse atherosclerotic
disease or microvascular stunning.
Conclusions—Although a majority of patients after stenting normalize CVR for the individual circulation (ie, normal CVR or normal rCVR), in those with impaired CVRstent, the analysis of coronary flow dynamics suggests several different physiological mechanisms. Additional assessment may be required to fully characterize the physiological result for such patients to exclude remediable luminal abnormalities.
Key Words: coronary disease • blood flow • stents • stenosis
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