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Circulation, Vol 87, 1354-1367, Copyright © 1993 by American Heart Association
NH Pijls, JA van Son, RL Kirkeeide, B De Bruyne and KL Gould
BACKGROUND. Severity of coronary artery stenosis has been defined in terms
of geometric dimensions, pressure gradient-flow relations, resistance to
flow and coronary flow reserve, or maximum flow capacity after maximum
arteriolar vasodilation. A direct relation between coronary pressure and
flow, however, may only be presumed if the resistances in the coronary
circulation are constant (and minimal) as theoretically is the case during
maximum arteriolar vasodilation. In that case, pressure measurements
theoretically can be used to predict maximum flow and assess functional
stenosis severity. METHODS AND RESULTS. A theoretical model was developed
for the different components of the coronary circulation, and a set of
equations was derived by which the relative maximum flow or fractional flow
reserve in both the stenotic epicardial artery and the myocardial vascular
bed and the proportional contribution of coronary arterial and collateral
flow to myocardial blood flow are calculated from measurements of arterial,
distal coronary, and central venous pressures during maximum arteriolar
vasodilation. To test this model, five dogs were acutely instrumented with
an epicardial, coronary Doppler flow velocity transducer. Distal coronary
pressures were measured by an ultrathin pressure-monitoring guide wire
(0.015 in.) with minimal influence on transstenotic pressure gradient.
Fractional flow reserve was calculated from the pressure measurements and
compared with relative maximum coronary artery flow measured directly by
the Doppler flowmeter at three different levels of arterial pressure for
each of 12 different severities of stenosis at each pressure level.
Relative maximum blood flow through the stenotic artery (Qs) measured
directly by the Doppler flowmeter showed an excellent correlation with the
pressure-derived values of Qs (r = 0.98 +/- 0.01, intercept = 0.02 +/-
0.03, slope = 0.98 +/- 0.04), of the relative maximum myocardial flow (r =
0.98 +/- 0.02, intercept = 0.26 +/- 0.07, slope = 0.73 +/- 0.08), and of
the collateral blood flow (r = 0.96 +/- 0.04, intercept = 0.24 +/- 0.07,
slope = -0.24 +/- 0.06). Moreover, the theoretically predicted constant
relation between mean arterial pressure and coronary wedge pressure, both
corrected for venous pressure, was confirmed experimentally (r = 0.97 +/-
0.03, intercept = 9.5 +/- 13.3, slope = 4.4 +/- 1.2). CONCLUSIONS. These
results provide the experimental basis for determining relative maximum
flow or fractional flow reserve of both the epicardial coronary artery and
the myocardium, including collateral flow, from pressure measurements
during maximum arteriolar vasodilation. With a suitable guide wire for
reliably measuring distal coronary pressure clinically, this method may
have potential applications during percutaneous transluminal coronary
angioplasty for assessing changes in the functional severity of coronary
artery stenoses and for estimating collateral flow achievable during
occlusion of the coronary artery.
ARTICLES
Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty
Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
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