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Resting Coronary Flow Velocity in The European Heart Journal – Cardiovascular Imaging (2012) 13,79–85 CLINICAL/ORIGINAL PAPERS doi:10.1093/ehjci/jer153 Resting coronary flow velocity in the functional evaluation of coronary artery stenosis: study on sequential use of computed tomography angiography and transthoracic Doppler Downloaded from https://academic.oup.com/ehjcimaging/article/13/1/79/2397059 by guest on 30 September 2021 echocardiography Esa Joutsiniemi 1, Antti Saraste 1,2*, Mikko Pietila¨ 1, Heikki Ukkonen 1,2, Sami Kajander 2, Maija Ma¨ki 2,3, Juha Koskenvuo 3, Juhani Airaksinen 1, Jaakko Hartiala 3, Markku Saraste 3, and Juhani Knuuti 2 1Department of Cardiology, Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland; 2Turku PET Centre, Kiinamyllynkatu 4-8, 20520 Turku, Finland; and 3Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland Received 10 March 2011; accepted after revision 2 August 2011; online publish-ahead-of-print 30 August 2011 Aims Accelerated flow at the site of flow-limiting stenosis can be detected by transthoracic Doppler echocardiography (TTDE). We studied feasibility and accuracy of sequential coronary computed tomography angiography (CTA) and TTDE in detection of haemodynamically significant coronary artery disease (CAD). ..................................................................................................................................................................................... Methods We prospectively enrolled 107 patients with intermediate (30–70%) pre-test likelihood of CAD. All patients under- and results went CTA using a 64-slice scanner. Using TTDE, the ratio of maximal diastolic flow velocity to pre-stenotic flow velocity (M/P ratio) was measured in the coronary segments with stenosis in CTA. In all patients, the results were compared with invasive coronary angiography, including measurement of fractional flow reserve when appropriate. All analyses were done blinded. TTDE was feasible in 276 of 285 evaluated coronary segments. Significant coronary stenoses were associated with a higher M/P ratio than non-significant stenoses (3.59 + 1.82 vs. 1.28 + 0.60, P , 0.001). The optimal M/P ratio for detection of significant stenosis was 2.2 (area under receiver operating charac- teristic curve 0.92, P , 0.001). Compared with the strategy of CTA alone, sequential CTA and focused TTDE had a better positive predictive value (PPV; 61 vs. 78%) and diagnostic accuracy (93 vs. 96%, P ¼ 0.006) without impairment of the negative predictive value (97 vs. 97%). ..................................................................................................................................................................................... Conclusion Sequential use of CTA and TTDE is feasible for combined anatomic and functional evaluation of coronary stenoses. Compared with coronary CTA alone, addition of TTDE improved PPV for detection of significant CAD. ----------------------------------------------------------------------------------------------------------------------------------------------------------- Keywords Coronary artery disease † Doppler echocardiography † Coronary flow † Computed tomography angiography Introduction identification of .50% coronary artery stenosis in patients with intermediate likelihood of coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is a promis- However, coronary CTA has only limited capability to assess the ing method for anatomic detection of coronary atherosclerotic severity of coronary artery stenosis.4 Studies comparing coronary plaques. Single-centre studies1 as well as multicentre studies2,3 CTA and single-photon emission computed tomography perfusion have demonstrated its high diagnostic accuracy for the imaging have indicated that only 40–65% of the stenoses classified * Corresponding author. Tel: +358 23130000, Fax: +358 23132030, Email: antti.saraste@utu.fi Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: [email protected] 80 E. Joutsiniemi et al. as significant by coronary CTA are associated with myocardial ischaemia.4 Similarly, the correlation comparing the stenosis sever- Table 1 Characteristics of study patients ity by coronary CTA and invasive coronary angiography has been Gender (male/female) 60/41 4 only modest. Because demonstration of myocardial ischaemia is Age (years) 64 (50–80) 5 important for management decisions of patients with CAD, func- Weight (kg) 78 (50–116) tional evaluation of the haemodynamic significance of stenosis Body mass index 26.6 (18.0–39.1) detected by coronary CTA remains an important challenge. Risk factors A flow-limiting coronary stenosis causes local acceleration and Family history of CAD 43 (42.6%) turbulence of flow at the site of stenosis that is detectable by trans- Diabetes 14 (13.9%) 6– 11 thoracic Doppler echocardiography (TTDE). Measurement of Impaired glucose tolerance 9 (8.9%) local acceleration in coronary artery flow without pharmacological Hypertension 40 (39.6%) Downloaded from https://academic.oup.com/ehjcimaging/article/13/1/79/2397059 by guest on 30 September 2021 provocation by TTDE is an attractive approach for the identifi- Hypercholesterolaemia 56 (55.5%) 6– 11 cation of flow-limiting coronary stenosis. Studies from differ- Current or previous smoker 26 (25.7%) ent groups have reported good feasibility and diagnostic Medication performance of the technique for the detection of significant ste- Statin 49 (48.5%) 6 –11 nosis in the left anterior descending (LAD) coronary artery. b-Blocker 58 (57.4%) Recently, visualization of the left circumflex artery (LCX) and Aspirin 72 (71.3%) right coronary artery (RCA) has become possible, albeit with a Long acting nitrate 8 (7.9%) lower success rate than the LAD.9,10,12 We hypothesized that sequential use of coronary CTA and TTDE could provide a combined anatomic and functional evalu- ation of coronary atherosclerotic plaques non-invasively. Anatomic with prospective ECG triggering and 19.9 mSv with retrospective information provided by coronary CTA could improve feasibility of gating.13 The images were analysed by an experienced cardiologist TTDE by allowing focused analysis of certain coronary segments. and a radiologist using ADW 4.4 Workstation (General Electric Measurement of local increase in flow velocity at the site of steno- Medical Systems) blinded to other results. The minimum vessel diam- sis by TTDE could in turn provide incremental information about eter was measured in two perpendicular planes. The degree of stenosis the haemodynamic significance of stenosis. Therefore, we designed was expressed as the percentage of minimum to the pre-stenotic a blinded study to test the feasibility of sequential CTA and TTDE diameter. The standard 17 vessel segment template was used and in evaluation of coronary stenoses and to compare it with CTA vessels ,1.5 mm in diameter were excluded. The stenoses .50% alone in the detection of significant CAD. We measured the were classified as significant. maximal-to-prestenotic flow velocity ratio (M/P ratio) by TTDE in the coronary segments with stenosis in CTA. Results of CTA Transthoracic Doppler echocardiography and TTDE were compared with the gold standard, invasive coron- The coronary artery segments with .20% stenosis in CTA were eval- ary angiography, including measurement of fractional flow reserve uated using TTDE by cardiologists that were blinded to the severity of (FFR) when appropriate. stenosis in CTA in a separate imaging session using Acuson Sequoia C512 ultrasound unit (Siemens Acuson, Mountain View, CA, USA) equipped with a standard 3.5-MHz transducer (3V2c). The expected Methods anatomic course of the coronary artery segments of interest was studied using colour Doppler mapping using all possible standard Patients and non-standard windows and views as described earlier.10 The vel- As part of an earlier study,13 we prospectively enrolled 107 out- ocity scale of colour Doppler was initially set to 0.24 m/s, but it was patients between 2 July and 9 August with chest pain and 30–70% changed actively. The colour box size was reduced to maintain the pre-test likelihood of CAD based on age, sex, symptoms, and the high frame rate. Briefly, the left main coronary artery (LM) and prox- result of the exercise test.5 Patients with previous CAD, atrial fibrilla- imal LAD were studied from the left parasternal short- and long-axis tion, iodine allergy, unstable angina, severe renal dysfunction, heart views focusing on area adjacent to the sinus Valsalva (Figure 1). failure, unstable asthma, or pregnancy were excluded. Six patients Origin of the first septal branch of the LAD marking border were excluded from the study, because of failure to perform TTDE between the proximal and the middle segments of the LAD could prior to invasive coronary angiography due to logistic reasons. Thus, be visualized in most patients. The middle and the distal LAD basal the final study population consisted of 101 patients whose character- and apical to the papillary muscle level, respectively, as well as the istics are summarized in Table 1. The study was conducted according proximal LCX covered by the left auricle were studied from left para- to the guidelines of Declaration of Helsinki, and the study protocol sternal windows at varying levels using modified short- and long-axis was approved by the ethics committee of the Hospital District of views focusing on the anterior inter-ventricular
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