PTCA An Investigational Tool and a Non-Operative Treatment of Acute Ischemia

416 Pages·1990·11.81 MB·English

by  Guy R. Heyndrickx

PCTA
AN INVESTIGATIONAL TOOL AND
A NON-OPERATIVE TREATMENT OF ACUTE ISCHEMIA
Developments in
Cardiovascular Medicine
VOLUME 101
PTCA
An Investigational Tool and
a Non-operative Treatment of
Acute Ischema
edited by
PATRICK W. SERRUYS
Profossor ofI nterventional Cardiology
Cardiac Catheterization Laboratory, Thorax Center,
Erasmus University, Rotterdam, The Netherlands
RUDIGER SIMON
Professor ofC ardiology
Department o/Cardiology, University Hospital,
Kiel, F.R.G.
KEVIN 1. BEATT
Academic Unit olCardiovascular Medicine.
Charing Cross and Westminster Hospital,
London, United Kingdom
Kluwer Academic Publishers
DORDRECHT I BOSTON I LONDON
Library of Congress Cataloging in Publication Data
PTCA, an investigational tool and a non-operative treatment of acute
ischemia/edited by Patrick W. Serruys, Riidiger Simon, Kevin 1.
Beatt.
p. cm.--{Deve1opments in cardiovascular medicine: 101)
Includes bibliographies.
ISBN-13:978-94-01O-6688-4 e-ISBN-13:978-94-009-0453-8
DOl: 10.1007/978-94-009-0453-8
1. Transluminal angioplasty. 2. Coronary heart disease
Treatment. I. Serruys, P.W. II. Simon, Riidiger, Dr. med.
III. Beatt. Kevin J. IV. Series: Developments in cardiovascular
medicine: v. 101.
[DNLM: 1. Angioplasty, Transluminal. 2. Coronary Disease
therapy. WI DE997VME v. 101/WG 300 P97445]
RD598.5.P784 1989
617.4' 12059-dc20
DNLM/DLC
for Library of Congress 89-15296
ISBN -13: 978-94-010-6688-4
Published by Kluwer Academic Publishers,
P.O. Box 17, 3300 AA Dordrecht, The Netherlands.
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© 1990 by Kluwer Academic Publishers
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Foreword
Obstruction of coronary blood flow and the resultant consequences are the
center stage pathophysiologic events in cardiology today. The speculations of
Jenner, Burns, Heberdin, McKenzie, Prinzmetal and many others had until now
been left to observations of isolated tissue and intact animal experimentation.
Only with the advent of Gruentzig's technique, which allowed us to 'work safely
inside the coronary arteries' are we able to observe the effects of coronary
occlusion in living conscious man. PTCA provides not only a therapeutic
modality for non-operatively opening coronary obstructions, but has also
provided the best model for studying the effects of acute ischemia on the heart.
The procedure also lead the way to all other interventional cardiology
developments, including modern thrombolysis in the setting of acute myocardial
infarction.
In his previous works, Serruys has examined how PTCA can serve as a model
for studying acute ischemia. In this book, he and his co-authors discuss the effects
of balloon-induced ischemia on the electrocardiographic changes, coronary
blood flow dynamics, cardiac muscle metabolism and left ventricular function, as
well as measures to counter these effects and provide for reperfusion in unstable
angina and acute myocardial infarction. Technology has expanded the 'eyes' of
the observer of these events. The authors use many techniques including ECG
recording from surface, endocardium, and intracoronary electrodes; angiographic
assessment of coronary flow pattern using digital techniques, as well as doppler
flow measurements; biochemical assessment of metabolic products stimulated by
ischemia; and digital angiographic and echo doppler assessment of left ventricular
function.
Observations of ischemia-induced and ischemia relieved using all the 'eyes'
available to the investigator in the 'experimental animal' (man) of greatest interest
will advance our understanding and quicken the day when ischemia can be
reliably controlled. In this book, Serruys and his co-authors have made
a significant contribution toward that end.
SPENCER B. KING III, M.D.
Contents
Foreword by Spencer B. King III, M.D. v
List of contributors xvii
PART ONE: AN INVESTIGATIONAL TOOL
From in-vitro to in-vivo model
1. Myocardial ischemia: Early adjustment and reversibility
by G.R. Heyndrickx, W. Wijns and S.F. Vatner 3
Instrumentation techniques for measurements of regional
myocardial function in conscious animals 3
Relationship between reduction in regional blood flow and
myocardial function 5
Adjustment to global LV ischemia 6
Adjustment to regional myocardial ischemia 8
Effects of reperfusion 11
Coronary artery stenosis versus coronary artery occlusion 14
Enzyme leakage from ischemic myocardium 16
Reperfusion injury 17
Summary 18
References 19
2. Early changes in wall thickness and epicardial wall motion during
percutaneous transluminal coronary angioplasty in man:
Similarities with in-vitro and in-vivo model
by P.W. Serruys, B. Jaski, F. Piscione, F. ten Kate, P. de Feyter,
M. van den Brand and P.G. Hugenholtz 23
Introduction 23
Echocardiographic changes in wall thickness 23
Changes in epicardial wall motion 25
viii Contents
Regional marker motion 26
Analysis of pressure-derived indexes during systole and diastole 27
Results 27
Changes in regional epicardial wall motion 28
Changes in global left ventricular function 30
Discussion 31
Early wall motion changes during acute ischemia 31
Wall motion abnormalities in chronic ischemia 33
References 34
3. Early mechanical changes associated with coronary artery
occlusion
by M. Marzilli 37
Introduction 37
Materials and methods 37
Results 38
Regional function after 30 sec coronary occlusion 38
Effects of longer and shorter occlusions 38
Discussion 40
References 42
Electrocardiographic changes
4. Coronary angiographic and hemodynamic determinants of ST-
segment response to acute coronary occlusion
by R.G. Macdonald and R.L. Feldman 43
Patient selection 43
Medications 43
Angioplasty procedure and measurements 44
Angiography 45
Results 45
Angiographic correlates 45
Discussion 46
Quantitation of ischemia: surface versus intracoronary ECG 49
Use of the model in evaluating drug therapy 49
Conclusion 50
References 50
5. Dynamic appearance of collaterals during coronary occlusion and
their impact on electrocardiographic changes and wall motion
abnormalities
by M. Cohen 53
Introduction 53
Contents ix
Methods 53
Study patients 53
Cardiac catheterization and angioplasty protocol 54
Results 60
Discussion 65
References 71
Role of collaterals during PTCA
6. Collaterals and coronary wedge pressure
by B. de Bruyne and B. Meier 75
Introduction 75
Assessment of coronary collateral circulation 75
Coronary wedge pressure: Definition and determinants 76
Coronary wedge pressure and angiographic extent of collaterals 77
Coronary wedge pressure and left ventricular function 82
Coronary wedge pressure and restenosis after PTCA 86
Conclusions 89
References 89
Coronary flow and flow resene
7. Intracoronary blood flow velocity, reactive hyperemia and
coronary blood flow reserve during and following PTCA
by P.W. Serruys, F. Zijlstra, H.c. Reiber, K. Beatt, G.J. Laarman,
J. Roelandt and PJ. de Feyter 93
Introduction 93
Patients and methods 93
Intracoronary blood flow velocity measurements 94
Protocol 95
Quantitative analysis of the coronary artery 95
Protocol of the investigational procedure 97
Coronary flow reserve measurements with digital subtraction
cineangiography 98
Results 99
The first study group: Coronary blood flow velocity during
PTCA as a guide line for assessment of the functional results 99
Second study group: A comparison of two methods to measure
coronary flow reserve in the setting of coronary angioplasty:
intracoronary blood flow velocity measurements with a
Doppler catheter, and digital subtraction cineangiography 101
Discussion 111
Intracoronary blood flow velocity: An on line assessement ofthe
functional result of the dilatation? 111
x Contents
Peak reactive hyperemia a useful functional guide line during
the procedure 112
Rationale for comparison of the two techniques to measure
coronary flow reserve 113
Maximal coronary blood flow after pharmacological vasodila-
tion versus reactive hyperemia induced by coronary occlusion 114
Limitations 115
Coronary flow reserve immediately after PTCA 115
Acknowledgements 117
References 117
Myocardial metabolism
8. Loss of hydrogen and potassium ions after short periods of
myocardial ischaemia in man
by P.A. Poole-Wilson 121
Introduction 121
Measurement of arterio-venous differences 121
Oxygen 122
Potassium 122
Hydrogen 123
Other effects of angioplasty 124
A unifying hypothesis 124
References 125
9. Myocardial release of hypoxanthine and lactate during coronary
angioplasty: A quickly reversible phenomenon, but for how
long?
by P.W. Serruys, F. Piscione, W. Wijns, lAJ. Hegge, E. Harmsen,
M. van den Brand, P. de Feyter, P.G. Hugenholtz and lW. de
long 127
Introduction 127
Patients and methods 128
PTCA technique 128
Lactate measurements 128
Hypoxanthine determination 129
Flow measurements 129
Statistical analysis 130
Results 130
Coronary hemodynamic measurements 130
Lactate and hypoxanthine metabolism 132
Discussion 134
Use of purine release as a marker for ischemia during transluminal
occlusion in man 134
Metabolism during reperfusion 138
Contents Xl
Summary 139
References 139
10. Myocardial release of hypoxanthine and urate during angioplasty:
Potential mechanism for free radical generation
by J.W. de Jong, T. Huizer, J.A. Nelson, W. Czarnecki, lJ.R.M.
Bonnier and P.W. Serruys 143
Methods 144
Patients 144
Assays 144
Results 146
Discussion 147
Acknowledgements 149
References 149
11. Regional myocardial nitrogen-13-glutamate uptake following
successful coronary angioplasty
by H. Tillmanns, R. Zimmermann, W.H. Knapp, F. Helus, P.
Georgi, B. Rauch, F.-J. Neumann, S. Girgensohn, W. Maier-
Borst and W. Kubler 151
Patients and methods 151
Results and discussion 152
References 153
Myocardial function
12. Left atrial function in acute transient ischemia on the left ventricle
by M. Grbic and U. Sigwart 155
Patients and methods 155
Results 156
Discussion 158
References 164
13. Left ventricular filling during acute ischemia
by M. Grbic and U. Sigwart 167
Introduction 167
Methods 167
Results 168
Left ventricular relaxation 168
Left ventricular stiffness 170
Left atrial contraction 171
Discussion and conclusions 172
References 174