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CORONARY ANGIOPLASTY: A CONTROLLED MODEL FOR ISCHEMIA

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DEVELOPMENTS IN CARDIOVASCULAR MEDICINE

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CORONARY ANGIOPLASTY: A CONTROLLED MODEL FOR ISCHEMIA

edited by

P.W. SERRUYS, M.D. Chief Cardiac Catheterization Laboratory, Thorax Center, Erasmus University Rotterdam, The Netherlands

G.T. MEESTER, M.D., PhD. Associate Professor of Cardiology, Erasmus University Rotterdam, The Netherlands

1986 MARTINUS NIJHOFF PUBLISHERS a member of the KLUWER ACADEMIC PUBLISHERS GROUP DORDRECHT / BOSTON / LANCASTER

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Distributors

for the United States and Canada: Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park Norwell, MA 02061, USA for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LAI 1 RN, UK for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands

Library of Congress Cataloging in Publication Data

Coronary angioplasty.

(Developments in cardiovascular medicine ; 58) Includes bibliographies. 1. Coronary heart disease--Research--Methodology.

2. Transluminal angioplasty--Diagnostic use. I. Serruys, P. W. II. Meester, G. T. (Geert T.) III. Series: Developments in cardiovascular medicine; v. 58. [DNLM: 1. Angioplasty, Transluminal. 2. Coronary Disease--therapy. WL DE997VME v.58 / WG 300 c8l92] RC685.C6C623 1986 616.1'23075 86-11341

ISBN -13: 978-94-010-8409-3 DOl: 10.1007/978-94-009-4295-0

Copyright

e-ISBN-13: 978-94-009-4295-0

© 1986 by Martinus Nijhoff Publishers, Dordrecht.

Softcover reprint of the hardcover 1 st edition 1986

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers, Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht, The Netherlands.

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Preface

Since the introduction of coronary angioplasty in 1977, this procedure has gained a steadily increasing position in the treatment of coronary artery obstmction. From the available evidence it can be estimated, that this thera­peutic tool will get even more additional momentum of many ten-thousands of patients to be treated in the next few years, due to a growing fraction of patients who are candidates for this intervention. Information about the indications, benefits and risks of coronary angioplasty is accumulating rapidly in addition to publications about refinements of the technique itself.

Recently, a number of investigators have realized that coronary angioplasty is not only a therapeutic tool, but can, during the procedure, be used as a source of diagnostic information. When the catheter is placed in a coronary artery obstruction, inflation of the balloon produces transient myocardial ischemia. Before, during, and after this period of severe ischemia, studies of the perfor­mance of the myocardium at risk can be carried out.

The fact that therapeutic coronary angioplasty is carried out in a cardiac catheterization laboratory which is by definition optimally equipped for the measurement of hemodynamic parameters, has probably also contributed to the effectuation of these investigations. The combination of hemodynamic and biochemical parameters with morphological information from the coronary angiogram can be utilized for the quantification of myocardial involvement and the success of coronary dilatation with angioplasty. Studies of interactions with pharmacological substances are also feasible and informative.

We feel that this new application of coronary angioplasty has a most promising future as a unique means to gather insight in the intricacies of myocardial oxygen supply and demand in patients with coronary artery disease.

For this book a series of contributions have been assembled from medical scientists all over the world, who present their experiences with the effects of transient localized myocardial ischemia during balloon inflation. These studies not only try to detail the effects of ischemia under these conditions, but also to

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explain the underlying mechanisms and to explore the utilization of these observations as a diagnostic test under clinical conditions.

Rotterdam, 11 april 1986 G.T. MEESTER P.W. SERRUYS

Dedicated to the memory of Andreas R. Gruentzig, M.D., F.A.C.C.

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Table of contents

1. Effects of acute myocardial ischemia and reperfusion in conscious animals G.R. HEYNDRICKX and S.F. VATNER Instrumentation techniques for measurements of regional myocar­dial function in conscious animals. Relationship between reduction in regional blood flow and myocardial function .. Adjustment to global LV ischemia .. Adjustment to regional myocardial ischemia .. Effects of reperfusion . Enzyme leakage from ischemic myocardium. Summary .... References

2. Early changes in wall thickness and epicardial wall motion during coronary angioplasty in man. Similarities with in vitro and in vivo model P.W. SERRUYS, B. lASKI, F. PISCIONE, F. ten KATE, P. de FEYTER, M. van den BRAND and P.G. HUGENHOL TZ

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3 4 7 9

12 14 15

Introduction .. 19 Echocardiographic changes in wall thickness .. 19 Changes in epicardial wall motion .. 21 Regional marker motion .... 22 Analysis of pressure-derived indexes during systole and diastole .. .. 23 Results............... 23 Changes in regional epicardial wall motion .. 24 Changes in global left ventricular function.. 27 Discussion 27

Early wall motion changes during acute ischemia .. 27 Wall motion abnormalities in chronic ischemia .. 30

References ... 30

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3. Intracoronary electrocardiogram during transluminal coronary angio­plasty B. MEIER and W. RUTISHAUSER Introduction and methods .................................................................................................................... 33 Results .............................................................................................................................................................................. 33 Discussion .................................................................................................................................................................. 36 References ................................................. ,................................................................................................................ 37

4. Clinical, electrocardiographic and hemodynamic changes during coro­nary angioplasty. Influence of nitroglycerine and nifedipine R. ERBEL, B. HENKEL, G. SCHREINER, W. CLAS, R. BREN­NECKE,H.KOPPandJ.MEYER Introduction ............................................................................................................................................................. 39 Methods ..................................................................................................................................................................... 39 Results .............................................................................................................................................................................. 41

Ischemic tolerance ..................................................................................................................................... 41 Ventricular function .............................................................................................................................. 43

Discussion ................................................................................................................................................................... 48 Summary ...................................................................................................................................................................... 51 References ................................................................................................................................................................. 52

5. Wall thickening and motion in transient myocardial ischemia: Simi­larities and discrepancies between different models ofischemia in man (Prinzmetal's angina, coronary angioplasty, Dipyridamole test) A. DISTANTE, E. PICANO and A. L'ABBATE Introduction ............................................................................................................................................................. 55 Echocardiographic markers of ischemia ............................................................................. 55 The clinical model of transmural vasospastic ischemia and coronary angioplasty ................................................................................................................................................................. 57 Evaluating the site of myocardial ischemia before coronary angio-plasty: a role for the Dipyridamole-echocardiography test .................. 58 References ................................................................................................................................................................... 60

6. Effect of prolonged balloon inflations on hemodynamics and coronary flow with respect to balloon position in patients undergoing coronary angioplasty R. SIMON, I. AMENDE, G. HERRMANN, G. REIL and P.R. LICHTLEN Introduction ........................................................................................................................................................... 63 Methods ......................................................................................................................................................................... 63 Results .............................................................................................................................................................................. 66

Coronary sinus flow ................................................................................................................................ 66 Coronary sinus flow and hemodynamics ..................................................................... 68 Collateral flow ................................................................................................................................................ 71

Discussion .. ..... ............. . ................................... . Flow during occlusion .... ...... ...... ..... ..... .............. .. . Reactive hyperemia ..... .............................. . Coronary sinus flow and hemodynamics Implications ............. ..

References ......................................... .

7. Myocardial release of hypoxanthine and lactate during coronary angioplasty: A quickly reversible phenomenon, but for how long? P.W. SERRUYS, F. PISCIONE, W. WIJNS, J.A.J. HEGGE, E. HARMSEN, M. van den BRAND, P. de FEYTER, P.G. HUGENHOLTZ and J.W. de JONG Introduction ................................................................................................... . Patients and methods ...

PTCA technique Lactate measurements ..... . Hypoxanthine determination ... Flow measurements .. Statistical analysis ..

Results ... Coronary hemodynamic measurements. ... ........... ............. . Lactate and hypoxanthine metabolism......................... ....

Discussion ...... ...... . Use of purine release as a marker for ischemia during transluminal occlusion in man ................................................................................ . Metabolism during reperfusion ... .

Summary. References ...

8. Role of potassium in the genesis of arrhythmias during ischemia. Evidence from coronary angioplasty P.A. POOLE-WILSON and S.c. WEBB Introduction .....

Electrolytes in the ischemic myocardium .. Calcium .. ............ ............ ....... . Sodium .. Hydrogen ion ... Potassium ..

Shortening of the action potential during myocardial ischemia .. Changes in the plasma potassium during myocardial ischemia .. Conclusion. References .................................... .

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72 72 74 74 75 75

77 78 78 79 80 80 81 81 81 85 85

85 90 91 91

95 96 96 96 96 98 99

100 100 100

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9 He ollateral pressure" (occlusion pressure) during coronary angioplasty in coronary artery disease P. PROBST Introduction ....................................................................................................................................................... . Methods .... Results ....................................................................................................................................................................... .

The relation between the collateral pressure (OP) and the amount of visible collaterals (study 1) ...... . ................................ . The influence of Nifedipine on the collateral pressure (study 2) The relation between the collateral pressure and the occurrence of restenosis (study 3) .............................................................................................................. .

Discussion .................................................................................................................................................................. . Summary ..................................................................................................................................................................... . References ................................................................................................................................................................ .

10. Assessment of the dynamic and functional characteristics of collateral flow observed during sudden controlled coronary artery occlusion M. COHEN and K.P. RENTROP Introduction ...................................................................................................... . Methods ................................................................................................................................................ .

105 105 107

107 109

109 110 113 114

115 115

Study patients .................................................................................................................................................. 115 Cardiac catheterization and angioplasty protocol.. ............................... 116 Study protocol ......................................... ........................................... 121

Results ........................................................................................................................................ .................................... 122 Changes in collateral filling during coronary occlusion (Fig. 5) .. 122 Hemodynamics .............................................................................................................................................. 123 Indices of myocardial ischemia with reference to collateral flow 124

Discussion ......................................................................................................... ........................................................ 127 The coronary collateral circulation is a dynamic circulation . 127 Can collateral circulation limit ischemia? ........................................ ....................... 128 Present study ....................................................................... ................................................ 127 Clinical implications .......................................... ........ ................................ 130

Summary ................................ ............................................................................ .............................................. 130 References ..... .......................................................................................................................... 131

11. Left ventricular cineangiography during coronary angioplasty M.E. BERTRAND, 1.M. LABLANCHE, 1.L. FOURRIER and G. TRAISNEL Introduction ............................................................................................................................................................. 133 Selection of the patients ..... ......................................... 134 Left ventricular cineangiography procedure during PTCA ........................ 134

Results ............................................................ . Left ventricular pressures .. Left ventricular volumes and ejection fraction .. Left ventricular diastolic function . Segmental wall motion. Reversibility of the ischemic changes ........... ........... .. Comments .............................................................. .

References.

12. Left ventricular filling during acute ischemia M. GRBIC and U. SIGW ART Introduction ........ Methods ... Results ..

Left ventricular relaxation. Left ventricular stiffness .. Left atrial contraction.

Discussion and conclusions .. References .................. .

13. Ejection filling diastasis during transluminal occlusion in man. Consideration on global and regional left ventricular function. P.W. SERRUYS, F. PIS ClONE, W. WIJNS, C. SLAGER, P. de FEYTER, M. van den BRAND, P.G. HUGENHOLTZ and G.T. MEESTER

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134 134 135 136 136 138 138 148

141 141 142 142 144 145 146 148

Introduction .. 151 Study population and protocol. 151 Methods ..... 152

Analysis of pressure derived indices during systole and diastole 152 Analysis of regional and global left ventricular function.. ... 153

Ejecting dynamics ....... 153 Filling dynamics ..... 154 Diastasis 156 Statistical analysis .. . 157

Results .. .. 157 Global left ventricular function during systole and diastole .... 157 Regional indexes of left ventricular ejection and filling and regional pressure-radius length relations . 164 Regional pressure-radius length relation .. 173

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Discussion ... . ...... uu.u..... . ...... u ...... uu 173 Myocardial ischemia, transient asynergy and altered relaxation 173 Uncoordinated segmental contraction as a cause of impaired filling dynamics ....... 175

Determinants of filling dynamics .. ..u.u.uu.u .. u..... 176 Role of the asynchronous contraction .. 177

Effect of coronary occlusion on left ventricular chamber stiffness and regional diastolic pressure-radius relations ............. uu .. u.u ... uu .... u.u ... u... 177

Significance of the upward shift in pressure-volume and pressure-radius relations ..'U.u ..... uu .. uu .......... u ....... u......... 178 Comparison with animal models of acute low-flow ischemia 178 Mechanism of increased myocardial stiffness..u..uu.u 179

Conclusion: PTCA as an ischemic model? . 182 Early wall motion during acute ischemia: how to interpret? .. 182 Are there clinical implications in chronic ischemia? . 183 Are there clinical implications for the PTCA procedure? 185

References ...uu.u...... 185

List of contributors

L' Abbate, Antonio CNR Universita di Pisa, Fisiologia Clinic a, Via Savi 8, 56100 Pisa, Italy

Amende, I. Medizinische Hochschule Hannover, Abteilung fuer Kardiologie, Karl-Wiechert-Allee 9,3000 Hannover 61, West Deutschland

Bertrand, Michel E. Division of Cardiology B, University Hospital, Lille, France

Van den Brand, M.

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Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738,3000 DR Rotterdam, The Netherlands

Brennecke, R. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1,6500 Mainz, West Deutschland

Clas, W. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1, 6500 Mainz, West Deutschland

Cohen, Marc Division of Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY 10029, U.S.A.

Di'stante, Alessandro CNR Universita di Pisa, Fisiologia Clinica, Via Savi 8, 56100 Pisa, Italy

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Erbel, Raimund II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1, 6500 Mainz, West Deutschland

De Feyter, Pim Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Fourrier, Jean L. Division of Cardiology B, University Hospital, Lille, France

Grbic, M. Centre Hospitalier Universitaire Vaudois, 1011 Laussanne, Switzerland

Harmsen, E. Department of Biochemistry, South Parkroad, Oxford OXI 3QV, United Kingdom

Hegge, Johan A.J. Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738,3000 DR Rotterdam, The Netherlands

Henkel, B. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1,6500 Mainz, West Deutschland

Herrmann, G. Medizinische Hochschule Hannover, Abteilung fuer Kardiologie, Karl­Wiechert-Allee 9,3000 Hannover 61, West Deutschland

Heyndrickx, Guy R. O.L.V. Ziekenhuis, Cardiovascular Center, Department of Physiology, 9300 Aalst, Belgium

Hugenholtz, Paul G. Erasmus University Rotterdam, Thoraxcenter, Department of Cardiology, P.O. Box 1738,3000 DR Rotterdam, The Netherlands

Jaski, Brian Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

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De Jong, J.W. Erasmus University Rotterdam, Cardiochemical Laboratories, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Ten Kate, Folkert Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Kopp, H. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1,6500 Mainz, West Deutschland

Lablanche, Jean M. Division of Cardiology B, University Hospital, Lille, France

Lichtlen, Paul R. Medizinische Hochschule Hannover, Abteilung fuer Kardiologie, Karl­Wiechert-Allee 9,3000 Hannover 61, West Deutschland

Meester, Geert T. Erasmus University Rotterdam, Thoraxcenter, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Meier, Bernhard Centre de Cardiologie, H6pital Cantonal Universitaire, 1211 Geneve 4, Switzerland

Meyer, J. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1,6500 Mainz, West Deutschland

Picano, Eugenio CNR Universita di Pisa, Fisiologia Clinica, Via Savi 8, 56100 Pisa, Italy

Piscione, Federico Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Poole-Wilson, P.A. Cardiothoracic Institute, 2 Beaumont Street, London WIN 2 DX, United Kingdom

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Probst, Peter Allgemeines Krankenhaus, Kardiologie, Universitaetsklinik, Garnisongasse 13, 1097 Vienna, Austria

Reil, G. Medizinische Hochschule Hannover, Abteilung fuer Kardiologie, Karl­Wiechert-Allee 9,3000 Hannover 61, West Deutschland

Rentrop, K. Peter Division of Cardiology, Mount Sinai Hospital, One Gustave Levy Place, New York, NY 10029, U.S.A.

Rutishauser, Wilhelm Centre de Cardiologie, Hopital Cantonal Universitaire, 1211 Geneve 4, Switzerland

Schreiner, G. II. Medizinische Klinik, Johannes Gutenberg Universitaet, Langenbeckstrasse 1,6500 Mainz, West Deutschland

Serruys, Patrick W. Erasmus University Rotterdam, Thoraxcenter, Catheterization Laboratory, P.O. Box 1738,3000 DR Rotterdam, The Netherlands

Sigwart, Ulrich Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland

Simon, R. Medizinische Hochschule Hannover, Abteilung fuer Kardiologie, Karl­Wiechert-Allee 9, 3000 Hannover 61, West Deutschland

Slager, Cees Erasmus University, Department of Haemodynamics, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

Traisnel, Gilles Division of Cardiology B, University Hospital, Lille, France

Vatner, Stephen S. \ Brigham and Woman's Hospital, Department of Medicine, Harvard Medical School, New England Regional Primate Research Centre, Southboro, 01772 MA, U.S.A.

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Webb, S.c. National Heart Hospital, 2 Beaumont Street, London WIN 2CX, United Kingdom

Wijns, William UCLA School of Medicine, Laboratory of Nuclear Medicine, Los Angeles, CA 90024, U.S.A.