Concurrent assessment of epicardial coronary artery stenosis and microvascular dysfunction using diagnostic endpoints derived from fundamental fluid dynamics principles.

BACKGROUND: Simultaneously measured pressure and flow distal to coronary stenoses can be combined, in conjunction with anatomical measurements, to assess the status of both the epicardial and microvascular circulations. METHODS AND RESULTS: Assessments of coronary hemodynamics were performed using fundamental fluid dynamics principles. We hypothesized that the pressure-drop coefficient (CDPe; trans-stenotic pressure drop divided by the dynamic pressure in the distal vessel) correlates linearly with epicardial and microcirculatory resistances concurrently. In 14 pigs, simultaneous measurements of distal coronary arterial pressure and flow were performed using a dual sensor-tipped guidewire in the setting of both normal and disrupted microcirculation, with the presence of epicardial coronary lesions of lt; 50% area stenosis (AS) and > 50% AS. The CDPe progressively increased from lesions of < 50% AS to > 50% AS and had a higher resolving power (45 +/- 22 to 193 +/- 140 in normal microcirculation; 248 +/- 137 to 351 +/- 140 in disrupted microcirculation) as compared to fractional flow reserve (FFR) and coronary flow reserve (CFR). Strong multiple linear correlation was observed for CDPe with combined FFR and CFR (r = 0.72; p < 0.0001). Further, the ratio of maximum pressure drop coefficient evaluated at the site of stenosis and its theoretical limiting value of minimum cross-sectional area was also able to distinguish different combinations of coronary artery diseases. CONCLUSIONS: The CDPe can be readily obtained during routine pressure and flow measurements during cardiac catheterization. It is a promising clinical diagnostic parameter that can independently assess the severity of epicardial stenosis and microvascular impairment.

Hemodynamic diagnostics of epicardial coronary stenoses: in-vitro experimental and computational study.

BACKGROUND: The severity of epicardial coronary stenosis can be assessed by invasive measurements of trans-stenotic pressure drop and flow. A pressure or flow sensor-tipped guidewire inserted across the coronary stenosis causes an overestimation in true trans-stenotic pressure drop and reduction in coronary flow. This may mask the true severity of coronary stenosis. In order to unmask the true severity of epicardial stenosis, we evaluate a diagnostic parameter, which is obtained from fundamental fluid dynamics principles. This experimental and numerical study focuses on the characterization of the diagnostic parameter, pressure drop coefficient, and also evaluates the pressure recovery downstream of stenoses. METHODS: Three models of coronary stenosis namely, moderate, intermediate and severe stenosis, were manufactured and tested in the in-vitro set-up simulating the epicardial coronary network. The trans-stenotic pressure drop and flow distal to stenosis models were measured by non-invasive method, using external pressure and flow sensors, and by invasive method, following guidewire insertion across the stenosis. The viscous and momentum-change components of the pressure drop for various flow rates were evaluated from quadratic relation between pressure drop and flow. Finally, the pressure drop coefficient (CDPe) was calculated as the ratio of pressure drop and distal dynamic pressure. The pressure recovery factor (eta) was calculated as the ratio of pressure recovery coefficient and the area blockage. RESULTS: The mean pressure drop-flow characteristics before and during guidewire insertion indicated that increasing stenosis causes a shift in dominance from viscous pressure to momentum forces. However, for intermediate (approximately 80%) area stenosis, which is between moderate (approximately 65%) and severe (approximately 90%) area stenoses, both losses were similar in magnitude. Therefore, guidewire insertion plays a critical role in evaluating the hemodynamic severity of coronary stenosis. More importantly, mean CDPe increased (17 +/- 3.3 to 287 +/- 52, n = 3, p < 0.01) and mean eta decreased (0.54 +/- 0.04 to 0.37 +/- 0.05, p < 0.01) from moderate to severe stenosis during guidewire insertion. CONCLUSION: The wide range of CDPe is not affected that much by the presence of guidewire. CDPe can be used in clinical practice to evaluate the true severity of coronary stenosis due to its significant difference between values measured at moderate and severe stenoses.