Evaluation of coronary collateral circulation in conscious humans

doi:10.1016/0002-9149(84)90070-5

The American Journal of Cardiology

Volume 53, Issue 9, 1 May 1984, Pages 1233-1238

https://doi.org/10.1016/0002-9149(84)90070-5 Get rights and content

Abstract

The physiologic importance of coronary collateral vessels was investigated in 19 men undergoing transient proximal occlusion of the left anterior descending (LAD) branch without sedative medication. No vasodilators were given before LAD balloon occlusion. Six men had angiographic filling of the LAD via coronary collateral vessels (Group 1) and 13 did not (Group 2). Aortic, distal coronary and left ventricular (LV) filling pressures and great cardiac vein blood flow (thermodilution) were recorded continuously during occlusion. During LAD occlusion, clinical and electrocardiographic evidence for transient myocardial ischemia occurred more often in patients in Group 2 than in Group 1, but the difference was not statistically significant. Heart rate and aortic and distal coronary pressures were similar in Groups 1 and 2. LV filling pressure was 3 mm Hg higher in Group 2 patients (p < 0.05). The aortic to distal coronary pressure difference and the distal coronary to LV filling pressure difference were also similar in Groups 1 and 2. However, residual great cardiac vein flow was 55% higher (p < 0.05) and the calculated coronary collateral resistance index was 45 % lower in patients in Group 2 compared with those in Group 1 (p < 0.01.)

Coupling of regional coronary venous blood flow estimates to pressure measurements routinely made during angioplasty is a new technique that allows evaluation of determinants of coronary collateral function in conscious humans. Coronary collateral vessels were found to be potentially physiologically important because clinical, electrocardiographic and hemodynamic evidence for transient myocardial ischemia occurred slightly less often and flow and pressure indexes of collateral perfusion were better in men with than in those without angiographic evidence of coronary collateral vessels.

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Cited by (47)

Determinants of prognostically relevant intracoronary electrocardiogram ST-segment shift during coronary balloon occlusion
2012, American Journal of Cardiology
Citation Excerpt :
That is, occlusive peripheral lead ECG ST-segment shift correlated with simultaneously obtained collateral function but was not predictive for mortality. Conversely, intracoronary ECG ST-segment was confirmed to be very sensitive to even a brief coronary occlusion of only 1 minute10,11 (Figure 1). Intracoronary electrocardiography after and not during vessel occlusion has been recently used for prediction of myocardial damage in patients with CAD undergoing elective PCI.12
The prognostic relevance of quantitative an intracoronary occlusive electrocardiographic (ECG) ST-segment shift and its determinants have not been investigated in humans. In 765 patients with chronic stable coronary artery disease, the following simultaneous quantitative measurements were obtained during a 1-minute coronary balloon occlusion: intracoronary ECG ST-segment shift (recorded by angioplasty guidewire), mean aortic pressure, mean distal coronary pressure, and mean central venous pressure (CVP). Collateral flow index (CFI) was calculated as follows: (mean distal coronary pressure minus CVP)/(mean aortic pressure minus CVP). During an average follow-up duration of 50 ± 34 months, the cumulative mortality rate from all causes was significantly lower in the group with an ST-segment shift <0.1 mV (n = 89) than in the group with an ST-segment shift ≥0.1 mV (n = 676, p = 0.0211). Factors independently related to intracoronary occlusive ECG ST-segment shift <0.1 mV (r² = 0.189, p <0.0001) were high CFI (p <0.0001), intracoronary occlusive RR interval (p = 0.0467), right coronary artery as the ischemic region (p <0.0001), and absence of arterial hypertension (p = 0.0132). “High” CFI according to receiver operating characteristics analysis was ≥0.217 (area under receiver operating characteristics curve 0.647, p <0.0001). In conclusion, absence of ECG ST-segment shift during brief coronary occlusion in patients with chronic coronary artery disease conveys a decreased mortality and is directly influenced by a well-developed collateral supply to the right versus left coronary ischemic region and by the absence of systemic hypertension in a patient's history.
Collateral pressure and flow in acute myocardial infarction with total coronary occlusion correlate with angiographic collateral grade and creatine kinase levels
2010, American Heart Journal
Citation Excerpt :
The analysis of the time course of collateral evolution during the first 24 hours after onset showed that distal pressures representing collateral flow did not change. However, flow is not determined by pressure only, but also by resistance; and it has been shown that collateral resistance gradually decreases in the chronic state.2,25 Yet, the results of the present study suggest that distal coronary resistance was not altered during the first 24 hours after AMI onset because Pd that did not change throughout this period correlated with the angiographic collateral grade that is a measure of both pressure and resistance.
The validity of angiographic collateral grade according to the Rentrop classification during acute myocardial infarction (AMI) and its relation to flow in occluded coronary arteries before angioplasty have never been evaluated.
We assessed the validity of the angiographic collateral grade according to Rentrop classification in relation to collateral pressure and flow beyond occluded coronary arteries during AMI. Pressure distal to coronary artery occlusions before balloon dilatation was measured in 111 patients undergoing angioplasty for AMI. We calculated the collateral flow index (CFI) and compared it to observed Rentrop grade and measured creatine kinase sum.
The values of pressure distal to coronary artery occlusions with respect to collateral grades 0 to 3 were 33 ± 12, 37 ± 13, 42 ± 10, and 60 ± 14 mm Hg (P < .0001). Overall CFI was 0.35 ± 0.13 (median 0.33), with CFI values of 0.3 ± 0.13, 0.33 ± 0.13, 0.39 ± 0.1, and 0.57 ± 0.2 for collateral grades 0 to 3, respectively (P < .0001). Larger creatine kinase elevation (P < .016) and higher white blood cell count (P < .022) were recorded in the lowest tertile CFI compared with highest tertile CFI group; but no difference in the global, regional, or infarct-related regional left ventricular contraction was found.
These observations demonstrate that the Rentrop classification is valid in AMI patients with occluded coronary arteries and that collaterals are recruited acutely. These collaterals, whose pressure-derived CFI during AMI was shown for the first time to be higher than its value reported in chronic conditions, may limit the immediate myocardial damage or the systemic inflammatory response. No impact on global or regional cardiac contraction was detected in a population where most patients were treated early.
Ischemic preconditioning in unstable coronary syndromes: Evidence for time dependence
1997, Journal of the American College of Cardiology
Objectives. We hypothesized a time-dependent relation between angina occurring spontaneously before percutaneous transluminal coronary angioplasty (PTCA) and the likelihood of an ischemic response during initial balloon occlusion. We further hypothesized that the ability to elicit the “classic” mode of PTCA-related preconditioning would vary with the interval from clinical angina to PTCA.
Background. Antecedent angina represents a potential for myocardial preconditioning in unstable ischemic coronary syndromes.
Methods. We studied 67 patients with Braunwald class III unstable coronary syndromes undergoing PTCA. The interval between the last spontaneous episode of angina preceding PTCA and initial balloon inflation was categorized as follows: 0 to 6 h; 6 to 12 h; 12 to 24 h; and >24 h.
Results. Across the various intervals, there was a significant difference (p = 0.004) in the proportion of patients with an absent ischemic response during the first balloon inflation (0 to 6 h, 50%; 6 to 12 h, 35%; 12 to 24 h, 23%; and >24 h, 4%). There was, however, no difference between the first and second inflations in the proportion of patients with a diminished ischemic response until 6 to 12 h (p = 0.017) had elapsed since the last spontaneous episode of angina. Patients whose angina last occurred >24 h before the first inflation showed the greatest inducibility of PTCA-related preconditioning.
Conclusions. Strong evidence exists for the occurrence of ischemic preconditioning in unstable coronary syndromes. Although the protective effect of spontaneous angina appears to wane beyond 6 h, recovery of preconditioning occurs from 6 to 12 h. Thus, preconditioning can be reinduced during PTCA with a marked potentiation of the effect at 24 h. This suggests an underlying time-dependent mechanism with a physiologic “half-life” of 6 to 12 h.
Comparison of collateral vascular responses in the donor and recipient coronary artery during transient coronary occlusion assessed by intracoronary blood flow velocity analysis in patients
1997, Journal of the American College of Cardiology
Objectives. This study was designed to evaluate the hemodynamic variables of the collateral circulation during acute coronary occlusion.
Background. There is limited information on the physiology of the collateral circulation in coronary artery disease.
Methods. Angiography of the contralateral donor artery was performed before and during balloon coronary occlusion in 57 patients with one-vessel disease. Recruitable collateral flow was assessed during coronary occlusion by blood flow analysis of the contralateral donor artery (n = 19) or the ipsilateral recipient artery (n = 15), or both (n = 23), using a Doppler catheter or guide wire. Ischemia was evaluated by the ST segment shift (≥0.1 mV) on a 12-lead electrocardiogram at 1 min of coronary occlusion.
Results. The presence (n = 39), compared with the absence (n = 18), of recruitable collateral vessels was associated with an increase of blood flow velocity in the donor artery (20 ± 19% vs. 4.8 ± 5.9% [mean ± SD], p = 0.003) and the recipient artery (velocity integral 7.2 ± 5.5 vs. 2.8 ± 2.2 cm, p = 0.02) related to a reduced relative collateral vascular resistance (9.2 ± 10 vs. 20 ± 11, p = 0.003). Collateral flow in the donor artery yielded a similar predictive value for recruitability of collateral vessels as collateral flow determined in the recipient artery or the coronary wedge/aortic pressure ratio (areas under the receiver operating characteristics curves 0.76 ± 0.07, 0.78 ± 0.08, 0.77 ± 0.07, respectively, p = NS). Collateral flow in the recipient artery was a better predictor for ischemia than collateral flow in the donor artery or angiographic grading of collateral vessels (areas 0.90 ± 0.05, 0.64 ± 0.10, 0.73 ± 0.07, respectively, p < 0.05).
Conclusions. Coronary blood flow velocity analysis of the donor and recipient coronary arteries can characterize the dynamics of the collateral circulation during acute coronary occlusion. The protective effect of recruitable collateral vessels relates to an increase of flow in the donor and recipient coronary arteries due to a reduced collateral vascular resistance. This study underscores the importance of physiologic variables for the evaluation of the function of recruitable collateral vessels.
(J Am Coll Cardiol 1997;29:1528–35)
Adaptation to myocardial ischemia during coronary angioplasty demonstrated by clinical, electrocardiographic, echocardiographic, and metabolic parameters
1997, American Heart Journal
It has been shown that brief episodes of myocardial ischemia can render the heart more resistant to a prolonged subsequent ischemic episode. This phenomenon, called “preconditioning,” has been described in human beings during coronary angioplasty with the use of clinical, electrocardiographic (ECG), or metabolic parameters. The goal of this study was to assess this phenomenon further with the use of echocardiographic and metabolic parameters in addition to clinical and ECG parameters. Eighteen patients with isolated stenosis of the left anterior descending coronary artery and a normal left ventricular function were included. Angioplasty consisted of four consecutive balloon inflations. Sequential changes in clinical, ECG (intracoronary ECG), echocardiographic, and metabolic parameters of myocardial ischemia were compared between the first and the fourth balloon inflations. Improved tolerance to myocardial ischemia with repeated coronary occlusions was demonstrated by a significant reduction in the severity of angina, ST-segment elevation, wall motion abnormalities, and lactate production. This study confirms the adaptation of myocardial ischemia to repeated coronary occlusions through measurement of clinical, ECG, echocardiographic, and metabolic parameters. (Am Heart J 1997;133:490-6.)
Left ventricular motion after bypass operation for coronary artery disease with collaterals
1994, The Annals of Thoracic Surgery
Left ventricular ejection changes obtained from left ventricle roentgenograms were analyzed before and after coronary artery bypass grafting in 22 consecutive patients with chronic obstructive left anterior descending coronary artery disease receiving collaterals before surgical revascularization. The collateral vessels all disappeared after surgical revascularization. After operation, ejection changes of anterobasal, anterolateral and apical walls supplied by the left anterior descending coronary artery improved from 43.6% ± 9.7% to 48.5% ± 8.6% (p < 0.05), from 35.2% ± 10.9% to 39.4% ± 9.5% (p < 0.05), and from 46.0% ± 10.6% to 50.0% ± 8.7% (p < 0.05), respectively. The improvement in left ventricular wall motion did not appear to be related to the extent of preoperative collateralization. Thus, left ventricular wall motion was impaired in the area supplied by collaterals and was improved by myocardial revascularization. These results suggest that coronary blood flow, even through well-developed collaterals, may not be sufficient, which may produce chronic active ischemia and impaired left ventricular wall motion.

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^☆: This study was supported by the Research Service of the Veterans Administration.

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Coronary heart diseaseEvaluation of coronary collateral circulation in conscious humans☆

Abstract

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

The coronary collateral circulation: a significant compensatory mechanism or a functionless quirk of nature

Circulation

An angiographic and clinical study of coronary collateral circulation

Basic Res Cardiol

Coronary collateral vessels: spectrum of physiologic capabilities with respect to providing rest and stress myocardial perfusion, maintenance of left ventricular function and protection against infarction

Am J Cardiol

Coronary collateral function during exercise

Circulation

Quantification of collateral resistance in acute and chronic experimental coronary occlusion in the dog

Circ Res

Coronary heart disease
Evaluation of coronary collateral circulation in conscious humans☆