Kern M J, Donohue T J, Aguirre F V, Bach R G, Caracciolo E A, Wolford T, Mechem C J, Flynn M S, Chaitman B
Department of Internal Medicine, Saint Louis University School of Medicine, MO.
J Am Coll Cardiol. 1995 Jan;25(1):178-87. doi: 10.1016/0735-1097(94)00328-n.
The objective of this study was to determine the feasibility, safety and outcome of deferring angioplasty in patients with angiographically intermediate lesions that are found not to limit flow, as determined by direct translesional hemodynamic assessment.
The clinical importance of some coronary stenoses of intermediate angiographic severity frequently requires noninvasive stress testing. Direct translesional pressure and flow measurements may assist in clinical decision making in patients with such stenoses.
Translesional spectral flow velocity (Doppler guide wire) and pressure data were obtained in 88 patients for 100 lesions (26 single-vessel and 74 multivessel coronary artery lesions) with quantitative angiographic coronary narrowings (mean +/- SD diameter narrowing 54 +/- 7% [range 40% to 74%]). Target lesion angioplasty was prospectively deferred on the basis of predetermined normal values, defined as a proximal/distal velocity ratio < 1.7 or a pressure gradient < 25 mm Hg, or both. Patients were followed up for 9 +/- 5 months (range 6 to 30).
In the deferred angioplasty group, translesional velocity ratios were similar to those of a normal reference group (mean 1.1 +/- 0.32 vs. 1.3 +/- 0.55) and significantly lower than those of a reference cohort of patients who had undergone angioplasty (2.27 +/- 1.2, p < 0.05). The mean translesional pressure gradient in the deferred angioplasty group was also lower than that in the angioplasty group (10 +/- 9 vs. 45 +/- 22 mm Hg, p < 0.001). At follow-up in the deferred angioplasty group, four, six, zero and two patients, respectively, had had subsequent angioplasty, coronary artery bypass graft surgery or myocardial infarction or had died. In one patient, death was related to angioplasty of a nontarget artery lesion, and one patient with multivessel disease had a cardiac arrest due to ventricular fibrillation 12 months after lesion assessment. Among the 10 patients requiring later angioplasty or coronary artery bypass grafting, only six procedures were performed on target arteries. No patient had a complication of translesional flow or pressure measurements.
These data demonstrate the safety, feasibility and clinical outcome of deferring angioplasty of coronary artery narrowings associated with normal translesional coronary hemodynamic variables. Given the practice of performing angioplasty without ischemic testing or when testing is inconclusive, translesional hemodynamic data obtained at diagnostic catheterization can identify patients in whom it is safe to postpone angioplasty.
本研究的目的是确定对于经血管造影显示为中等病变且经直接跨病变血流动力学评估发现不限制血流的患者，延迟进行血管成形术的可行性、安全性及结果。
一些血管造影严重程度中等的冠状动脉狭窄的临床重要性常常需要进行无创负荷试验。直接跨病变压力和血流测量可能有助于对此类狭窄患者进行临床决策。
对88例患者的100处病变（26处单支血管病变和74处多支血管冠状动脉病变）进行了跨病变频谱血流速度（多普勒导丝）和压力数据采集，这些病变经定量血管造影显示冠状动脉狭窄（平均±标准差直径狭窄54±7%[范围40%至74%]）。基于预先确定的正常值（定义为近端/远端速度比<1.7或压力梯度<25 mmHg，或两者均符合），前瞻性地延迟对靶病变进行血管成形术。对患者进行了9±5个月（范围6至30个月）的随访。
在延迟血管成形术组中，跨病变速度比与正常参照组相似（平均值1.1±0.32对1.3±0.55），且显著低于已接受血管成形术的参照队列患者（2.27±1.2，p<0.05）。延迟血管成形术组的平均跨病变压力梯度也低于血管成形术组（10±9对45±22 mmHg，p<0.001）。在延迟血管成形术组的随访中，分别有4例、6例、0例和2例患者随后接受了血管成形术、冠状动脉旁路移植术或心肌梗死或死亡。1例患者的死亡与非靶血管病变的血管成形术有关，1例多支血管病变患者在病变评估后12个月因室颤发生心脏骤停。在10例后来需要进行血管成形术或冠状动脉旁路移植术的患者中，仅对靶血管进行了6次手术。没有患者出现跨病变血流或压力测量的并发症。
这些数据证明了对于跨病变冠状动脉血流动力学变量正常的冠状动脉狭窄延迟进行血管成形术的安全性、可行性及临床结果。鉴于在未进行缺血试验或试验结果不确定时进行血管成形术的做法，在诊断性心导管检查时获得的跨病变血流动力学数据可以识别出延迟血管成形术安全的患者。
