Segmental comparison between coronary angiography and positron emission tomography reveals low predictive value of epicardial flow for viability

Z Koszegi
1998 European Heart Journal  
The functional significance of the anterograde and retrograde filling of coronaries on angiography is controversial. Methods and Results Eighteen patients with 27 severe lesions (>85% diameter stenosis) after previous extensive myocardial infarction were selected. The left ventricle was divided into 33 segments for regional comparison of epicardial flow (as assessed by angiography) and tissue perfusion as well as metabolism (as measured by 13NH3_ and 18FDG-PET). Viability was defined as normal
more » ... defined as normal perfusion (>80% relative of maximum 13NH3 activity) or mismatch defect (> 1·2 metabolismlfiow ratio). A method has been developed to register the 'lesion predicted region', determined on the basis of angiography, in the same polar map as derived from the positron emission tomography data. Distal to the lesion, the anterograde epicardial flow was evaluated by Thrombolysis in Myocardial Infarction (TIMI) criteria (TIMI flow 0-3), and retrograde filling was graded on a 0-3 scale (collateral grade 0-3). TIMI flow grade and retrograde collateral grade in every lesion predicted region segment were summed to indicate the total o 195-668XJ98/060959 + 09 $18.00/0 hj970856 segmental epicardial flow. Out of the 594 segments, 369 were associated with a severe lesion. Among them, significantly higher average perfusion and metabolic activities were found in segments of good epicardial filling (summed epicardial flow ~ 3) than in the territories of limited epicardial flow (summed score <3): 65·4 ± 17% vs 45·6 ± 10 (P=O'OOI%) and 68·6 ± 16% vs 47·4 ± 11% (P=0'0004), respectively. However, when we analysed the predictive value of angiographically detectable good epicardial flow for positron emission tomography viability criteria then the positive predictive value was found to be as low as 0'5, while the negative predictive value was considerably higher (0'82). Conclusion After myocardial infarction, angiographically detectable limited epicardial flow reveals scarred segments while good epicardial contrast filling does not necessarily indicate maintenance of nutritive function. (Eur Heart J 1998; 19: 959-967) Key Words: Positron emission tomography, coronary angiography, collaterals, myocardial viability. damage[l-3 1 . The functional significance of retrograde filling during cardiac catheterization is also controversiaI 14 -61 . Although coronary angiography is the gold standard for visualization of coronary vessel diameter above 0·1 mm, it has limited value for measuring regional myocardial perfusion. Myocardial contrast echocardiography, with intracoronary injection of sonicated contrast, offers superior resolution for the evaluation of the microcirculation[7-91. In addition to single photon emission tomography, positron emission tomography with perfusion C 3 NH 3 , H 2 15 0) and metabolic CSFDG, lIe-acetate) tracers is the most sophisticated non-invasive method for the assessment of myocardial perfusion and viabilityll(l-12 1 . Background The functional significance of the anterograde and retrograde filling of coronaries on angiography is controversial. Methods and Results Eighteen patients with 27 severe lesions (>85% diameter stenosis) after previous extensive myocardial infarction were selected. The left ventricle was divided into 33 segments for regional comparison of epicardial flow (as assessed by angiography) and tissue perfusion as well as metabolism (as measured by 13NH3_ and 18FDG-PET). Viability was defined as normal perfusion (>80% relative of maximum 13NH3 activity) or mismatch defect (> 1·2 metabolismlfiow ratio). A method has been developed to register the 'lesion predicted region', determined on the basis of angiography, in the same polar map as derived from the positron emission tomography data. Distal to the lesion, the anterograde epicardial flow was evaluated by Thrombolysis in Myocardial Infarction (TIMI) criteria (TIMI flow 0-3), and retrograde filling was graded on a 0-3 scale (collateral grade 0-3). TIMI flow grade and retrograde collateral grade in every lesion predicted region segment were summed to indicate the total o 195-668XJ98/060959 + 09 $18.00/0 hj970856 segmental epicardial flow. Out of the 594 segments, 369 were associated with a severe lesion. Among them, significantly higher average perfusion and metabolic activities were found in segments of good epicardial filling (summed epicardial flow ~ 3) than in the territories of limited epicardial flow (summed score <3): 65·4 ± 17% vs 45·6 ± 10 (P=O'OOI%) and 68·6 ± 16% vs 47·4 ± 11% (P=0'0004), respectively. However, when we analysed the predictive value of angiographically detectable good epicardial flow for positron emission tomography viability criteria then the positive predictive value was found to be as low as 0'5, while the negative predictive value was considerably higher (0'82). Conclusion After myocardial infarction, angiographically detectable limited epicardial flow reveals scarred segments while good epicardial contrast filling does not necessarily indicate maintenance of nutritive function. (Eur Heart J 1998; 19: 959-967) Key Words: Positron emission tomography, coronary angiography, collaterals, myocardial viability. damage[l-3 1 . The functional significance of retrograde filling during cardiac catheterization is also controversiaI 14 -61 . Although coronary angiography is the gold standard for visualization of coronary vessel diameter above 0·1 mm, it has limited value for measuring regional myocardial perfusion. Myocardial contrast echocardiography, with intracoronary injection of sonicated contrast, offers superior resolution for the evaluation of the microcirculation[7-91. In addition to single photon emission tomography, positron emission tomography with perfusion C 3 NH 3 , H 2 15 0) and metabolic CSFDG, lIe-acetate) tracers is the most sophisticated non-invasive method for the assessment of myocardial perfusion and viabilityll(l-12 1 .
doi:10.1053/euhj.1997.0856 pmid:9651722 fatcat:mmftav4ajna33inm7jvklpy5ye