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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Determinants of Coronary Steal in Chronic Total Coronary Occlusions

Donor Artery, Collateral, and Microvascular Resistance

Gerald S. Werner, MD^_*,_*, Michael Fritzenwanger, MD^_*, Dirk Prochnau, MD^_*, Gero Schwarz, MD^_*, Markus Ferrari, MD^_*, Wilbert Aarnoudse, MD, Nico H.J. Pijls, MD PhD and Hans R. Figulla, MD^_*

^_* Clinic for Internal Medicine I, Friedrich-Schiller-University Jena, Jena, Germany
Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands.

Manuscript received August 17, 2005; revised manuscript received November 21, 2005, accepted November 28, 2005.

^_* Reprint requests and correspondence: Prof. Dr. Gerald S. Werner, Medizinische Klinik I, Klinikum Darmstadt, Grafenstrasse 9, D-64283 Darmstadt, Germany. (Email: gerald.werner{at}med.uni-jena.de).

OBJECTIVES: We aimed to assess the mechanisms of coronary steal by direct hemodynamic measurements of the collateral circulation in chronic total coronary occlusions (CTO).

BACKGROUND: Coronary steal may cause ischemia despite well-developed collaterals in coronary artery disease.

METHODS: Fifty-six patients were studied during recanalization of a CTO. Before recanalization, the fractional flow reserve in the donor artery (FFR_D) at the takeoff of the collaterals and the coronary flow reserve were recorded. After crossing the occlusion, the distal coronary flow velocity was measured by a Doppler wire (APV_Occl), and distal pressure by a pressure wire. Changes of these parameters were assessed during intravenous adenosine (140 µg/kg/min). Resistance indexes for the donor artery (R_D), collaterals (R_C), and microcirculation (R_P) were calculated.

RESULTS: Adenosine caused a decrease of APV_Occl (i.e., coronary steal, in 26 patients [group S], an increase in 19 patients [group R], and no change in 11 patients). The FFR_D was lower in group S. R_D and R_C increased in group S, while R_D did not change significantly and R_C decreased in group R. Patients with steal had more severe regional dysfunction. Patients with steal but without an FFR_D <0.8 tended to have an impaired microvascular function.

CONCLUSIONS: We could demonstrate that coronary steal in man is mainly due to a hemodynamically significant donor artery lesion, but can also occur due to an impaired vasodilatory reserve of the microcirculation in the absence of a donor artery lesion. Coronary steal may have an adverse influence on the preservation of myocardial function by collaterals.

Abbreviations and Acronyms   APVOccl = average peak velocity distal to the occlusion   CFR = coronary flow reserve   CTO = chronic total coronary occlusion   FFRD = fractional flow reserve in the donor artery at collateral takeoff   LV = left ventricle/ventricular   PAo = mean aortic pressure   PD = mean pressure in the donor artery at collateral takeoff   POccl = mean pressure distal to the occlusion   PRA = mean right atrial pressure   RC = collateral resistance index   RCP = collateral pathway resistance index   RD = donor artery epicardial resistance index   RP = peripheral myocardial resistance index   TIMI = Thrombolysis In Myocardial Infarction

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