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Assessment of flow velocity reserve by transthoracic Doppler echocardiography and venous adenosine infusion before and after left anterior descending coronary artery stenting

^a Section of Cardiology II, Institute of Cardiac Surgery, University of Rome "La Sapienza," Rome, Italy

View larger version (15K): [in a new window]   Figure 1 Diastolic (A) and systolic (B) coronary flow reserve (CFR) in patients and control subjects (see text for details). Note the steeper slope of the intra-time effect in patients with left anterior descending coronary artery (LAD) disease in the upper panel, who also present with the lower data dispersion both before and after stenting, meaning that diastolic CFR is more suitable than systolic CFR to index pre-stenting versus post-stenting Doppler results.

View larger version (35K): [in a new window]   Figure 2 Diastolic coronary flow reserve in patients with left anterior descending coronary artery disease before and early after stent implantation (p < 0.0001). Confidence intervals (95%) of the average value obtained in 23 consecutive control subjects provide a direct comparison to visually estimate how the variable distributes before and after the procedure. There is a clear overlap between the post-stent reserve distribution and average values measured in control subjects, indicating a high probability of normalized reserve after the procedure. Conversely, values measured before the procedure are far from normal in the large majority of patients.

View larger version (111K): [in a new window]   Figure 3 (A) Increase in color Doppler signal intensity and velocity flow map during adenosine infusion. (B) Coronary angiogram of a patient with 95% stenosis of the left anterior descending coronary artery (LAD), and corresponding transthoracic rest and hyperemic Doppler velocities, with a damped diastolic coronary flow reserve (CFR) of 0.7 due to a decrease in peak diastolic velocity from 30 to 21 cm/s. (C, D) Pre-stenting and post-stenting coronary angiograms of a patient with 85% stenosis of the proximal LAD, and corresponding transthoracic Doppler velocities, with a diastolic CFR of 1.4 on the day before stenting (C), increasing to 2.5 after the procedure (D). Of note, the post-procedural increase in diastolic CFR is due to a reduction in rest and an increase in hyperemic velocity, as compared with pre-stenting values.