Author + information
- Received February 26, 2018
- Revision received July 10, 2018
- Accepted July 17, 2018
- Published online October 15, 2018.
- Yousif Ahmad, BMBSa,
- Matthias Götberg, MD, PhDb,
- Christopher Cook, MBBSa,
- James P. Howard, MBBChira,
- Iqbal Malik, MBBS, PhDc,
- Ghada Mikhail, MBBS, PhDc,
- Angela Frame, MScc,
- Ricardo Petraco, MD, PhDa,
- Christopher Rajkumar, MBBSa,
- Ozan Demir, MBBSc,
- Juan F. Iglesias, MDd,
- Ravinay Bhindi, MBBS, PhDe,
- Sasha Koul, MD, PhDb,
- Nearchos Hadjiloizou, MBBS, PhDc,
- Robert Gerber, MDf,
- Punit Ramrakha, MDc,
- Neil Ruparelia, MBBS, DPhilc,
- Nilesh Sutaria, MBChB, MDc,
- Gajen Kanaganayagam, MBBS, PhDc,
- Ben Ariff, MBBS, PhDc,
- Michael Fertleman, MBBChirc,
- Jon Anderson, MBChBc,
- Andrew Chukwuemeka, MBBS, MDc,
- Darrel Francis, MBBChir, MDa,
- Jamil Mayet, MBChB, MDa,
- Patrick Serruys, MD, PhDa,
- Justin Davies, MBBS, PhDa and
- Sayan Sen, MBBS, PhDa,∗ ()
- aNational Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom
- bDepartment of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden
- cDepartment of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- dCardiology Department, Lausanne University Hospital, Lausanne, Switzerland
- eDepartment of Cardiology, Royal North Shore Hospital, Sydney, Australia
- fDepartment of Cardiology, Conquest Hospital, St. Leonards-on-Sea, United Kingdom
- ↵∗Address for correspondence:
Dr. Sayan Sen, National Heart and Lung Institute, 2nd Floor, B Block, Hammersmith Hospital, Imperial College London, London W12 0HS, United Kingdom.
Objectives In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve.
Background A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied.
Methods Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR.
Results Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001).
Conclusions Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.
Drs. Gotberg, Cook, and Petraco have conducted teaching sessions supported by Volcano. Dr. Sen has attended and conducted teaching sessions supported by Volcano, St. Jude Medical, Medtronic, Pfizer, and AstraZeneca; has received research grant support from Philips, AstraZeneca, Medtronic, and Pfizer; and has received speaking honoraria from Pfizer and Volcano-Philips. Drs. Mayet and Davies hold patents pertaining to the instantaneous wave-free ratio technology, which is under license to Volcano. Dr. Davies has served as a consultant for and has received significant research funding from Volcano. Prof. Serruys has received grants and personal fees from Phillips Medtronic and ReCor Medical. The authors are grateful for infrastructural support from the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. They also would like to acknowledge the support of the Academy of Medical Sciences (WHCP_P53077). Drs. Cook (MR/M018369/1) and Sen (G1000357) are supported by the Medical Research Council. Dr. Howard is supported by the Wellcome Trust (PS3162_WHCP). Drs. Petracp (FS/11/46/28861), Davies (FS/05/006), and Francis (FS 04/079) are supported by the British Heart Foundation). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 26, 2018.
- Revision received July 10, 2018.
- Accepted July 17, 2018.
- 2018 The Authors